Every finding on record at Legacy at Jacksonville

Based on observation, interview, and record review, the facility failed to ensure residents environment remained as free of accident hazards as is possible for 1 of 5 residents (Resident #1) reviewed for accident hazards. The facility failed to serve coffee at an appropriate temperature resulting in Resident #1 acquiring burns to his left and right inner thighs from a coffee spill. The noncompliance was identified as PNC. The past noncompliance began on 5/22/26 and ended on 5/23/26. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of burns, infection, and hospitalization.Findings included: Record review of Resident #1's face sheet, dated 6/1/26, indicated Resident #1 was a [AGE] year-old male admitted on [DATE] with diagnoses of unspecified dementia (altered cognition), type 2 diabetes (insulin resistance) with chronic kidney disease, and need for assistance with personal care. Record review of a quarterly MDS assessment, dated 5/20/2026, indicated Resident #1 had a BIMS score of 6 which indicated severely impaired cognition and he required assistance for all ADLs. He required setup or clean-up assistance with eating/drinking. Record review of a comprehensive care plan, dated 11/10/2025, indicated Resident #1 had an ADL self-care performance deficit. Interventions were in place including providing supervision as needed for eating. Record review of Resident #1's comprehensive care plan, revisions on 5/22/26, indicated the resident was at risk of burns due to hot liquids. Resident #1 noted to remove lid at times and did not follow education risks related to hot liquid safety. Interventions were put in place including coffee and other hot liquids should not be served if over 140 degrees, if hot liquid was spilled on resident staff should poor room temperature or lower temperature liquid on the affected area of the resident, and resident reinforced to use a cup with a lid. There were no previous hot liquid safety interventions care planned. Record review of an event note for a burn, dated 5/22/26, indicated Resident #1 received a burn in the dining room to his right and left inner thighs, caused by coffee, tea, or other hot liquid. The description of the event indicated CNA A was taking residents to the dining room and another resident stated that Resident #1 had spilled coffee on himself. The event note indicated the cup of coffee was reportedly sitting too close to the edge of the table and when Resident #1 moved back from the table the coffee spilled on his lap. Redness was noted to right and left inner thighs. Resident #1 complained of a burning sensation and cold compressors were applied and a scheduled pain medication was administered. Interviews were attempted with CNA A on 6/1/26 at 1:28 p.m., 1:40 p.m., 2:23 p.m., and 3:48 p.m. Voice mail was left requesting a return call, but no call was received. Record review of a skin assessment, dated 5/22/26 at 9:07 a.m., indicated Resident #1 had the following new findings: To left inner thigh: reddened area from mid anterior (nearer the front) thigh to inner posterior (nearer the rear) thigh from spilled coffee. To right inner thigh: reddened area from mid anterior thigh to posterior thigh. One fluid filled blister to distal portion (away from center of body or point of attachment) measuring 1X 1 cm Ice water compresses applied and treatment order received for silver ointment until healed. Record review of a skin assessment, dated 5/22/26 at 11:37 a.m., indicated Resident #1 had the following new findings: Additional fluid filled blister # 2 also to distal portion measuring 0.3x 0.3 cm Record review of an injury note dated 5/23/26 at 11:57 a.m. indicated Resident #1 had the following noted injury: right thigh intact blister, left thigh (2) small burns Record review of facility Coffee Temperature Log, dated 05/16/26 through 05/22/2026, indicated on 5/22/26 coffee was served with a temperature of 160 degrees by Dietary Aide D's initials. During an observation and interview on 6/1/26 at 9:50 a.m., [NAME] Aide C said she was generally responsible for checking the temperature on the coffee prior to it being served to residents. [NAME] Aid C said she checked the temperature after every pot of coffee that was brewed and added ice to the coffee to reach a desired temperature of 140 or below. [NAME] Aide C said the risk of serving coffee to residents that was too hot could result in burns. [NAME] Aide C was observed calibrating the thermometer and checking the temperature of the coffee in the coffee dispenser in the dining room. The temperature of the coffee was observed to be 137.0 degrees. During an interview on 6/1/26 at 10:00 a.m., the DM said all staff who worked in the kitchen were trained in the proper procedures for making coffee. The DM said part of that process included checking the temperature of the coffee and making sure it was below 140 degrees. The DM said the coffee maker brewed coffee at 200 degrees and then ice was added to cool down the coffee to serving temperature. The DM said she audited the coffee temperature logs daily to ensure they were filled out and the temperature was below 140 degrees. The DM said on the day of the incident Dietary Aide D failed to check the temperature of the coffee prior to serving it to the residents. The DM said the coffee temperature was checked after the incident and the temperature was found to be 160 degrees. The DM said the policy was to serve coffee at 140 degrees or below to prevent burns. During an interview on 6/1/26 at 10:10 a.m., Resident #1 said he was sitting in the dining room and his coffee was on the edge of the table. Resident #1 said when someone moved the coffee fell over into his lap. Resident #1 was unable to state who moved causing the coffee to fall over. Resident #1 said he felt pain rated 9/10 on a 0/10 scale from the coffee burn. Resident #1 said staff acted immediately to assist him and applied ice to the burns which was effective at relieving some of the pain. Resident #1 said the burns do not hurt him unless staff were doing wound care, then the pain would be up to 5/10, which he said was okay. Resident #1 said there was no lid on his coffee cup when it spilled, but there were always lids on the coffee cups now. During an observation on 6/1/26 at 10:15 a.m., LVN B completed wound care for Resident #1. Resident #1's skin was observed and an open wound was noted to his right inner thigh along with redness. Discoloration was noted to his left inner thigh, but no redness or blisters. LVN B completed wound care following provided wound care orders of applying alginate calcium once daily and covering with gauze island with border dressing. During an interview on 6/1/26 at 10:15 a.m., LVN B said she was the treatment nurse and she completed an initial wound assessment of Resident #1 after he was burned. LVN B said Resident #1 had redness to both inner thighs and two fluid-filled blisters, one on each thigh. LVN B said the blister had resolved on the resident's left thigh and redness had mostly resolved, only discoloration remained. LVN B said Resident #1 had a nickel sized blister on his right thigh the previous day, but it must have ruptured overnight, because it was now an open wound. LVN B said Resident #1 generally did not complain of pain during his wound care, but he did receive scheduled pain medication. LVN B said Resident #1's left thigh was healed and as of 6/1/26 the most recent wound orders were performed. Record review of Resident #1's wound care physician's orders, dated 6/1/26, indicated for burn wound of the right thigh, add alginate calcium once daily and discontinue silver sulfadiazine 1%. Continue with gauze island with border dressing. During an interview on 6/1/26 at 3:13 p.m., the ADM said immediately following the incident she asked the HS to take the temperature of the coffee. The ADM said the HS went into the kitchen and retrieved the thermometer and checked the temperature of the coffee and it was 106 degrees. The ADM said she then interviewed Dietary Aide D and Dietary Aide D said she did not check the temperature of the coffee prior to serving it to residents on that day. The ADM said Dietary Aide D told her she checked the coffee temperature immediately after the resident was burned and it was 160 degrees. The ADM said Dietary Aide D wrote the 160-degree temperature down on the temperature checking log. The ADM said Dietary Aide D said she added ice to the coffee to cool it down resulting in the lower 106-degree temperature when checked by the HS. The ADM said Dietary Aide D was able to verbalize all steps that should have been taken to check the temperature of the coffee prior to serving but failed to do so. The ADM said Dietary Aide D said she did not check the temperature of the coffee before serving it to residents because she was not the one who brewed the coffee. The ADM said Dietary Aide D was terminated as a result of the incident and all other staff received in-service training. Interviews were attempted with Dietary Aide D on 6/1/26 at 1:22 p.m., 2:28 p.m., and 3:46 p.m. Voice mail was left requesting a return call but no call was received. During an interview on 6/1/26 at 4:03 p.m., the HS said on 6/1/26, after Resident #1 was burned by coffee, he went into the kitchen to check the temperature of the coffee. The HS said Dietary Aide D reported the temperature was 106 degrees. The HS said he checked the temperature of the coffee in the dispenser and noted it to be 106 degrees. The HS said he reported his findings directly to the ADM and did not interview any kitchen staff members. Record review of coffee temperature log, dated 5/22/26 and filled out by Dietary Aide D, indicated coffee the temperature was 160 degrees when served. Record review of an undated facility policy titled, Guidelines on Serving Coffee in the Nursing Facility, indicated: .The standard for coffee service will be 140 degrees, unless the facility's residents have stated an overwhelming preference for coffee to be served at a higher temperature and additional safety measures have been implemented . It was determined these failures resulted in Resident #1 being harmed on 5/22/2026. Facility took the following actions to correct the non-compliance: Record review of AD Hoc QAPI meeting for coffee burns, dated ??, indicated all steps in protocol were taken and the MD was informed of the facility plan. Record review of Resident Response List, dated 6/1/26, indicated hot liquid assessments were conducted on all residents who consumed hot liquids in the facility on 5/22/26. Record review of Resident #1's care plan, revision dated 5/22/26, indicated it was updated to include interventions for received burns and hot liquids. Interventions included coffee and other hot liquids should not be served if over 140 degrees, if hot liquid was spilled on self, staff should pour room temperature or lower temp liquid on the affected area of the resident, and Resident #1 was to use a cup with a lid. Record review of coffee temperature logs, dated 01/01/2026 to 06/02/2026, indicated no other instances of coffee being served above the 140 degree limit. Record review of Coffee Temperature Monitoring logs, dated5/22/26 to 6/2/26, indicated the DM would, at least 5 days per week, ensure dietary staff were logging coffee temperatures prior to making accessible to residents and that the temperatures were 140 degrees or less. All monitoring checks were conducted. Record review of Coffee Temperature Monitoring logs, dated 5/22/26 to 6/2/26, indicated the DM would, at least 5 times per week, ensure any dietary initiated interventions for those at risk for hot liquids were in place as care planned. All checks were completed and care plans were being followed. Record review of Coffee Temperature Monitoring logs, dated 5/22/26 to 6/2/26, indicated the DON would, at least 5 times per week, ensure any nursing initiated interventions for those at risk for hot liquids are in place as care planned. All checks were completed and care plans were being followed. Record review of Coffee Temperature Monitoring logs, dated 5/22/26 to 6/2/26, indicated the DM or DON would ask at least 10 staff per week what temperature coffee and other hot liquids should be prior to making accessible or serving to residents. All checks were completed with appropriate staff responses. Record review of an Employee Disciplinary Report, dated 5/22/26 to 6/2/26, indicated Dietary Aide D was terminated on 5/22/26 for reason .[Dietary Aide D] failed to meet their job duty/responsibility expectations. On 05/22/2026 it was found that [Dietary Aide D] failed to ensure that the required temperature was accurate to serve residents, resulting in an injury to a resident. During interviews and observation on 6/1/26 date at 11:15 a.m. through 11:50 a.m. time with kitchen staff members DM, [NAME] Aid E, Dishwasher F indicated all staff knew the proper procedure for checking coffee temperatures, logging the temperature on the temperature log sheet, and to not serve coffee to residents if it was above 140 degrees. Observation of [NAME] Aide E reflected the ability to correctly calibrate the thermometer and check the temperature of the coffee. During an observation on date 6/1/26 of sampled temperatures of coffee dispensers in the facility in the dining room reflected coffee temperatures of 137 degrees at 9:50 a.m. and 115 degrees at 3:15 p.m. Sampled temperatures of a coffee dispenser in a separate bistro area at 3:09 p.m. reflected coffee temperature of 130.6 degrees. Record review of coffee temperature log, dated 6/1/26, indicated coffee had been served at appropriate temperatures below 140 degrees. During interviews on 6/1/26 date at 11:15 a.m. to 11:50 a.m. time with sampled residents Resident #2, #3, #4, #5 all indicated the coffee temperature had never been too hot. All residents interviewed indicated they would prefer the coffee to be hotter but were satisfied with the temperatures.

Based on interviews and record reviews the facility failed to ensure all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegations were made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility for 1 of 4 (Resident #3) residents reviewed for abuse.LVN B failed to report an allegation of verbal abuse from CNA A involving Resident #3 to the Administrator immediately but no later than 2 hours on 5/1/2026.This failure could place residents at risk of abuse.Findings included:Record review of an admission Record for Resident #3 dated 5/11/2026 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of neurocognitive disorder with Lewy bodies (a progressive brain disorder leading to a decline in cognition, movement and behavioral changes) major depressive disorder (a persistent sadness or loss of interest in doing things) and Parkinsonism (a term used to describe slowed movements, stiffness, tremors and balance issues).Record review of a care plan for Resident #3 dated 5/4/2026 indicated he had a history of trauma that may have a negative impact related to alleged verbal abuse received by staff. Interventions included to monitor for escalating anxiety, depression or suicidal thoughts and report immediately to the nurse.Record review of a Quarterly MDS Assessment for Resident #3 dated 2/26/2026 indicated he was unable to complete the interview with a score of 99. He was dependent on staff for all ADLs.Record review of a care plan for Resident #3 dated 2/25/2026 indicated he had impaired cognitive function/dementia or impaired thought processes. Interventions included to communicate with the residents, family/caregivers regarding resident's capabilities and needs.Record review of a PIR dated 5/3/2026 indicated a report was sent to the state agency with an allegation of Abuse from an incident that occurred on 5/1/2026 involving Resident #3. LVN B stated she heard CNA A say to Resident #3 you better be glad that didn't hit me or I would've slit your throat. The incident occurred on 5/1/2026 but staff did not report to the Administrator until 5/3/2026.During an observation and interview on 5/3/2026 at 10:09 am, Resident #3 was sitting in a specialized chair asleep with CNA A present. CNA A said Resident #3 did not really speak and he did not wake up when Surveyor called his name.During an interview on 5/3/2026 at 10:11 am, CNA A was sitting in the tv room by Resident #3 in a chair. She said she had been employed at the facility for 18 years. She said when Resident #3 was alert he never said much. She said he ate a mechanical soft diet and had to be fed all of his meals. She said sometimes when staff fed him, he would spit out his food. She said last Friday (5/1/2026) she informed RN C that he spit out his tea during the evening meal and RN C told her to give him something else to drink. She said the Administrator called her that Sunday (5/3/2026) along with the DON who was on the phone that an incident occurred when someone said that she would cut Resident #3's throat. She said she did not say that. She said the tv was loud and RN C was right behind her by a medication cart. She said Resident #3 never spit at her and spit in a different direction.During an interview on 5/3/2026 at 10:37 am, RN C said she had been employed at the facility since 2023. She said she worked on 5/1/2026 along with CNA A. She said she overheard CNA A say that Resident #3 did not want any food, and she asked CNA A if Resident #3 would take a shake. She said CNA A replied back that he had spit it out. She said CNA A was sitting by Resident #3 the entire time and he spit his food out in front of him and not at CNA A. She said she did not hear the entire interaction but was told Resident #3 spit out his food. She said she was contacted by the DON to provide a statement after the incident.During an interview on 5/11/2026 at 11:29 am, LVN B said she worked part time at the facility since February 2026 but had been employed since September 2025. She said on 5/1/2026 she arrived at work at the facility at about 5:45 pm for her shift and had just counted the medication cart with RN C. She said it was loud on that evening and all of a sudden, she heard some yelling in the dining area. She said CNA A was giving Resident #3 some orange juice and he had spit it out. She said she did not see Resident #3 spit it out but did see the orange juice on the floor. She said she heard CNA A say, you better be glad that did not hit me, or I would have slit your throat. She said she did not do anything at that point. She said CNA A was upset about the schedule and she asked another staff member if what she had heard was something she needed to report. She said it was reported to the DON a few days later. She said she thought CNA A made the statement because she was stressed about the schedule. She said CNA A was a great staff member and felt like it was said out of anger and her mood but did not think she would ever harm anyone. She said if she witnessed any abuse/neglect she would report it immediately to the Administrator/DON and verbalized the abuse coordinator was the Administrator. She said she was now aware that any incident of abuse must be reported immediately to the DON/Administrator and by not reporting in a timely manner residents could be at risk for further abuse that was unseen. She said in her mind CNA A was a good nurse aide and thought what CNA A said she did not mean it, and then when one of the night nurses said she needed to report it they did.During an interview on 5/11/2026 at 12:48 pm, the DON said she had been employed at the facility for 2 1/2 months. She said she spoke to LVN B on 5/3/2026 following the incident on 5/1/2026 who stated she overheard CNA A while she was passing medications say something like Resident #3 spit on the floor and CNA A said if it hit her, she would have slit Resident #3's throat. She said LVN B stated the incident happened on 5/1/2026 and immediately educated LVN B on the importance of reporting timely for any allegations of abuse. She said there could be risk of abuse going undetected and other residents could be affected if not reported timely. She said the abuse should be reported immediately to the Administrator and then down the chain. She said CNA A was suspended pending the investigation.During an interview on 5/11/2026 at 1:02 pm, the Administrator said she had been at the facility for 3 years. She said she was the abuse coordinator for the facility and was responsible for reporting incidents to the state agency. She said she received a text message from the DON on 5/3/2026 that LVN B informed her that she heard CNA A verbally abuse Resident #3 after he spit out his juice. She said the incident occurred on 5/1/2026 but she was not notified until 5/3/2026. She said the staff were aware they should have reported it to her immediately and have since been retrained. She said during her investigation the only staff that heard CNA A verbally abuse Resident #3 was LVN B. She said RN C was directly behind CNA A and Resident #3 at the time of the incident and denied CNA A saying that. She said if no one reported abuse timely then the abuse could continue.Record review of a facility policy titled Abuse/Neglect undated indicated, .The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. 3. Verbal abuse: examples include but are not limited to threats of harm; E. Reporting: 1. Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse must report this to the DON/Administrator. State law mandates that citizens report all suspected cases of abuse. 2. When a suspected abuse or potential victim comes to the attention of any employee, that employee will make an immediate verbal report to the Abuse Preventionist or designee. If the discovery occurs outside of normal business hours, the Abuse Preventionist and/or designee will be called. A. If the allegations involve abuse or result in bodily injury, the report is to be made withing 2 hours of the allegation.

Based on observation, interview, and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs for 1 of 5 residents (Resident # 63), and 5 of 5 medication carts (LVN Cart N#100/200, LVN Cart N#200/300, LVN Cart S#400, RN Cart S#500, and LVN Cart S#600), reviewed for pharmacy services. *LVN D failed to use the proper technique for administration of eye drops for Resident #63 on 4/28/2026. *LVN E signed the controlled substance count sheets for the end of their shift at the beginning of their shift on LVN Cart N#100/200 on 04/29/2026. *LVN D signed the controlled substance count sheets for the end of their shift at the beginning of their shift on LVN Cart N#200/300 on 04/29/2026. *LVN A did not sign the controlled substance count sheets at the beginning of their shift on LVN Cart S#400 on 04/29/2026. *RN C signed the controlled substance count sheets for the end of their shift at the beginning of their shift on RN Cart S#500 on 04/29/2026. *LVN B did not sign the controlled substance count sheets at the beginning of their shift on LVN Cart S#600 on 04/29/2026. These failures had the potential to place residents at risk for not receiving the intended therapeutic effect of prescribed medications, ineffective treatment, administration of medications that are no longer safe or effective, and inaccurate medication control practices, which could lead to potential resident harm. Findings included: Resident (#63), named in the allegation, was a 74- year-old female who admitted to the facility on [DATE]. She had diagnoses which included Chronic obstructive pulmonary disease, depressive disorder, dysphagia (difficulty swallowing), hypothyroidism, hypertension, chronic viral hepatitis C, contracture left hand, cognitive communication deficit, failure to thrive, and myalgia (muscle pain or aches). According to a Minimum Data Set (MDS) dated [DATE] she had a BIMS score of 15 indicated cognitive function intact.A review of physician orders dated 04/29/2026 indicated Artificial Tears Ophthalmic Solution 1.4 % (polyvinyl phone alcohol) instill 1 drop in both eyes three times a day for dry eyes start date 04/08/2024. 1.Observation on 4/28/2026 at 10:10 a.m., revealed during a medication pass observation, the surveyor observed LVN D administer eye drops to Resident #63. LVN D assembled the required equipment and followed general aseptic technique (creating a designated area free from microorganisms). However, LVN D failed to use the proper technique for administration of eye drops. Specifically, LVN D did not don (to put on) gloves, did not gently pull the resident's lower eyelid down to create a conjunctival pocket (a small pocket), and did not instruct the resident to look upward during installation of the eye drops. During an interview on 4/28/2026 at 10:30 a.m., LVN D said she had been trained in the proper administration and care of eye drops, and further said improper administration may reduce medication effectiveness. LVN D stated the correct technique included maintaining aseptic technique, don (to put on) gloves, instructing the residents to look upward toward the top of their head, and gently lowering the lower eyelid to create a conjunctival sac to ensure the eye drop is properly instilled. During an interview on 4/28/2026 at 11:40 a.m., the Director of Nursing (DON) stated that nursing staff were trained in the proper administration of eye drops, including the facility guidelines and procedural steps. After reviewing the facility policy and professional standards of practice, the DON acknowledged that steps of the procedure were not followed during the observed medication administrations. The DON said she was responsible for training and monitoring staff to ensure medication is administered correctly and that all protocols are followed, she further said that all nursing staff would be re-in-serviced on the proper technique for the administration of eye drops. A record review of the facility policy on Instillation of Eye Drops (PCU037-Eye Application of eyedrops/ointments) dated 3/2025 indicated. # 2 Steps in the Procedure: Wash hands, don (to put on) gloves, Use aseptic technique.Application of Eye Drops/Ointments:Gently pull the lower eyelid down. Retract lower lid (Make a pocket). Instruct the resident to look up.Drop the medication into the mid lower eyelid fornix (Conjunctival fornix is the loose, folded, pocket-like tissue joining the inner eyelid to the eyeball surface).Do not allow the eye drop to fall onto the eyeball. 2. During an observation on 4/29/2026 at 9:35 AM. RN C signed the controlled substance count sheets for both the oncoming and off-going shift count at the beginning of the shift on RN Cart S#500 on 04/29/2026 a 6am to 6pm shift. During an observation on 4/29/2026 at 9:38 AM.LVN D signed the controlled substance count sheets for both the oncoming and off going shift count at the beginning of the shift on LVN Cart N#200/300 on 04/29/2026 a 6am to 6pm shift. During an observation on 4/29/2026 at 9:40 AM.LVN E signed the controlled substance count sheets for the oncoming and off going shift count at the beginning of the shift on LVN Cart N#100/200 on 04/29/2026 a 6am to 6pm shift. During an observation on 4/29/2026 at 9:43 AM.LVN A did not signed the controlled substance count sheet at the beginning of her shift on LVN Cart S#400 on 04/29/2026 a 6am to 6pm shift. During an observation on 4/29/2026 at 9:44 AM. LVN B did not sign the controlled substance count sheets at the beginning of their shifts. On LVN Cart S#600 on 04/29/2026 a 6am to 6pm shift. During an interview on 04/29/2026 at 09:45 AM., with RN C, she stated she was aware that the off going controlled substance count documentation should not be signed until the end of her shift. She said this practice may result in inaccurate medication counts, and failure to identify discrepancies. During an interview on 04/29/2026 at 09:47 AM., with LVN D, she said nurses should not sign the narcotic count sheet for the off-going shift until the end of the correct narcotic count. She said signing the controlled substance count documentation ahead of time creates a risk that the actual narcotic count was not verified at the time of shift change. During an interview on 04/29/2026 at 09:50 AM., with LVN E, said she was aware that nurses should not sign the narcotic count sheet for the off-going shift until the end of narcotic count, or they were leaving their shift. She further said this practice could delay detection of missing controlled substances. During an interview on 04/29/2026 at 09:55 AM., with LVN A, she stated she was aware that nurses should sign the narcotic count sheet in agreement with the off-going shift after completion of the narcotic count. She said forgetting to sign the controlled substances count at shift change could create the potential for inaccurate narcotic accountability. During an interview on 04/29/2026 at 09:59 AM., with LVN B, she stated she was aware that the narcotic count sheet should be signed after each medication counted agreed with the quantity stated on the controlled count record. She said the controlled substance count was completed with the off going nurse but forgot to sign the substance-controlled sheet. She said this practice could create the potential for inaccurate narcotic accountability. Durning an Interview on 04/29/2026 at 12:00 PM., with the DON, she stated nurses should only sign and acknowledge the controlled drug count after verifying the medications on hand and confirmed the quantity of each medication matched the quantity documented on the controlled drug count record. She further stated she was not aware staffs nurses were not signing the count sheets at the correct times, and it was the DON responsibility to monitor the nurses. The DON said controlled medication accountability records and audits record are kept on the medication cart. When completed, audit and accountability records are submitted to the DON and kept on file. A record review of the facility's sign on/off sheet on 04/29/2026 at 12:30 PM., indicated signing below acknowledges that you have counted the controlled drugs on hand and have found that the quantity of each medication counted were in agreement with the quantity stated on the Controlled Drug-Count Record. A record review of the facility's policy and procedure document titled Controlled Medications-Administration, dated 3/2025 indicated all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II -V of the comprehensive Drug Abuse and Control Act of 1976) revised November 2022.#8. Nursing staff coming on duty and nurses going off duty make the count together and document and report any discrepancies to the director of nursing services.

Based on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 1 of 4 residents (Resident #92) reviewed for care plans. The facility failed to ensure Resident #92 had a baseline care plan that included interventions to address his admission diagnoses and physician orders within 48 hours of admission. This failure could place newly admitted residents at risk of receiving inadequate care and services.Findings included: A record review of a face sheet dated 04/28/2026 indicated Resident #92 was an [AGE] year-old male who admitted to the facility on [DATE]. He had diagnoses which included pneumonia (infection of the lungs), chronic congestive heart failure (known as CHF, a chronic, progressive condition where the heart cannot pump blood efficiently causing fatigue, swelling, and shortness of breath), chronic kidney disease (kidney damage leading to causing the kidneys to work less efficiently), chronic obstructive pulmonary disease (known as COPD, a progressive, incurable lung disease that causes obstructed air flow , making it difficult to breathe), malignant neoplasm of the prostate (cancer of the prostate), osteoarthritis (a degenerative joint disease leading to pain, stiffness, and reduced mobility), and weakness. A review of the physician's orders dated 02/06/2026 indicated Resident #92 had allergies to aluminum hydroxide, calcium carbonate, cefdinir, magnesium carbonate, magnesium hydroxide, and Protonix. A record review of an admission MDS dated [DATE] indicated Resident #92 had a BIMS score of 00 which indicated he had difficulties with short-term memory, orientation, and attention and required extensive assistance with most of his activities of daily living. A review of the medical records indicated Resident #92 did not have a baseline care plan. A review of the progress notes dated 02/14/2026 indicated Resident #92 discharged from the facility on 02/14/2026. During an interview with the DON on 04/28/2024 at 01:45 PM, she said a 48-hour care plan should have been completed when the charge nurse admitted Resident #92. She said the completion of the Nursing admission Assessment was designed to identify any assessment findings of concern and trigger them for the baseline care plan. The DON said Resident #92's Baseline care Plan was not completed because the Nursing admission Assessment was incomplete. The DON said she was new to the facility and was not sure who was responsible for ensuring the Baseline Care Plans were completed. She said the purpose of the Baseline Care Plan was to provide directions for caring for a resident and without it, a resident could be at risk for not receiving the care and services he or she requires. A record review of the facility's undated Baseline Care Plan policy indicated the following: Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission.The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. 1. The baseline care plan will:a. Be developed within 48 hours of a resident's admission. b. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to:i. Initial goals based on admission orders. ii. Physician orders. iii. Dietary orders.iv. Therapy services. v. PASARR recommendation, if applicable .

Based on observation, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored securely for one of six halls (Hall 400) reviewed for storage of medications. The facility failed to ensure all drugs and biologicals were securely stored when LVN A took possession of hydrocodone-acetaminophen tablets and kept them for approximately 2 hours while charting. This failure placed residents at risk for drug diversion and consuming non-prescribed medication.Findings included: 1. Record review of Resident #1's face-sheet revealed an [AGE] year-old male, initially admitted to facility on 10/17/23, and readmitted on [DATE]. Resident's diagnosis included: Type 2 Diabetes, senile degeneration of brain (age-related cognitive decline), and unspecified dementia (altered cognition). Record review of a facility Controlled Substance Report indicated Resident #1 was ordered hydrocodone-acetaminophen 5-325 mg 1 tablet by mouth every 8 hours as needed for pain with a last fill date 1/15/2026 for a 30-day supply (90 tablets). The next fill date was indicated to be 2/10/2026. Record review of a statement dated 2/10/26 written by LVN A indicated .At approximately 3:00pm I was handed 45 pills of hydrocodone for a resident. I set card down beside me and continued to chart for 2 more hours when I got distracted and answered to a resident's needs without securing narcotics and when I returned medication card was missing. I searched all med carts, med rooms, supply closets and treatment cart. I was unable to locate medication. Immediately notified ADON and administrator. Record review of Resident #1's progress note dated 2/19/26 at 4:56 p.m. indicated Resident #1 had orders for Hydrocodone-Acetaminophen oral tablets every 8 hours as needed for moderate-severe pain. Record review of the narcotic administration log indicated Resident #1 received hydrocodone-acetaminophen on 2/10/26 at 7:30 a.m. and had 30 tablets remaining. During an interview and observation on 2/24/26 at 10:00 a.m., Resident #1 was sitting in a wheelchair in a common area watching television. Resident #1 appeared calm and in no acute distress. There was no facial grimacing, or observable signs of physical distress were noted. Resident #1 said he took medication for pain, as needed. Resident #1 said his medication was always available when he asked for it, and it was effective at controlling his pain level. During an interview on 2/24/26 at 11:35 a.m., LVN B said she worked on 2/10/26, the day the hydrocodone-acetaminophen tablets went missing. LVN B said she saw LVN A take delivery of the medications, but she did not see if she locked the medication up or not. LVN B said she didn't see the medication lying out in the open. LVN B said she did not note any residents standing near the nurse's station or reaching over nurse's station counter during the timeframe. LVN B said she assisted in searching for the medication but was unable to locate it. During an interview on 2/24/26 at 2:05 p.m., LVN C said she worked 2/10/26; the day the hydrocodone-acetaminophen tablets went missing. LVN C said she saw LVN A take delivery of the medication but did not know she didn't lock it up in the med cart. LVN C said she didn't see the medication lying out in the open at any point. LVN C said she was out of the facility on break when the medication went missing. During an interview on 2/24/26 at 2:15 p.m., LVN A said on 2/10/26 at approximately 3:00 p.m., she received hydrocodone tablets for Resident #1 from the pharmacy. LVN A said after another nurse signed with her to receive the medication, instead of locking the medication in the medication cart, she placed it on the desk in front of her computer and began charting for approximately 2 hours. LVN A said she should have immediately locked the medication away. LVN A said she got up to assist another resident and forgot about the medication. LVN A said when she returned to the nurse's station, the medication was gone. LVN A said she searched for the missing medication and alerted the DON and ADM immediately. LVN A said staff were unable to locate the medication. LVN A said Resident #1 had ample supply of the medication on hand and did not miss any doses. LVN A said she completed a pain assessment on Resident #1 post-incident and noted no pain. LVN A said the facility interviewed all staff working on the unit at the time, assessed all residents taking similar medications, audited the narcotic administration log, and thoroughly searched all areas in and around the nurse's station. During an interview on 2/24/26 at 2:30 p.m., the DON said she had only worked at the facility for 6 days and was aware of the allegation but had no direct knowledge. The DON said she was responsible for supervision of the nursing staff, and her expectation was for controlled medications to be immediately locked up for safe keeping when received. The DON said risks to residents for unsecured medication could be a resident consumed a medication they were not prescribed. During an interview on 2/24/26 at 2:45 p.m., the ADM said she was notified of the missing medication immediately after it went missing. The ADM said she went to the unit and assisted in searching for the medication but was unable to locate it. The ADM said all staff working the unit were interviewed and all nurses working the South halls were drug-tested with no positive results. The ADM said all controlled medication logs were audited and all residents who took similar medications received assessments. The ADM said Resident #1 had a sufficient supply of medication on the med cart and no missed doses occurred. Record review of facility policy Controlled Medication - Ordering & Receipt dated 2025 indicated .Medications listed in Schedule II, are stored under double lock in a locked cabinet or safe designed for that purpose, separate from all other medications.

Based on observations, interviews, and record reviews, 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 1 of 4 residents (Resident #1) reviewed for infection control. The facility failed to ensure CNA A and LVN B followed enhanced barrier precautions and wore a gown and gloves when providing incontinent care to Resident #1 on 11/10/2025. This failure could place residents at risk for cross contamination and infection. Findings included: Record review of Resident # 1's facility face sheet revealed Resident #1 was a [AGE] year-old female and admitted on [DATE] with diagnosis of encounter for gastrostomy (a tube placed in the stomach to assist with feeding). Record review of Resident 1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 12 indicating intact cognition, relied on staff for all ADL's, was incontinent of bowel and bladder, and required a feeding tube. Record review of Resident #1's comprehensive care plan dated 10/08/2025 revealed Resident #1 required a feeding tube, but did not address EBP.Record review of Resident #1's consolidated orders revealed Resident #1 did not have an order for EBP.During an observation on 11/10/2025 at 10:03 am, LVN B and CNA A entered Resident #1's room to reposition her and provide incontinent care. During care, it was observed that the resident had a feeding tube. Neither LVN B nor CNA A had applied PPE before providing care to Resident #1 who had a feeding tube in place. There was no sign on Resident #1's door indicating EBP was required. During an interview on 10/11/2025 at 10:19 am, CNA A said that if a resident needed EBP, there would be a sign on the door and PPE outside the door. She said she provided care to Resident #1, and she did have a feeding tube and should be on EBP. She said she failed to put on PPE when she and the nurse gave care and by doing so infections could spread. During an interview on 10/11/2025 at 10:25 am, LVN B said that any resident that had a wound, feeding tube, or device like an intravenous catheter should be on EBP. She said she was not sure why Resident #1 did not have a sign and PPE outside her room, and she had forgotten when she and CNA A provided care. She said when residents were on EBP a gown and gloves must be worn with direct contact patient care. She said the ADON and the DON were responsible for putting out the signs and PPE, but she should have known. She said by not following EBP infections could spread.During an interview on 11/10/2025 at 10:31 am, the DON said she was the infection prevention nurse and she and the ADON were responsible for ensuring the residents that required EBP that those measures were in place. She said she overseen the staff to ensure they were following the program and Resident #1 had moved rooms and they failed to ensure the EBP sign, and PPE followed her. She said she expected that all staff followed the EBP program for all residents to prevent the spread of infections.During an interview on 11/10/2025 at 4:17 pm, the Administrator said the DON was responsible for the infection control and EBP program in the facility. She said there were clinical meetings every morning and EBP was discussed. She said the staff were notified verbally and there was a sign posted on the door as well to indicate EBP. She said she expected all staff to always follow the EBP program and if they were unsure, they needed to ask. She said if staff were not following EBP infections could happen. Record review of the facility's policy titled Enhanced Barrier Precautions dated 4/01/2024 indicated, .Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. A peripheral intravenous line (not a peripherally inserted central catheter) is not considered an indwelling medical device for the purpose of EBP. EBP are used in conjunction with standard precautions and 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.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 1 of 8 residents (Resident #1) reviewed for care plans. The facility failed to develop a comprehensive care plan that included Resident #1's enhanced barrier precautions related to her feeding tube.This failure could place residents at risk of not having individual needs met and cause residents not to receive needed services.Findings included:Record review of Resident # 1's facility face sheet revealed Resident #1 was a [AGE] year-old female and admitted on [DATE] with diagnosis of encounter for gastrostomy (a tube placed in the stomach to assist with feeding). Record review of Resident 1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 12 indicating intact cognition, relied on staff for all ADL's, was incontinent of bowel and bladder, and required a feeding tube. Record review of Resident #1's comprehensive care plan dated 10/08/2025 revealed Resident #1 required a feeding tube but did not address EBP.Record review of Resident #1's consolidated orders revealed Resident #1 did not have an order for EBP.During an interview on 11/10/2025 at 2:47 pm, the MDS said she was responsible for completing MDS assessments and the comprehensive care plan. She said, with Resident #1, she admitted to the facility with a feeding tube and her comprehensive care plan should have reflected that EBP was required. She said that a comprehensive care plan should have all the resident care areas, interventions and goals. If a care plan was not completed thoroughly and accurately, the residents could have an adverse reaction or change in condition. During an interview on 11/10/2025 at 3:00 pm, the DON said the MDS nurse was responsible for completing the comprehensive care plan accurately and completely. She said that a resident requiring EBP should be care planned as such. She said there was a regional nurse that oversaw the care plans, and they had a plan to start a care plan review to audit all care plans in the facility. She said an incomplete care plan could affect resident care. During an interview on 11/10/2025 at 4:12 pm, the Regional Reimbursement Nurse said that she was responsible for oversight of the care plans, and she had recognized an issue with the care plans last week. She said she had discussed her findings with the team today about a plan to correct them but had not gotten that plan in place. She said inaccurate care plans could result in a lapse of care. During an interview on 11/10/2025 at 4:17 pm, the Administrator said the DON was responsible for the oversight of the care plans, but ultimately fell on her. She said the regional reimbursement nurse came weekly as well and had identified an issue with the care plans last week, but they had not yet put a plan in place to correct the issue. She said they were looking to start an audit today. She said she expected all comprehensive care plans to be completed accurately and thoroughly to prevent delays in resident care. Record review of an undated facility policy titled Comprehensive Care Planning indicated, .The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.

Based on interview and record review, the facility failed to ensure residents were informed of how to file a grievance for 8 of 8 confidential interviews reviewed for grievances. Residents were not informed of their right to file a grievance during their stay in the facility. This failure could place residents at risk of a decreased quality of life, decreased awareness of their rights and decreased execution of their rights. Findings included: During a record review of resident council meeting minutes from the past four months (January 2025, December 2024, November 2024 and October 2024) they revealed a grievance form had not been explained to them or how to use the form. During a confidential interview on 02/04/2025 at 10:00 AM , eight confidential interviewees said they did not know how to file a grievance. They said the Activity Director, or the Social Worker had never reviewed or explained a grievance form with them. During an interview on 02/04/2025 at 11:10 AM, the Activity Director said she does not do handle grievances. She said the Social Worker handle grievances; she has never explained grievances or the grievance form to the residents. During an interview and observation on 02/04/2025 at 11:19 AM, the Social Worker said she explains the grievance form to residents when they have an issue. She said she has never explained the grievance form to the residents, of the resident council. She said she completes the form and forwards the completed form to the Administrator, who is the Grievance Officer. When ask if residents could complete a grievance form by themself and if they knew where to get a grievance form, the Social Worker said yes, and forms were kept at both nurse's station and in the Administrator's office. When the Social Worker checked both nurse's station, in the presence of this surveyor, she could not locate any grievances forms, at either nurse station. When the Social Worker inquired with the Administrator, the Administrator was not able to locate a grievance form. The Administrator said she had reviewed the grievance form with the residents at the resident council meeting, in October 2024. It took the Administrator more than 5 minutes before she produced a blank grievance form. Review of the Resident Council Meeting signature log, for October 2024, revealed the Administrator's signature was not indicated on the signature log, as a staff member in attendance. Review of a document titled Resident and Family Grievances, with a revised date of 02/01/2025. Policy Explanation and Compliance Guidelines: . #6. Information on how to file a grievance or complaint will be available to the resident. #8. A grievance may be filed anonymously.

Based on observation, interview and record review the facility failed to ensure accurate assessments were completed for 2 of 10 residents (Resident #17and Resident #54) reviewed for accuracy of assessments. The facility failed to ensure Resident #17's quarterly MDS assessment dated [DATE] was not inaccurately coded for restraint use. The facility failed to ensure Residents #54's admission MDS assessment dated [DATE] was accurately coded for Preadmission Screening and Resident Review (PASRR). These failures could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. Findings included: 1.A record review of Resident #17's face sheet dated 02/12025 indicated she was a [AGE] year-old female who admitted to the facility on [DATE]. She had diagnoses which included chronic obstructive pulmonary disorder (a group of lung diseases that cause airflow obstruction and breathing problems), congestive heart failure (condition where the heart muscle is weakened and cannot pump blood effectively, leading to fluid build-up in the lungs), low back pain, and anxiety. A record review of Resident #17's quarterly MDS dated [DATE] indicated she had a BIMS score of 14 which indicated her cognition was intact and she was able to answer questions. The same MDS indicated Resident #17 had a limb restraint that was being used less than once daily. A record review of Resident #17's physician orders dated from 11/01/2024 to 02/05/2025 revealed there was no order for a restraint during this time. A record review of Resident #17's care plan dated 02/04/2025 did reveal any indication of restraints being used. An observation and interview on 02/03/2025 at 12:18 PM noted Resident #17 lying in bed. She was noted to be alert, oriented to person, place, and time. No restraint was visualized to be in use. During observation and interview on 02/03/2025 at 12:50 PM Resident #17was noted sitting in her recliner, eating lunch. Resident #17 said she was able to transfer herself from her bed to recliner and back. She said she could walk short distances without assistance but could not walk much due to shortness of breath. No restraint was observed to be in use. Resident #17 said she knew what a restraint was, gave examples of restraints, and said she had never had a restraint. An observation on 02/04/2025 at 09:12 AM noted Resident #17 sitting in her recliner in her room. No restraint was noted in use. Resident #17 said she had never had a restraint of any kind. During an interview with the LVN B on 02/04/2025 at 09:15 AM, she said Resident #17 had never had a restraint. During an interview on 02/04/2025 at 09:45 AM, the MDS Nurse said Resident #17 did not require a restraint. She said the facility was restraint free. When asked about the documentation of restraint use on the quarterly MDS dated [DATE], the MDS Nurse said it was a typo error. The MDS Nurse said the facility used the RAI Version 3.0 Manual as their guideline for completing the MDS accurately. During an interview with the DON on 02/04/2025 at 10:12 AM, she said the facility did not have any restraints is use. She said Resident #17 had never had a restraint and the MDS was coded incorrectly. She said she would get with the MDS nurse and address it. 2. A review of Resident #54's face sheet for February 2025 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included major depressive disorder, anxiety disorder, unspecified psychosis not due to a substance or known physiological condition, Dementia, and insomnia. A review of Resident #54's PASRR Level 1 screening dated 8/24/2020 indicated she was positive for MI. A review of Resident #54's PASRR Evaluation dated 10/16/2020 indicated she was positive for mental illness but did not meet the PASRR definition for mental illness for specialized services. A review of Resident #54's admission MDS dated [DATE] Section A1500. Preadmission Screening and Resident Review (PASRR) indicated No if resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Section I Active Diagnoses under Psychiatric/Mood Disorder indicated the resident had anxiety disorder, depression. During an interview on 02/05/2025 at 11:15 AM, the MDS Coordinator said the facility used the RAI Version 3.0 Manual as the policy for completing MDS assessments. She said Section A 1500 indicated if the resident was positive for mental illness. She said she did not realize the Section I Active Diagnoses was related to Section A PASRR screening documentation. She said the local authority had found residents that did not qualify for PASRR services because they did not meet the PASRR definition for mental illness for specialized services and thought she had to answer no because they did not qualify for services. She said she did not know Section A had to be coded as positive for mental illness, intellectual disability, or developmental disability even though they did not qualify for PASRR services. During an interview on 02/05/2025 at 1:15 PM the DON said she thought the local authority made the determination whether the resident was positive for a mental illness. She said she thought that indicated they no longer had the mental illness instead of meeting the PASRR definition for mental illness for specialized services. She said it was very confusing since the RAI was not clear. She said the RAI manual was used to ascertain accuracy of the MDS, and she would check with her corporate MDS. A review of the RAI Version 3.0 Manual indicated the following: SECTION P: RESTRAINTS Intent: The intent of this section is to record the frequency over the 7-day look-back period that the resident was restrained by any of the listed devices at any time during the day or night. Assessors will evaluate whether or not a device meets the definition of a physical restraint and code only the devices that meet the definition in the appropriate categories of Item P0100. . Proper interpretation of the physical restraint definition is necessary to understand if nursing homes are accurately assessing devices as physical restraints and meeting the federal requirement for restraint use (see Centers for Medicare & Medicaid Services. [2007, June 22] 41695

Based on observations, interviews, and record reviews, 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 1 of 5 residents (Residents #139) reviewed for Enhanced Barrier Precautions. LVN B failed to don (to put on) a gown prior to administering medications through Resident #139's PICC line (A peripherally inserted central catheter, a thin flexible tube inserted into a vein in the upper arm and threaded into a large vein near the heart. This failure could place residents under their care at risk for the transmission of communicable diseases and infections. Findings included: 1.Record review of a face sheet dated 02/05/2025 indicated Resident #139 was a [AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses which included Encephalopathy (a broad term for any brain disease that alters brain function or structure), Sepsis (a life-threatening condition that occurs when the body's immune system has an extreme response to an infection), pneumonia ( infection that inflames air sacs in one or both lungs, which may filled with fluid), acute cystitis ( an inflammation of the bladder, typically caused by a bacterial infection), hemiplegia ( a medical condition characterized by paralysis or weakness on one side of the body), and Type II Diabetes Mellitus. Record review of the quarterly MDS dated [DATE] noted Resident #139 had a BIMS score of 06 which indicated the resident was severely impaired. Record review of the Resident #139's physician orders indicated an order dated 02/01/2025 for Resident #139 to be given Cefazolin in Sodium Chloride Intravenous Solution 2-0.9 GM/100ml - % (Cefazolin sodium Chloride) Use 2 gram intravenously every 8 hours. Route: intravenous piggyback IVBP over 30min via PICC line. During an MED-PASS observation and interview on 02/04/2025 at 2:30 PM, LVN B, verified medication order, medication name, and expiration date on the medication, prepared her intravenous piggyback (IVPB) setup supplies, and the administering IVPB antibiotic (Abx) medication. She obtained the prescribed IVPB Abx., performed hand hygiene, sanitized her hands, and donned a pair of gloves. LVN B did not don the required PPE gown, that she was supposed to for the EBP. LVN B entered Resident # 139's room and informed Resident #139 she was going to administer her IVPB Abx. medication. LVN B performed the necessary premedication assessment, used an antiseptic alcohol wipe to cleanse the port of the main IV line and allowed it to dry, and assessed patency of the resident's IV site for signs of infiltration or inflammation. LVN B, ensured that all air had been removed, hung the IVPB Abx. medication connected to the IV pump, at the correct rate to infused over 30 minutes. After leaving the resident room and returning to the med. cart, LVN B was asked questions concerning Enhanced Barrier Precautions (EBP), she said, she did not don the appropriate PPE (a gown), because she did not think of a PICC line being under the category of a central line, and donning the appropriate PPE was important to reduce the risk of infection. There was no signage to indicate outside Resident #139's door to indicate EBP were necessary. There was no container with PPE in it outside Resident #139's room door. On 02/04/2025 at 03:20 PM, LVN C said, she understood what EBP stood for Enhanced Barrier Precaution, and it had to do with infection control. She said, EBP meant staffs were supposed to wear a mask, gown, and gloves when handling catheters and wounds. When surveyor asked LVN C to review the EBP sign on a Resident's door, LVN C read the sign aloud, saying that a gown and gloves were to be used during high-contact resident care activities. LVN C said, the staff had received in-services on infection control and EBP. On 02/05/2025 at 03:30 PM, DON said, she was the Infection Preventionist for the facility. She said, she expected the nurses to follow the facilities policies on infection control and prevention including the policies on EBP. She said, she expected the nurses, and the staff to follow the guidelines of EBPs to reduce the risk for transmission of infection. The DON said, the Charge Nurses reports' Enhanced Barrier Precaution patients to the CNAs, and venders providing direct care at beginning of shifts, and upon arrival daily. The DON said, the purpose of EBP was to reduce the risk of spreading infection. The DON said, LVN B should have donned a gown prior to handling Resident #139 PICC line and hanging the IVPB antibiotic. A record review of the facility's policy dated 04/1/2024 and titled Enhanced Barrier Precautions indicated the following: The policy of this facility is to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. The initiation of Enhanced Barrier Precautions will be obtained for residents with any of the following: Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers), and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes). A record review of the facility's policy dated 2001 MED-PASS, revised July 2014, title Policies and Practices- Infection Control indicated the following: The facility's infection control policies and practices are intended to facilitate, maintain a safe, sanitary, comfortable environment, help prevent, and manage transmission of diseases and infections. The objectives are to establish guidelines for implementing Isolation Precautions, availability and accessibility of supplies and equipment necessary for Standard and Transmission -Based Precautions.

Based on observations, interviews and record reviews, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 19 residents (Resident #42) reviewed for pharmacy services. LVN A failed to ensure Resident # 42's medications were secure and left physician ordered medications at the bedside. LVN A failed to ensure Resident #42 swallowed her medications. These failures could place residents at risk for not receiving the therapeutic effects of ordered medications and consuming medications that were not ordered for them. Findings include: Record review of Resident #42's quarterly MDS dated [DATE] reflected an [AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses which included hypertension (elevated blood pressure), stroke (damage to the brain from interruption of its blood supply), and history of urinary tract infection (infections that occur in any part of the urinary system) Resident #42 had a BIMS score of 10 which indicated her cognition was moderately impaired. Record review of Resident #42's physician orders dated January/2024 reflected Resident #42 had orders for medications to be administered at least once a day which included including cranberry supplement (for urinary health), potassium (to treat low potassium), calcium (osteoporosis), vitamin B12 (for malnutrition), vitamin D3 (bone health), Plavix (to prevent blood clots), Lasix (fluid overload), Remeron (appetite stimulant), and Mybertriq (to treat overactive bladder). Record review of Resident #42's Medication Administration Record for 01/22/2024 reflected LVN A had administered the medications ordered to be given between 06:00 AM-10:00 AM. Record review of Resident #42's physician orders dated January 2024 did not reflect an order for the resident to self-administer medications. Record review of Resident #42s medical records did not reflect an assessment of the resident's ability to self-administer medications safely was completed. Review of Resident #42's Care Plan for January 2024 did not reflect Resident #42 was to be allowed to self-administer her own medications. During an observation and interview on 01/22/2024 at 10:33 AM, Resident #42 was noted to be sitting in a wheelchair in her room with an over-the-bed table in front of her. No staff were in the room. Resident was alone. paper towel with 2 (two) small, white pills lying on it was noted on the table top along with a small plastic medication cup with 1 (one) large white capsule and 1 (one) large dark red capsule in it. Resident #42 picked up one of the small white pills and put it into her mouth. After taking a sip of water, Resident #42 picked up the second small white pill, placed it in her mouth and took a sip of water. Resident #42 could not identify what the 2 white pills were. She then pushed the plastic medication cup with the 2 capsules in it back on the table and said she wanted to trade one of the capsules. She could not identify the capsules. Resident #42 said some staff stayed with her until she took her medicine and some of the staff left her medications with her to take on her own. During observations at 10:47 AM, LVN A returned to Resident #42's room, picked up the plastic medication cup with the 2 capsules in it and asked resident #42 why she had not taken those medications. Resident #43 told the nurse that she did not like to take all her medications at the same time and was waiting a little while to take the white capsule. LVN A identified the white capsule as potassium and asked Resident if she would take it. Resident #42 then took the white capsule, placed it in her mouth, and took a sip of water. Resident #42 told LVN A she did not want to take the red capsule and that she wanted to trade it for a tablet of the same drug. Resident #42 told LVN A that she could swallow tablets easier than capsules. LVN said the red capsule was a cranberry supplement and she would check the resident's orders and get back with the resident. During an interview with LVN A on 01/22/2024 at 10:41 AM, she said she left Resident #42's medications on the over-the-bed table for the resident to take. LVN A said she was supposed to stay with the resident until she had taken all her medications. LVN A said the policy for administering medications was for the nurse to stay with the resident to ensure the medications are taken. LVN A did not respond to being asked if there was a reason for leaving the medications at bedside and not ensuring the resident took her medications. During an interview with LVN B on 01/22/2024 at 11:40 AM, she said the nurses were responsible for administering medications to residents. LVN B said nurses were required to stay with each resident until medications were taken and swallowed. During an interview with the DON on 01/22/2024 at 11:05 AM, she said she expected the nurses to stay with the residents when giving medications and ensure they took them. She said residents who did not take their medications were at risk for not receiving the intended therapeutic effect of their medications. She said residents could hoard their untaken medications and risk overdosing themselves and residents who wander may take unattended medications if left sitting out. Record review of the facility's general policy titled Administering Medications including the following: 24. 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. Record review of the facility's policy titled Administering Oral Medications indicated the following: Purpose The purpose of this procedure is to provide guidelines for the safe administration of oral medications. Steps in the Procedure: 21. Remain with the resident until all medications have been taken. Record review of the facility pharmacy's policy titled Specific Medication Administration Procedures reflected the following: Procedures F. Administer medication and remain with resident while medication is swallowed .Do not leave medications at bedside, unless specifically ordered by prescriber. 37495

Based on observation, interviews, and record review the facility failed to ensure, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 6 residents (Resident #70) reviewed for medication storage. The facility failed to ensure Resident #70's TUMS, an over-the-counter medication, was properly stored. This failure could place residents at risk for adverse reactions . Findings include: Record review of Resident #70's face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #70 had diagnoses which included vascular dementia (problems with reasoning, planning, judgment, and memory caused by lack of blood flow to the brain), cognitive communication deficit (difficulty with any aspect of communication due to an underlying cause), peripheral vascular disease (restricted blood flow to the arms, legs, or other body parts due to blood vessels), hypertension (high blood pressure), and myocardial infarction (Damage to the heart muscle caused by a loss of blood supply to the heart muscle due blockages in the arteries). Record review of the Quarterly MDS , dated 11/08/23, indicated Resident #70 had a BIMS score of 12, which indicated she was moderately impaired cognitively. Record review of the Order Summary Report, dated 1/24/24, indicated Resident #70 had an order for Calcium Carbonate Antacid Tablet Chewable 500 mg, give 1 tablet by mouth every 12 hours as needed for indigestion. Record review of a Medication Administration Record (MAR) for January 2024 indicated Calcium Carbonate Antacid Tablet Chewable 500 mg was not administered as needed to Resident #70. During an observation and interview on 1/22/24 at 11:34 a.m., Resident #70 was in her room sitting in her recliner. There was a half full bottle of TUMS (Calcium Carbonate Name Brand) chewable tablets sitting on top of her refrigerator. Resident #70 said she took medication as needed for indigestion and kept a bottle of TUMS on top of her refrigerator to take. Resident #70 said it had been a while since she last took one and she could not remember the last time she did . During an observation on 1/23/24 at 9:42 a.m., there was a half full bottle of TUMS (Calcium Carbonate Name Brand) chewable tablets in Resident #70's room sitting on top of her refrigerator. During an observation on 1/24/24 at 12:09 p.m., there was a half full bottle of TUMS (Calcium Carbonate Name Brand) chewable tablets in Resident #70's room sitting on top of her refrigerator. During an observation and interview on 1/24/24 at 12:09 p.m., LVN B said she was the nurse responsible for administering medications to Resident #70. LVN B said a resident needed a physician's order to administer a medication and to self-administer it. LVN B said all medications should be secured on the medication cart. LVN B said she was unaware Resident #70 had bottle of TUMS in her room. LVN B observed a bottle of TUMS (Calcium Carbonate Name Brand) chewable tablets sitting on top of Resident #70's refrigerator. LVN B said she had been Resident #70's charge nurse for the past three days and never saw the bottle of TUMS on her refrigerator. LVN B said Resident #70 did not have a physician's order to self-administer medications and the bottle should be taken out of her room. LVN B said if medications were not secured and administered by staff a resident was at risk for adverse reactions which could result in hospitalization . LVN B took the bottle of TUMS out of the room and secured it on the medication cart . During an interview on 1/24/24 at 12:23 p.m., the DON said in order for a resident to self-administer medications, a resident had to be evaluated before an order could be written. The DON said a resident needed to be alert, oriented, cognitive, educated, and demonstrate the ability to safely administer their medications to her or someone else on the interdisciplinary team. The DON said medications should be locked up between uses if a resident did not have an order to self-administer medications and expected the nursing staff to look for medications when they entered a resident's room. The DON said she was unaware Resident #70 had a bottle of TUMS in her room. The DON said Residents #70 was not evaluated and did not have an order to self-administer medications. The DON said if medications were not secured and administered by staff a resident was at risk for adverse reactions which could result in hospitalization . Record review of the facility's Self-Administration of Medications policy, revised on 12/2016, indicated Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medication is clinically appropriate for the resident . 8. Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer will be stored on a central medication cart or medication room . 9. Staff shall identify and give to the charge nurse any medications found at the bedside that are not authorized for self-administration Record review of the facility's Storage of Medications policy, revised on 04/2007, indicated Policy Statement. The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .2. The nursing staff shall be responsible for maintaining medication storage .7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use

Based on record review and interview the facility failed to ensure the arbitration agreement contained all the required elements for 1 of 20 residents reviewed for arbitration. (Resident #44) The facility did not ensure the arbitration agreement contained the required elements: *Failed to ensure the arbitration agreement was explained in a form and manner including a language the resident or representative understood *Failed to explain the right not to sign the agreement as a condition of admission. *Failed to provide the right to rescind in 30 calendar days of signing These failures could place the residents or the residents' responsible parties in binding agreements not fully understood, have a loss of their legal rights, and cause negative psychological issues. Findings included: Record review of a face sheet dated 12/01/22 indicated Resident #44 was a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of dementia, and cognitive communication deficit . The face sheet indicated Resident #44's daughter was her Responsible Party and emergency contact. Record review of an Admission MDS dated [DATE] indicated Resident #44 was Hispanic or Latino. The MDS indicated she usually was understood and usually understands. The MDS indicated she had severe cognitive impairment. Record review of the Comprehensive Care Plan dated 09/12/2022 and updated on 11/28/22 indicated Resident #44's primary language was Spanish. The intervention for this care plan need was to provide a translator as necessary to communicate with the resident. During an interview on 11/29/22 at 10:18 a.m., the Responsible Party stated Resident #44's Admission Agreement and Arbitration Agreement was signed by another family member . The Responsible Party stated she had asked the Admissions Specialist to provide her with a copy of the Admission Agreement and Arbitration Agreement due to the fact Resident #44 and her spouse neither completely understood English nor spoke English. Resident #44's Responsible Party stated she had not been given the opportunity read and review the forms prior to the signing by her parents. The Responsible Party indicated Resident #44 was not informed of what she was signing. Record review of undated Admission Agreement included: In Consideration of the mutual promises contained in this agreement, the parties agree as follows: l.1. Terms and Terminations: Patient/Resident agrees to reside in the Health Care Center. This agreement shall remain in effect until terminated by Patient/Resident in accordance with applicable law or terminated by the Health Care Center as provided in Article IV. lll. 1. Patient/Resident Responsibilities: Patient/Residents shall abide by the reasonable policies and rules of the Health Care Center which are included herein by reference. V.5. Complete Agreement: This Agreement, the Agreement Addendum (s), and the documents list on the Acknowledgement page attached to this Agreement and made a part hereof constitute the entire agreement between the parties. The Agreement may not be amended except in writing executed by the parties or the successors. VI. Arbitration: Pursuant to the Federal Arbitration Act, any action, dispute, claim or controversy of any kind (e.g., whether in agreement or in tort, statutory or common law, legal or equitable, or otherwise) now exists or hereafter arising between the parties in any way arising out of pertaining to or in connection with provision of health care services, any agreement between the parties, the provision f other goods or services by the Health Care Center or other transactions, agreements or agreements of any kind whatsoever, any part present or future incidents, omissions, acts, error, practices or occurrence causing injury to either party where by the other party or its agents, employees or representatives may be liable in whole or in part, or any other aspects of the past, present, or future relationships between the parties shall be resolved by binding arbitration administered by the National Arbitration Forum. The undersigned Acknowledge that each of them has read an understood this agreement, and that each of them voluntarily consents to all its terms. Review of the Arbitration agreement revealed inside of the Admission Agreement was only provided in English. The Arbitration Agreement was a portion of the Admission Agreement. The total agreement provided one signature line. The Agreement did not contain separated signature lines where a declination was possible without declining the Admission Agreement. The Admission Agreement with the Arbitration Agreement did not provide a timeframe of 30 days for declination from the Arbitration Agreement. The Admission Agreement with the Arbitration Agreement did not express the Arbitration Agreement would not affect admission to the facility. Record review of Resident #44's Admission Agreement: Dispute Resolution Plan page 16: It is hereby agreed and understood that any dispute, difference and /or disagreement of any kind whatsoever, whether statutory or contractual, which arises from the services and/or products provided or relating in any way to the general business relationship of the parties to this agreement, shall be, as the sole available remedy, resolved through mandatory mediation and/or binding arbitration, rather than litigation. The parties agree and acknowledge that the business relationship involves interstate commerce and that nay such mediation or arbitration shall be governed by the Federal Arbitration Act (FAA) and conducted in accordance with the Rules of Mediation and Arbitration as then in effect and administered by the Dispute Solutions, Inc. The cost of any arbitration hereunder, including the cost of the record or transcripts thereof, if any, administrative fees, attorney's fees and all other fees involved, shall be paid by the party determined by the arbitrator to be the prevailing party, or otherwise allocated in an equitable manner a determined by the arbitrator. Record review of the Dispute Resolution Plan revealed on page 64, The Federal Arbitration Act has been around since the 1920's and arbitration is widely used today to resolve problems. The Dispute Resolution Plan is required and the mandatory way for all residents and the Health Care Center to resolve any potential legal problems. During an interview on 11/28/22 at 3:00 p.m., the Admission Specialist stated she assisted Resident #44's spouse and generally all the responsible party/resident s with signing of the Admission Agreement and Arbitration Agreement. The Admission Specialist indicated the spouse was present in the facility therefore she asked him to sign the agreement. The Admission Specialist stated there had been only one family refuse to sign the Arbitration Agreement since 2020. The Admission Specialist stated there were no Arbitration Agreements in other languages, in particularly Spanish. The Admission Specialist stated Resident #44's spouse was not provided the Arbitration in his first language of Spanish due to the fact she does not speak Spanish and could not provide him with a clear understanding of agreement. The Admission Specialist the Arbitration Agreement did not contain a declination timeframe. During an interview on 12/01/22 at 10:33 a.m., the DON stated she had never read the Arbitration Agreement. The DON stated no one had been refused admission related to the Arbitration Agreement. The DON stated by not providing the Arbitration Agreement in a language the resident or responsible party understood could cause them to enter in an agreement without being fully informed. During an interview on 12/01/22 at 11:40 a.m., the Administrator stated the cooperation had not updated the Arbitration Agreement with the new regulation therefore the agreement was missing required key elements. The Administrator stated not providing the Arbitration in a language understood by the responsible party/resident could cause there to be a binding agreement not fully understood. During an interview on 12/01/22 at 11:50 a.m., the Administrator stated there was not a policy related to Arbitration.

Based on interview and record review, the facility failed to ensure that residents are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record, and residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 1 resident of 6 residents reviewed (Resident #9) for unnecessary medications. The facility failed to attempt a gradual dose reduction for the medication Seroquel 25mg 1/2 tab every night, originally ordered on 02/09/22 for Resident #9. Resident #9 was administered an antipsychotic, Seroquel (quetiapine fumarate), to treat adjustment disorder with mixed anxiety and depressed mood and never received an attempted gradual dose reduction. This failure could place residents at risk of receiving unnecessary medications. Findings include: Record review of Resident #9's Admission Record dated 11/30/22 indicated Resident was a [AGE] year-old male who originally admitted to the facility on [DATE] and had readmitted on [DATE] with the diagnoses of Alzheimer's disease, adjustment disorder with mixed anxiety and depressed mood, diabetes, and metabolic encephalopathy (acute confusion). Record review of Resident #9's MDS dated [DATE] indicated the resident had a short-term and long-term memory problem with severely impaired cognition. He could not complete a BIMS assessment. The MDS indicated the resident required extensive assist of one person for bed mobility, transfers, toileting, eating, dressing, personal hygiene, and he required total assistance of one person for bathing. The MDS also indicated the resident received 7 days of an antipsychotic medications in the look back period with no gradual dose reduction being attempted. Record review of Resident #9's care plan revised on 01/07/22 indicated that resident used a psychotropic medication (Seroquel) related to delusions. Record review of Resident #9's Order Summary Report dated 11/30/22 indicated the resident had an order for: Seroquel 25mg tab 1/2 tab by mouth at bedtime for agitation related to adjustment disorder with mixed anxiety and depressed mood. A 1/2 tab equal to 12.5mg that restarted on 02/09/22, discontinued on 5/16/22 and re-started on 05/16/22. Record review of the Psychotropic & Sedative/Hypnotic Utilization By Resident dated 08/07/22, 09/08/22, and 10/22/22 indicated Resident #9 was ordered Seroquel (Quetiapine Fumarate tab 25mg tab1/2 (12.5mg) every night at bedtime started on 02/09/22 and a gradual dose reduction had not been performed. Record review of the Psychotropic & Sedative/Hypnotic Utilization By Resident dated 11/20/22 indicated that Resident #9 was ordered Seroquel (Quetiapine Fumarate tab 25mg tab1/2 (12.5mg) every night at bedtime started on 02/09/22 and a gradual dose reduction was recommended by the pharmacy consultant but the form had not been sent to the physician or noted. During an interview on 12/02/22 at 10:49 AM with the DON, she said when residents received a new order for an antipsychotic medication it should be evaluated in 14 days and the pharmacist should have been monitoring the medications monthly. The DON said they had a pharmacy consultant that came in monthly to review all resident medications and Resident #9 had been monitored. She said the gradual dose reduction should have been performed within the first quarter of the medication begin date. She stated she guessed they missed it. The DON said Resident #9's medication Seroquel was started on 02/09/22 after a different medication was discontinued because it was requested by Resident #9's family member. The DON said she knew that antipsychotic medications should not be given to residents with dementia and Alzheimer's. She said Resident #9 had a diagnosis of adjustment disorder, but he did not have a diagnosis for mental illness. The DON said she knew he should not have been on the medication. She said the failure in not having a gradual dose reduction for an antipsychotic medication or a proper diagnosis could be a disservice to resident and potentially result in harm. The DON said she was responsible for monitoring the pharmacy recommendations monthly and had one for Resident #9 dated 11/19/22 but had not had the time to send to the physician. During an interview on 12/01/22 at 12:37 PM with the Administrator, he said the pharmacy consultant and the nurse managers should have been monitoring resident medications, but the DON was ultimately responsible for ensuring the residents' medications have a proper diagnosis for use and were being monitored correctly. The Administrator said monitoring antipsychotic medications was very important for compliance reasons and there could have been a resident not being at a therapeutic dose. He said there were also risks with giving antipsychotic medications to residents with dementia. Record review of the facility policy for Antipsychotic Medication Use indicated . Policy Statement Antipsychotic medications may be considered for resident with dementia after medical, physical, functional, psychological, emotional psychiatric, social and environmental causses of behavioral symptoms have been identified and addressed. Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. Policy Interpretation and Implementation 1. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective .4. The Attending Physician and the facility staff will identify acute psychiatric episodes and will differentiate them from enduring psychiatric conditions .6. Diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident. 7. Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record, consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders

Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, the expiration date when applicable and stored all drugs and biologicals in locked compartments for 2 residents (Resident #65 and Resident #74) of 20 in the sample. The facility did not ensure Resident #65's Artificial Tears were properly stored. The facility did not ensure Resident #74's medications were properly stored by leaving them at the bedside. This failure could place residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications, or harm by ingestion. Findings: Record review of Resident #65's Admission Record dated 11/30/22 indicated that resident was an [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of chronic obstructive pulmonary disease (lung disease), atrial fibrillation (increased heart rates), macular degeneration (eye problem), diabetes, and dementia. Record review of Resident #65's MDS dated [DATE] indicated the resident had a BIMS of 14 which meant he was cognitively intact. The MDS also indicated the resident was independent with bed mobility, transfers, and eating. He required supervision with toileting, person hygiene, and bathing. Record review of Resident #65's care plan dated 3/11/21 indicated Resident #65 had a problem of impaired visual function related to macular degeneration, dry eyes with no interventions of eye drops. During an observation on 11/28/22 at 11:40 AM revealed Resident #65 had a bottle of artificial tears sitting on his bed side table. During an observation on 11/29/22 at 09:06 AM revealed Resident #65 had a bottle of artificial tears remained on the bed side table. During an interview on 11/30/22 at 9:50 AM Resident #65 said he had an eye surgery, and he had the bottle of artificial tears on the bed side table because he used them as needed because his eyes dried out at times. Record review of Resident #65's Order Summary Report dated 11/30/22 indicated Resident #65 did not have an order for artificial tears. During an interview on 11/30/22 at 10:02 AM with LVN A, she said no residents in the facility should have had medications in their rooms, and that no one self-medicated. She said all medications were to be locked in the medication carts or in the medication room. LVN A said if a resident had a medication in their room, it could place that resident or other residents at risk of overuse. LVN A also said the resident could have allergies to medications and could be a risk if the nurse was unaware of the use. LVN A said she was unaware of Resident #65 having the artificial tears at his bedside. She said other residents could have picked up the medication and used it, swallowed it, or overdosed. LVN A said she would have removed the medication and notified the doctor for orders if Resident #65 needed the medication. During an interview on 12/01/22 at 10:32 AM with the DON, she said all medications should be kept by the nurse on the medication carts, whether they were over the counter or prescription. She said she was unaware Resident #65 had eye drops in his room. The DON said all staff had responsibility of ensuring medications were not in resident rooms. She said they performed champion rounds daily to check resident rooms for issues as well as items that should not be in the rooms. The DON said when residents had medications in their rooms it placed a risk for other resident to retrieve the medications, and misuse the medications. During an interview on 12/01/22 at 12:37 PM with the Administrator, he said medications should not be kept at the bed side. He said nursing staff were responsible for ensuring residents did not have medications in rooms. The Administrator said there was always a potential risk for residents with medications at the bed side, but he did not think a resident would overdose from eye drops. 33249 2. Record review of a face sheet dated 11/30/22 indicated Resident #74 was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of rectal abscess, high blood pressure, and anemia. Record review of a Quarterly MDS dated [DATE] indicated Resident #74 was understood and understood others. The MDS indicated Resident #74 memory was intact. Record review of the comprehensive care plan dated 02/28/22 indicated Resident #74 had impaired memory cognitive function or impaired thought process related to short term memory loss. The goal was Resident #74 would maintain a current level of cognitive function. The interventions for Resident #74 included asking yes or no questions, communicate with the resident, family, caregivers, regarding Resident #74's capabilities. During an observation and interview on 11/28/22 at 11:05 AM revealed Resident #74 had plastic medication cups on her over the bed table. Two of the medication cups were full of a brown liquid and the third had numerous tablet and capsule form medications. During an interview with Resident #74 she stated one of the brown liquids was last night's medication and the other two were the medications from this morning . Record review of the consolidated physician's orders dated 11/30/22 indicated Resident #74 orders for: *Vitamin C 500 mg one tablet by mouth daily *Colace Capsule 100 mg one capsule by mouth daily *Ferrous Sulfate 325mg one by mouth two times daily *Metoprolol Tartrate 25 mg give 12.5 mg twice daily *Multivitamin with Minerals one table by mouth daily *Potassium Chloride Extended Release 20 milliequivalents one tablet by mouth daily *Protein liquid 30 milliliters by mouth twice daily *Sodium chloride 1 gram one tablet by mouth daily *Vitamin B12 one tablet by mouth daily *Zinc 50 mg one by mouth daily During an interview on 11/28/22 at 11:10 AM RN H stated she was responsible for the care of Resident #74. RN H stated the medications at bedside could cause Resident #74 to receive a double dose of medications and/or another resident could access the unsecured medications . RN H said she would ask MA N why the medications were left at the bedside. During an interview and record review on 11/28/22 at 11:20 AM MA N stated she had left the medications at Resident #74's bedside. MA N reviewed the medication administration record and noted the medications were vitamin C, Colace, Iron Sulfate, metoprolol, multivitamin with minerals, [NAME] flu, Potassium extended release, Sodium, Vitamin B12, Vitamin D3, and Zinc. MA N said Resident #74 was not ready to take the medication and request the medication be left at bedside. MA N stated leaving medications at bedside could cause a resident to get multiple medications too close together or another resident could take them by mistake. Record review of MA N's Clinical Proficiencies including medication administration was completed on 11/17/22. Record review of MA N's Medication Administration Skills Assessment completed on 11/17/22 indicated MA N passed the assessment in the areas of: 12. Resident observed to ensure medications are swallowed 14. Medications are not left on top of the cart or at the residents bedside 15. Refused/withheld medications are properly noted. Notify the MD. During an interview on 12/01/22 at 10:31 a.m., the DON stated the medications should be kept by the nurse or medication aides. The DON stated the facility used champion rounds to monitor for areas of concern that required correction. The DON stated leaving medications at bedside could lead to anyone taking the medications. During an interview on 12/01/22 at 11:40 AM the Administrator stated medications should not be kept at bedside. The Administrator stated the nursing was responsible for ensuring medications were stored properly. The Administrator stated the blood pressure medication left at bedside could affect another resident's blood pressure. Record review of a Storage of Medication policy and procedure dated April 2007 indicated the facility shall store all drugs and biologicals in a safe, secure, and orderly manner.

Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 20 residents reviewed for personal hygiene. (Resident #12) The facility failed to ensure Resident #12 received assistance with shaving of her facial hair. This failure could place residents who were dependent on staff to perform personal hygiene at risk of embarrassment, decreased self-esteem, or decreased quality of life. Findings included: Record review of face sheet dated 11/30/22 indicated Resident #12 was a [AGE] year-old female, who admitted to the facility on [DATE], and readmitted on [DATE] with the diagnoses of tremors (shaking), cognitive communication deficit, glaucoma, and contractures (deformity and rigidity of joint) of her right and left hands. Record review of the Medicare MDS 10/28/22 indicated Resident #12 usually was understood, and usually understood others. The MDS in Section C0400 indicated she was unable to recall. Resident #12's BIMS was 0, indicating severe cognitive impairment. The MDS section G0110 indicated Resident #12 required extensive assistance of one staff for personal hygiene including shaving. Record review of a comprehensive care plan dated 03/15/19 indicated Resident #12 had an ADL Self Care Performance Deficit related to limited mobility and limited range of motion. The goal of the care plan indicated Resident #12 would maintain current level of function with her ADLs. The interventions indicated Resident #12 required total assistance from 1-2 staff for hygiene. Record review of the Documentation Survey Report dated 12/01/22 indicated Resident #12 received personal hygiene on 11/27/22 on the evening shift, 11/29/22 on the day shift and evening shift, and on 11/30/22 on the evening shift. During an observation on 11/28/22 at 11:35 a.m. revealed Resident #12 was sitting in her chair in her room. Resident #12 had dark brown and gray colored facial hair on her chin measuring 1/4 inches in length. Resident #12 was unable to state if she desired the chin hair to be removed. During an observation on 11/29/22 at 9:15 a.m. revealed Resident #12 continued to have facial hair to her chin and now her upper lip. During an observation and interview on 11/30/22 at 9:04 a.m. revealed LVN D confirmed Resident #12 had facial hair on her chin and upper lip. LVN D indicated the CNAs were responsible for ensuring ADLs were completed. LVN D indicated the nurses were responsible for ensuring the ADLs were completed by the CNAs. LVN D indicated the facial hair should be moved with showers. LVN D indicated she was Resident #12's nurse. LVN D stated a female having facial hair could be a dignity issue due to being embarrassed . During an interview on 11/30/22 at 9:10 a.m., CNA E stated anyone in nursing was responsible for ensuring the residents were shaved . CNA E indicated she did provide care to Resident #12. During an interview on 11/30/22 at 9:14 a.m., CNA F stated she had worked 4 months in the facility. CNA F indicated she did provide care to Resident #12. CNA F stated she was aware of the facial hair on Resident #12's chin and upper lip. CNA F stated she had not had the time yet to remove the facial hair . CNA F stated she would be embarrassed to have facial hair. During an interview on 12/01/22 at 10:15 a.m., the DON indicated the charge nurses were responsible for oversight of the CNAs performing the personal hygiene needs and then the nurse managers were responsible for oversight of the nurses. The DON stated Resident #12 could feel embarrassed to have facial hair. During an interview on 12/01/22 at 11:40 a.m., the Administrator stated it would be great to have no residents with ADL care issues. The Administrator stated the nursing floor staff were responsible for providing personal hygiene. The Administrator stated a woman having undesired facial hair could be a dignity issue. Record review of a Shaving the Resident policy and procedure dated October 2010 indicated the purpose of the procedure was to promote cleanliness, and to provide skin care. Notify the supervisor if the resident refuses the procedure.

Based on record review and interview the facility failed to ensure the Arbitration Agreement included the provision of a neutral arbitrator, a convenient venue, and the retention of resolution for 5 years for 1 of 1 facility reviewed for Arbitration Agreements. The facility failed to ensure the Arbitration Agreement contained a section indicating the provision of a convenient venue. The facility failed to ensure the Arbitration Agreement contained the requirements of retention of the resolutions. These failures could place the residents or the residents' responsible parties in binding agreements not fully understood, have a loss of their legal rights, and cause negative psychological issues. Findings included: Record review of the undated Admission Agreement included: In Consideration of the mutual promises contained in this agreement, the parties agree as follows: l.1. Terms and Terminations: Patient/Resident agrees to reside in the Health Care Center. This agreement shall remain in effect until terminated by Patient/Resident in accordance with applicable law or terminated by the Health Care Center as provided in Article IV. lll. 1. Patient/Resident Responsibilities: Patient/Residents shall abide by the reasonable policies and rules of the Health Care Center which are included herein by reference. V.5. Complete Agreement: This Agreement, the Agreement Addendum (s), and the documents list on the Acknowledgement page attached to this Agreement and made a part hereof constitute the entire agreement between the parties. The Agreement may not be amended except in writing executed by the parties or the successors. VI. Arbitration: Pursuant to the Federal Arbitration Act, any action, dispute, claim or controversy of any kind (e.g., whether in agreement or in tort, statutory or common law, legal or equitable, or otherwise) now exists or hereafter arising between the parties in any way arising out of pertaining to or in connection with provision of health care services, any agreement between the parties, the provision of other goods or services by the Health Care Center or other transactions, agreements or agreements of any kind whatsoever, any part present or future incidents, omissions, acts, error, practices or occurrence causing injury to either party where by the other party or its agents, employees or representatives may be liable in whole or in part, or any other aspects of the past, present, or future relationships between the parties shall be resolved by binding arbitration administered by the National Arbitration Forum. The undersigned Acknowledge that each of them has read an understood this agreement, and that each of them voluntarily consents to all its terms. Record review of the Admission Agreement : Dispute Resolution Plan page 16: It is hereby agreed and understood that any dispute, difference and /or disagreement of any kind whatsoever, whether statutory or contractual, which arises from the services and/or products provided or relating in any way to the general business relationship of the parties to this agreement, shall be, as the sole available remedy, resolved through mandatory mediation and/or binding arbitration, rather than litigation. The parties agree and acknowledge that the business relationship involves interstate commerce and that nay such mediation or arbitration shall be governed by the Federal Arbitration Act (FAA) and conducted in accordance with the Rules of Mediation and Arbitration as then in effect and administered by the Dispute Solutions, Inc. The cost of any arbitration hereunder, including the cost of the record or transcripts thereof, if any, administrative fees, attorney's fees and all other fees involved, shall be paid by the party determined by the arbitrator to be the prevailing party, or otherwise allocated in an equitable manner a determined by the arbitrator. Record review of the Dispute Resolution Plan revealed on page 64 of the Admission Agreement, The Federal Arbitration Act has been around since the 1920's and arbitration is widely used today to resolve problems. The Dispute Resolution Plan is required and the mandatory way for all residents and the Health Care Center to resolve any potential legal problems. During an interview on 11/28/22 at 3:00 p.m., the Admission Specialist stated she assisted the responsible party/resident with signing of the Admission Agreement and Arbitration Agreement. The Admission Specialist stated there had been only one family refuse to sign the Arbitration Agreement since 2020. The Admission Specialist indicated all admissions receive the same Admission Agreement. During an interview on 12/01/22 at 10:33 a.m., the DON stated she had never read the Arbitration Agreement. The DON stated no one had been refused admission related to the Arbitration Agreement. The DON stated the Arbitration Agreement should be updated to include the required elements. During an interview on 12/01/22 at 11:40 a.m., the Administrator stated the corporation had not updated the Arbitration Agreement with the new regulation and the requirements therein. The Administrator stated the Arbitration Agreement failed to address the selection of a convenient venue for both parties. During an interview on 12/01/22 at 11:50 a.m., the Administrator stated there was not a policy related to Arbitration.

Based on interview, and record review, the facility failed to ensure that licensed staff were able to demonstrate the specific competencies and skill sets necessary to care for resident's needs for 3 out of five licensed staff (LVN A, LVN B, and LVN C) reviewed for skills competency. The facility failed to ensure that LVN A, LVN B, and LVN C, who were all charge nurses for the resident with the tracheostomy, were competent in providing tracheostomy care. This failure had the potential to affect residents by placing them at an increased and unnecessary risk of exposure to staff who lack the appropriate skills competencies to provide care that is safe and capable of minimizing accidents, hazards, and communicable diseases and infections. Findings include: Record review of the Record of In-Service dated 11/02/21 indicated the staff were in-serviced on trach care procedures, setup, and equipment. The in-service also indicated no evidence LVN A, LVN B, and LVN C were a part of the in-service. Record review of the Respiratory Therapy Training Competency checklist revised November 2014 indicated that all hired nursing employees should have been completed initially on hire and annually. Record review of the proficiency checklist in the employee files for LVN A, LVN B, and LVN C indicated no evidence the nurses had been trained or evaluated for tracheostomy care. Record review of the daily staffing attendance schedules dated 11/28/22-11/30/22 indicated LVN B was the charge nurse on the South hall numbers 400-600 for 6PM to 6AM (night) shift, LVN C was the charge nurse for the North hall numbers 100-300 for 6PM to 6AM (night) shift, and LVN A was the charge nurse for South hall number 600 on 11/29/22 on the shift 6AM to 6PM (day) shift. Both LVN B and LVN C worked as the only nurses in the facility on 11/28/22 6PM-6AM (night) shift. Record review of the 672 form for the facility dated 11/28/22 indicated that the facility had 1 resident with a tracheostomy. During an interview on 12/1/22 at 9:34 AM LVN A was the charge nurse for the resident with a tracheostomy on 12/1/22 and said that she did not know how to perform tracheostomy care for the resident with a tracheostomy if he could not provide care himself. LVN A said she had not had a training in which she learned tracheostomy care and had to perform a return demonstration of the knowledge. LVN A said if she was the charge nurse and the resident needed a nurse for tracheostomy care, she would try to find and grab a more seasoned nurse to assist her in caring for the resident. LVN A said she had not been a nurse very long. Attempted to call LVN C on 12/01/22 at 9:49 AM, there was no answer. Attempted to call LVN B on 12/01/22 at 9:50 AM, there was no answer. During an interview on 12/01/22 at 12:43 PM the Administrator said he expected all nurses to be checked off on competencies to care for the residents. He said he was not aware staff were not trained for tracheostomy care. He said ultimately the DON was responsible for training staff on tracheostomy care, and there could be health issues and problems for residents if a nurse on the floor caring for a resident with a tracheostomy did not know how to provide care. During an interview on 12/01/22 at 1:50 PM the DON said they did not have a policy for proficiency. The DON said they only had a policy for staff development. She said it was important for nurses to be in-serviced and checked off on tracheostomy care when they had a resident with a tracheostomy. The DON said not being trained could cause a resident harm, but the resident performed his tracheostomy care himself. The DON said there were several scenarios that could come about but a nurse could always get help from another nurse in the building. The DON said she is responsible for ensuring all nurses were competent in providing care to residents and the Corporate Respiratory Therapist would come whenever she called her for her to provide tracheostomy training.

Based on interview, and record review, the facility failed to review, and revise a person-centered comprehensive care plan for 1 of 20 residents reviewed for care plans (Residents #78). The facility failed to revise the care plan with interventions specific to each fall for Resident #78. This failure could place residents at risk of not having their individualized needs met in a timely manner and communicated to providers and could result in a decline in physical well-being and care needs not being addressed. Findings included: Record review of Resident #78's face sheet, dated 09/29/22, indicated Resident #78 was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of respiratory failure (develops when the lungs can't get enough oxygen into the blood), coronary heart disease (caused by plaque buildup in the wall of the arteries that supply blood to the heart), and high blood pressure. Record review of Resident #78's most recent comprehensive MDS, dated [DATE] indicated Resident #78 made himself understood and was able to understand others. Resident #78 had a BIMS score of 11 which indicated he was cognitively moderately impaired. The MDS indicated Resident #78 required extensive assistance with bed mobility, transfers, dressing, eating, personal hygiene, and total assist with bathing. The MDS indicated Resident # 78 was frequently incontinent of bowel and bladder. The MDS indicated Resident # 78 had 2 or more minor injuries related to falls since admission. During a record review of the fall care plan dated 09/12/22 indicating the resident was at risk for falls related to gait balance, poor communication/comprehension and unaware of safety needs. Goals: The resident will be free of minor injury through next review. Approach: Anticipate and meet resident needs, be sure call light in reach and encourage resident to use and staff to respond promptly and PT to evaluate and treat as ordered or PRN (as needed). The care plan lacked documentation of interventions for the following falls: 10/13/22 fall due to attempted self-transfer from bed (fell on mat) to wheelchair. 10/18/22 fall due to attempted self-transfer from bed (fell behind bedroom door) with abrasion to right temple. 10/23/22 fall due to attempted self-transfer from bed (fell in front of bed on knees) resulting in a skin tear to left forearm. 11/02/22 fall due to attempting to reach for books. 11/05/22 fall due to attempting to ambulate without assist. 11/15/22 fall due to attempting self-transfer. 11/25/22 fall due to resident ambulating without assistance resulting in a skin tear and bump to forehead. 11/27/22 fall due to attempted self-transfer from wheelchair to bed resulting in a skin tear to right elbow and forearm. During an interview on 11/30/22 at 2:09 p.m., the DON said they place a new intervention following any falls on the 24-hour report and the nurses communicated this to the CNA'S upon shift huddle. The DON said they have implemented interventions for Resident #78 falls and they should be on his care plan. During a record review of the 24-hour report of the following dates 10/13/22, 10/18/22, 10/23/22, 11/02/22, 11/05/22, 11/15/22,11/25/22, and 11/27/22, did not revealed any fall interventions for Resident #78. During a record review of Resident #78's care plan on 11/30/22 at 4:00 p.m., revealed some updates had been done to the residents care plan related to falls and interventions. The new interventions revealed low bed, enabler bars and remind resident to use assistive device as needed. During an interview on 11/30/22 at 4:35 p.m., CNA P said they usually do a huddle at shift change but she was not aware of individual residents' care plans or where they are located to review resident's needs. During an interview on 12/01/22 at 9:10 a.m., ADON K said they talk about falls in the morning meetings and discuss any interventions needed. ADON K said the MDS nurse was the person responsible for updating the care plans. ADON K said they could have place Resident #78 on a toileting program or other interventions but because of his dementia they did not. ADON K said care plans should be updated to reflect care of residents. During an interview on 12/01/22 at 9:33 a.m., ADON M said they talk about falls in the morning meetings and they meet weekly about falls and follow up if needed. ADON M said the MDS Nurse updated the care plan while in the morning meeting for all interventions. ADON M said she did not touch the care plans but would implement an intervention if not done by the nurses for falls. ADON M said the care plan was used for daily care of the residents. During an interview on 12/01/22 at 9:58 a.m., MDS O said they talk about all changes in the morning meetings and then she usually updated the care plans daily. MDS O said they meet weekly to talk about falls and if they see where they need to add or delete interventions to a care plan it would be done during the meeting. MDS O said she updated Resident #78's care plan with interventions after his falls as discussed in the meetings. MDS O said the care plan was the plan of care and everyone had access to the care plan. MDS O said if something was not on the care plan it could potentially change the resident's outcome of care. During an interview on 12/01/22 at 10:30 a.m., the ADM said the process after each fall was to find the root cause and then put intervention(s) in place. The ADM said they talked about falls in the morning meetings and usually the charge nurses started the process, and the ADON/DON followed up. The ADM said he was ultimately responsible for all residents' care. The ADM said without completed care plans it could possibly impede care. During an interview on 12/01/22 at 11:21 a.m., the DON said the charge nurses completed the incident report, added interventions, and discussed with staff at shift huddle. The DON said the ADONs was to follow up on all falls to make sure interventions are in place. The DON said she reviewed the incident reports and if interventions had not been added, she would add them. The DON said they had not tried a toileting plan or had set times to check on Resident #78. The DON said they discussed falls in morning meetings and the MDS Nurse updated the care plan. The DON said she periodically looked at care plans to make sure they was completed. The DON said incomplete care plans could cause care to be missed. Record review of care plan policy dated December 2016, indicated, A comprehensive person-centered care plan that includes measurable objective and timetable to meet the residents physical psychosocial and functional needs is developed and implemented for each resident .#11 Care plan interventions are chosen only after careful data gathering, proper sequence of events, careful consideration of the relationship between the residents problem area and their causes and the relevant clinical decision making . #13 Assessments of residents are ongoing and care plans are revise as information about the resident and the residents' condition changes.

Based on observation, interview, and record review the facility failed to ensure that residents requiring respiratory care are provided care, consistent with professional standards of practices for 3 of 9 residents reviewed for respiratory care (Resident #271, #2 and #41). The facility did not ensure Resident #271, #2 and #41's oxygen concentrator filters were clean for 3 days. The facility did not ensure Resident #271's oxygen tubing was dated. These failures could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory distress. Findings Included: 1. Record review of consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders indicated Resident #271 received oxygen therapy to maintain oxygen saturation above 92%. The orders indicated oxygen concentrator filters were cleaned/changed every Sunday with a start date 9/15/21. The orders indicated oxygen tubing were changed and dated every Sunday night with a start date 9/19/21. During an interview on 9/15/21 at 1:30 p.m., the DON said Resident #271 did not have a MDS at this time due to residing in the facility less than the allotted 14 days required to have the MDS completed. Record review of the baseline care plan dated on 9/8/21 indicated Resident #271 received oxygen therapy. During an observation on 9/13/21 at 11:15 a.m., Resident #271 was sitting in his wheelchair looking out the window and oxygen was being used by the resident via the nasal cannula. The oxygen tubing was not dated. Resident #271's oxygen concentrator filter was covered in a thick layer of dust. During an observation on 9/13/21 at 3:10 p.m., Resident #271 was lying in bed and had oxygen via nasal cannula. The oxygen tubing was not dated. Resident #271's oxygen concentrator filter was covered in a thick layer of dust. During an interview and observation on 9/14/21 at 9:13 a.m., Resident #271 was sitting in his wheelchair. There was an oxygen concentrator next to his bed, the concentrator was not turned on, and the oxygen tubing was laid across the concentrator. The oxygen tubing was not dated. Resident #271's oxygen concentrator filter was covered in a thick layer of dust. Resident #271 said he used his oxygen most of the time to help with shortness of breath. During an observation on 9/14/21 at 2:45 p.m., Resident #271 was sitting in his wheelchair and oxygen was being used by the resident via nasal cannula. The oxygen tubing was not dated. Resident #271's oxygen concentrator filter was covered in a thick layer of dust. During an interview on 9/15/21 at 10:52 a.m., RN A said oxygen concentrators filters were cleaned by the night nurse weekly on Sunday nights. RN A said the nasal cannula tubing should be changed and dated by the night nurse weekly on Sunday nights. RN A said it was important for oxygen concentrator filters to be clean to prevent dust and germs from entering the nasal cannula. RN A said it was important for nasal cannula tubing to be dated to be prevent a respiratory infection. During an observation on 9/15/21 at 11:15 a.m., Resident #271 was sitting in his wheelchair in the bathroom. There was an oxygen concentrator next to his bed, the concentrator was turned on, and the oxygen tubing was laid across the concentrator. The oxygen tubing was not dated. Resident #271's oxygen concentrator filter was covered in a thick layer of dust. During an interview on 9/15/21 at 11:59 a.m., LVN B said the night nurse on Sunday nights were responsible for ensuring that filters were clean, and the nasal cannula tubing was dated. LVN B said it was important for oxygen concentrator filters to be clean to prevent dirt and particles from entering the nasal cannula. LVN B said it was important for nasal cannula tubing to be dated to know the last time it was changed to prevent a respiratory infection. During an interview on 9/15/21 at 12:25 p.m., the DON said the night nurse on Sunday nights were responsible for ensuring that filters were clean and nasal cannula tubing were change and dated. The DON said this task will prompt the charge nurse in PCC to complete this task. The DON said most likely Resident #271 tubing was not change or dated because there was not an order put in to change/date the oxygen tubing or clean the filter until 9/15/21 when the surveyor bought it to her attention. The DON said she expected the nurses to clean/change the oxygen concentrator filters and change/date the tubing weekly per the physician order. The DON said she expected the charge nurse to put orders in when a resident received an order and the ADON was responsible for reviewing the admissions for accuracy. The DON said the ADON has been out and was unable to review Resident #271 orders for accuracy. During an interview on 9/15/21 at 1:07 p.m., the administrator said the charge nurse was responsible for ensuring that filters were clean and nasal cannula tubing were change and dated. The administrator said spot checks were done at least once a week but was unable to tell the surveyor the last spot check that was completed. The administrator said he expected the nurses to clean/change the oxygen concentrator filters and change/date the tubing weekly per the physician order. 2. Record review of the order summary report dated 09/15/2021 indicated Resident#41 was [AGE] years old, admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the order summary report dated 09/15/2021 indicated Resident#41 had an order dated 10/21/2020 for oxygen as needed for shortness of breath and to titrate at 2-3 liters per minute for oxygen saturation at or below 90%. Resident#41 had an order dated 06/29/2021 to check oxygen filter for placement and cleanliness every week on Sunday and as needed. Record review of the MDS dated [DATE] indicated Resident#41 had intact cognition. Resident#41 had shortness of breath while lying flat. Record review of the most updated care plan initiated on 08/26/2019 indicated Resident#41 was at risk for shortness of breath, difficulty breathing, lung congestion and increased coughing related to her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During observations on 09/13/2021 the following was noted: *10:40 A.M. Resident#41 had an oxygen concentrator next to her wheelchair. Resident#41 was sitting in a wheelchair wearing a nasal cannula. The filter on the oxygen concentrator had dust covering it. The concentrator was on and functioning at 2 liter per minute. *3:13 P.M. Resident#41's oxygen concentrator filter had dust covering it. The concentrator was on and functioning at 2 liter per minute. During observations on 9/14/2021 the following was noted: *09:36 A.M Resident#42's oxygen concentrator filter had dust covering it. The concentrator was on and functioning at 2 liter per minute. *02:49 P.M. Resident#42's oxygen concentrator filter had dust covering it. The concentrator was on and functioning at 2 liter per minute. During an observation on 9/15/2021 Resident#41's oxygen concentrator had dust covering it. The concentrator was on and functioning at 2 liter per minute. 3. Record review of the order summary report dated 09/15/2021 indicated Resident#2 was [AGE] years old, admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the order summary report dated 09/15/2021 indicated Resident #2 had an order dated 03/24/2021 for oxygen 0.5-3 liters per minute continuous via nasal cannula titrated to keep oxygen saturation greater than 88%. Record review of the MDS dated [DATE] indicated Resident#2 had received supplemental oxygen both prior to arriving at this facility and while a resident of this facility. Resident#2 had shortness of breath when lying flat. Record review of the most updated care plan dated 02/26/2021 for Resident#2 failed to address the use of supplemental oxygen and need to change or clean the filter on the oxygen concentrator. The care plan stated that Resident#2 had altered respiratory status/difficultly breathing related to chronic obstructive respiratory failure. During an observation on 09/13/2021 the following was noted: *10:22 A.M. Resident#2 had an oxygen concentrator next to the bed. Resident# was resting in bed wearing a nasal cannula. The oxygen concentrator's filter was covered with dust. The concentrator was on and functioning at 1 liter per minute. *3:12 P.M. Resident#2's oxygen concentrator filter was covered with dust. The concentrator was on and functioning at 1 liter per minute. During an observation on 09/14/2021 the following was noted: *9:35 A.M. Resident#2's oxygen concentrator was on and functioning at 1 liter per minute. The filter on the oxygen concentrator was covered with dust. *2:48 P.M. The filter on the oxygen concentrator was covered in dust. The concentrator was on and functioning at 1 liter per minute. During an observation on 09/15/2021 at 9:35 A.M., Resident#2's oxygen concentrator was on and functioning at 1 liter per minute. The oxygen concentrator filter was covered in dust. The concentrator was on and functioning at 1 liter per minute. During an interview on 09/15/2021 at 1:08 p.m., RN A said that on every Sunday or as needed, the night shift nurse is responsible for changing/cleaning the filters on the oxygen concentrators. RN A said that she remembers reading this policy as she had only been working at the facility for a few weeks. During an interview on 09/15/2021 at 1:12 p.m., LVN B said that the filters on the oxygen concentrators were cleaned/changed very Sunday on night shift. LVN B said this was the facility policy for cleaning the filters on the oxygen concentrators During an interview on 09/15/2021 at 1:18 p.m., the DON said that cleaning/changing out filters on the oxygen concentrators was on the nurse task list and was due every Sunday night. This task will pop up on the treatment record along with changing out oxygen tubing and humidifiers. During an interview on 09/15/2021 at 1:22 p.m., the administrator said Point Click Care would prompt when to change/clean oxygen concentrator filters. The administrator said when the order for oxygen is put in this creates checks to clean/change the oxygen concentrator filter as well as changing out the oxygen tubing. The charge nurse has the responsibility to follow these orders. Record review of a Oxygen Administration policy revised on 10/2010 does not address oxygen concentrators filters or when to clean and date oxygen tubing.

Based on observation, interview, and record review, the facility failed to ensure an effective infection prevention and control program to prevent the development and transmission of communicable diseases was implemented by the facility regarding COVID-19 (a new respiratory disease which can cause mild to severe illness with most severe illness in adults [AGE] years and older) for 11 of 95 employees reviewed for infection control . (CNA A, ADON B, LVN C, CNA D, NA E, CNA F, LNV G, LVN H, RN J, and Cook K) The facility did not: - prevent CNA A from working after reporting symptoms on her COVID-19/Respiratory Virus Screening tool on 12/14/2020 and 12/15/2020. - prevent ADON B from working after reporting symptoms on her COVID-19/Respiratory Virus Screening tool on 12/16/2020 and 12/18/2020. - prevent LVN C from working after reporting symptoms on her COVID-19/Respiratory Virus Screening tool on 12/15/2020, 12/16/2020, and 12/21/2020 - prevent CNA D from working after reporting symptoms on her COVID-19/Respiratory Virus Screening tool on 12/13/2020 and 12/16/2020. - prevent NA E from working after reporting symptoms on her COVID-19/Respiratory Virus Screening tool on 12/16/2020, 12/17/2020, 12/18/2020, and 12/25/2020. - prevent CNA F from working after reporting symptoms on her COVID-19/Respiratory Virus Screening tool on 12/23/2020, 12/24/2020, and 12/28/2020. - prevent LVN G from working after reporting symptoms on her COVID-19/Respiratory Virus Screening tool on 12/24/2020. - prevent LVN H from working after reporting symptoms on her COVID-19/Respiratory Virus Screening tool on 12/16/2020. - prevent RN J from working after reporting symptoms on her COVID-19/Respiratory Virus Screening tool on 12/22/2020. - prevent Cook K from working after reporting symptoms on her COVID-19/Respiratory Virus Screening tool on 12/18/2020. - prevent the DON from working after reporting symptoms on his COVID-19/Respiratory Virus Screening tool on 12/18/2020. An Immediate Jeopardy (IJ) situation was identified on 12/29/2020. While the IJ was removed on 12/30/20, the facility remained out of compliance at actual harm that is not an immediate threat with a scope identified as pattern, due to the facility's need to evaluate the effectiveness of their plan of removal. These failures could place residents at risk for exposure to the COVID-19 virus, serious illness and/or death. Findings included : A COVID-19 Prevention and Control policy last updated 10/28/2020 indicated the following: .1. The Infection Preventionist and/or designee will monitor any ill healthcare personnel. Staff who develop a fever and respiratory symptoms will be: (screened out) a. Instructed not to report to work, or if at work to stop resident-care activities, don a facemask, and promptly notify their supervisor and the Infection Preventionist and/or designee before leaving work. B. Exclude from work until at least 72 hours after they no longer have a fever (without the use of fever-reducing medicines such as [MEDICATION NAME]) An Employee Screening Process Policy and Procedure dated 10/22/2020 indicated the following: .DON/Designee: . b. review and direct employee and screener regarding any questions that surface during the screening process. Document the direction given on the screening form . Screener: a. Conduct health screening for all employees (including agency) for each department schedule for the day . c. Immediately stop any employee who requires further review on the screening form and alert the DON/designee for direction . The website https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html accessed on 1/5/2021 indicated the following: .Evaluate and Manage Healthcare Personnel. - Implement sick leave policies that are non-punitive, flexible, and consistent with public health policies that support HCP to stay home when ill. - Create an inventory of all volunteers and personnel who provide care in the facility. Use that inventory to determine which personnel are non-essential and whose services can be delayed if such restrictions are necessary to prevent or control transmission. - As part of routine practice, ask HCP (including consultant personnel and ancillary staff such as environmental and dietary services) to regularly monitor themselves for fever and symptoms consistent with COVID-19. - Remind HCP to stay home when they are ill. - If HCP develop fever (T?100.0oF) or symptoms consistent with COVID-19 while at work they should inform their supervisor and leave the workplace. Have a plan for how to respond to HCP with COVID-19 who worked while ill (e.g., identifying and performing a risk assessment for exposed residents and co-workers). - HCP with suspected COVID-19 should be prioritized for testing. - Screen all HCP at the beginning of their shift for fever and symptoms of COVID-19. - Actively take their temperature* and document absence of symptoms consistent with COVID-19. If they are ill, have them keep their cloth face covering or facemask on and leave the workplace. - *Fever is either measured temperature >100.0oF or subjective fever. Note that fever may be intermittent or may not be present in some individuals, such as those who are elderly, immunosuppressed, or taking certain medications (e.g., NSAIDs). Clinical judgement should be used to guide testing of individuals in such situations During an interview on 12/29/2020 at 9:30 a.m., the corporate RN said the DON was currently out of the facility because he was sick. During an interview on 12/29/2020 at 10:20 a.m., RN L said CNA A told her she tried to call in with symptoms of COVID and the DON told her she could work since she didn't have a fever. She said CNA A lost her sense of smell during a shift and reported it to the DON. The DON told CNA A that she could not smell or taste because she was wearing a N95 mask. She said CNA D was also told to work with symptoms because she did not have a fever. During an interview on 12/29/2020 at 10:59 a.m., CNA A said on 12/13/2020 she reported to ADON B that she started to feel sick during her shift. She said that the DON told ADON B she could continue to work because she did not have a fever. She said she continued to work. She said on 12/14/2020 she reported symptoms on her COVID-19/Respiratory Virus Screening tool and was able to work. She said during her shift on 12/15/2020 she discovered she lost her sense of smell while performing incontinent care on a resident and reported it to ADON B. ADON B informed the DON of her symptoms and the DON told her she could continue to work because she did not have a fever and she could not smell anything because she was using the N95 masks. She said that towards the end of her shift she was having to ask staff to assist her in caring for residents because she was sore from body aches and could barely move. She said she was tested on [DATE] for COVID because she lost her sense of smell and she received her positive results on 12/16/2020 or 12/17/2020 when she was off work. She said she was still sick and unable to work. She said she works the North side (COVID negative unit) of the building. During an interview on 12/29/2020 at 11:09 a.m., CNA D said she was sent home during her shift on 12/13/2020 because she was having symptoms during her shift. She said she came back to work a few days later and was sent home during her shift again because of symptoms. She said she had reported the symptoms she was having on her COVID-19/Respiratory Virus Screening tools for both 12/13/2020 and 12/16/2020 but was allowed to work part of her shifts before her symptoms made it too difficult to work. She said was still COVID positive and unable to work. She said she works the North side (COVID negative unit) of the building. During an interview on 12/29/2020 at 2:00 p.m., ADON B said she worked the week of 12/14/2020 with COVID like symptoms. She said she did not have a fever. She said she the last day she worked before testing positive for COVID was 12/18/2020 and she received results that she was COVID positive on 12/22/2020. She said the DON was aware of her symptoms but said she could work because she did not have a fever. She said CNA A reported symptoms to her and the DON said that she could continue to work because she did not have a fever. She said CNA A was visibly sick during her shifts. She said that 28 out of the 33 COVID positive residents had resided on the North side (COVID negative) of the building where she and CNA A worked. She said she did test positive for COVID. During an interview on 12/29/2020 at 2:17 p.m., LVN C said she was having symptoms of COVID the week of 12/14/2020 but the DON said she could continue to work because she did not have a fever. She said she was aware that CNA A and ADON B were told the same by the DON. She said she did test positive for COVID. CNA A's COVID-19/Respiratory Virus Screening tool dated 12/14/2020 at 6:18 a.m. indicated she had a headache. The COVID-19/Respiratory Virus Screening tool indicated if any symptom was marked to notify the nurse on duty of a positive screen for evaluation. There was no documentation to indicate she was evaluated. CNA A's COVID-19/Respiratory Virus Screening tool dated 12/15/2020 at 6:18 a.m. indicated she had a headache and muscle/body aches. The COVID-19/Respiratory Virus Screening tool indicated if any symptom was marked to notify the nurse on duty of a positive screen for evaluation. There was no documentation to indicate she was evaluated. CNA A's Time Detail Report dated 12/30/2020 indicated she worked 12/14/2020 from 6:20 a.m.-2:15 p.m. and 12/15/2020 from 6:24 a.m.-3:00 p.m. ADON B's COVID-19/Respiratory Virus Screening tool dated 12/16/2020 at 7:22 a.m. indicated she had a cough and congestion/runny nose. The COVID-19/Respiratory Virus Screening tool indicated if any symptom was marked to notify the nurse on duty of a positive screen for evaluation. There was no documentation to indicate she was evaluated. ADON B's COVID-19/Respiratory Virus Screening tool dated 12/18/2020 at 7:50 a.m. indicated she had a cough. The COVID-19/Respiratory Virus Screening tool indicated if any symptom was marked to notify the nurse on duty of a positive screen for evaluation. There was no documentation to indicate she was evaluated. ADON B'S Time Detail Report dated 12/30/2020 indicated she worked 12/14/2020-12/18/2020. LVN C's COVID-19/Respiratory Virus Screening tool dated 12/15/2020 at 6:00 a.m. indicated she had a headache and congestion/runny nose. The COVID-19/Respiratory Virus Screening tool indicated if any symptom was marked to notify the nurse on duty of a positive screen for evaluation. There was no documentation to indicate she was evaluated. LVN C's COVID-19/Respiratory Virus Screening tool dated 12/16/2020 indicated she had congestion/runny nose. The COVID-19/Respiratory Virus Screening tool indicated if any symptom was marked to notify the nurse on duty of a positive screen for evaluation. There was no documentation to indicate she was evaluated. LVN C's COVID-19/Respiratory Virus Screening tool dated 12/21/2020 at 6:18 a.m. indicated she had a headache and congestion/runny nose. The COVID-19/Respiratory Virus Screening tool indicated if any symptom was marked to notify the nurse on duty of a positive screen for evaluation. There was note signed by the DON on the screening form that said OK, no temp, no body aches. LVN C's Time Detail Report dated 12/30/2020 indicated she worked 12/14/2020-12/18/2020 and 12/21/2020. CNA D's COVID-19/Respiratory Virus Screening tool dated 12/13/2020 at 6:00 a.m. indicated she had a sore throat. The COVID-19/Respiratory Virus Screening tool indicated if any symptom was marked to notify the nurse on duty of a positive screen for evaluation. There was no documentation to indicate she was evaluated. CNA D's COVID-19/Respiratory Virus Screening tool dated 12/16/2020 indicated she had a cough. The COVID-19/Respiratory Virus Screening tool indicated if any symptom was marked to notify the nurse on duty of a positive screen for evaluation. There was no documentation to indicate she was evaluated. CNA D's Time Detail Report dated 12/30/2020 indicated she worked 12/13/2020 and 12/16/2020. NA E's COVID-19/Respiratory Virus Screening tool dated 12/16/2020 at 3:35 a.m. indicated she worked the front desk and had a sore throat, cough, headache and congestion/runny nose. The COVID-19/Respiratory Virus Screening tool indicated if any symptom was marked to notify the nurse on duty of a positive screen for evaluation. There was no documentation to indicate she was evaluated. NA E's COVID-19/Respiratory Virus Screening tool dated 12/16/2020 at 5:49 a.m. indicated she worked the front desk and had a sore throat, cough, and congestion/runny nose. The COVID-19/Respiratory Virus Screening tool indicated if any symptom was marked to notify the nurse on duty of a positive screen for evaluation. There was an unsigned note on the form that said, Nurse approved entrance at this time. NA E's COVID-19/Respiratory Virus Screening tool dated 12/17/2020 indicated she worked the front desk and had a sore throat and cough. The COVID-19/Respiratory Virus Screening tool indicated if any symptom was marked to notify the nurse on duty of a positive screen for evaluation. There was no documentation to indicate she was evaluated. NA E's COVID-19/Respiratory Virus Screening tool dated 12/18/2020 at 5:40 a.m. indicated she worked the front desk and had a cough and congestion/runny nose. The COVID-19/Respiratory Virus Screening tool indicated if any symptom was marked to notify the nurse on duty of a positive screen for evaluation. There was no documentation to indicate she was evaluated. NA E's COVID-19/Respiratory Virus Screening tool dated 12/25/2020 at 5:45 a.m. indicated she worked the front desk and had a cough. The COVID-19/Respiratory Virus Screening tool indicated if any symptom was marked to notify the nurse on duty of a positive screen for evaluation. There was no documentation to indicate she was evaluated. NA E's Time Detail Report dated 12/30/2020 indicated she worked 12/14/2020-12/18/2020 and 12/22/2020-12/25/2020. CNA F's COVID-19/Respiratory Virus Screening tool dated 12/23/2020 at 10:00 p.m. indicated she had muscle/body aches and congestion/runny nose. The COVID-19/Respiratory Virus Screening tool indicated if any symptom was marked to notify the nurse on duty of a positive screen for evaluation. There was no documentation to indicate she was evaluated. CNA F's COVID-19/Respiratory Virus Screening tool dated 12/24/2020 at 10:00 p.m. indicated she had muscle/body aches and congestion/runny nose. The COVID-19/Respiratory Virus Screening tool indicated if any symptom was marked to notify the nurse on duty of a positive screen for evaluation. There was no documentation to indicate she was evaluated. CNA F's COVID-19/Respiratory Virus Screening tool dated 12/28/2020 at 10:00 p.m. indicated she had muscle/body aches and congestion/runny nose. The COVID-19/Respiratory Virus Screening tool indicated if any symptom was marked to notify the nurse on duty of a positive screen for evaluation. There was no documentation to indicate she was evaluated. CNA F's Time Detail Report dated 12/30/2020 indicated she worked 12/23/2020, 12/24/2020, 12/27/2020, and 12/28/2020. LVN G's COVID-19/Respiratory Virus Screening tool dated 12/24/2020 at 5:20 p.m. indicated she had a cough and a headache. The COVID-19/Respiratory Virus Screening tool indicated if any symptom was marked to notify the nurse on duty of a positive screen for evaluation. There was no documentation to indicate she was evaluated. LVN G's Time Detail Report dated 12/30/2020 indicated she worked 12/24/2020. LVN H's COVID-19/Respiratory Virus Screening tool dated 12/16/2020 at 5:45 p.m. indicated she had a sore throat. The COVID-19/Respiratory Virus Screening tool indicated if any symptom was marked to notify the nurse on duty of a positive screen for evaluation. There was no documentation to indicate she was evaluated. LVN H's Time Detail Report Dated 12/30/2020 indicated she worked 12/16/2020. RN J's COVID-19/Respiratory Virus Screening tool dated 12/22/2020 at 5:53 p.m. indicated she had new loss of taste or smell. The form indicated she was previously positive for COVID on 10/21/2020. The COVID-19/Respiratory Virus Screening tool indicated if any symptom was marked to notify the nurse on duty of a positive screen for evaluation. There was no documentation to indicate she was evaluated. RN J's Time Detail Report dated 12/30/2020 indicated she worked 12/22/2020. Cook K's COVID-19/Respiratory Virus Screening tool dated 12/18/2020 at 6:41 a.m. indicated she had a sore throat, cough, headache fatigue, and congestion/runny nose. The COVID-19/Respiratory Virus Screening tool indicated if any symptom was marked to notify the nurse on duty of a positive screen for evaluation. There was no documentation to indicate she was evaluated. Cook K's Time Detail Report dated 12/30/2020 indicated she worked 12/18/2020. The DON's COVID-19/Respiratory Virus Screening tool dated 12/18/2020 at 8:15 a.m. indicated he had vomiting/diarrhea. The COVID-19/Respiratory Virus Screening tool indicated if any symptom was marked to notify the nurse on duty of a positive screen for evaluation. There was no documentation to indicate he was evaluated. An undated positive COVID results list indicated the following: - on 12/13/2020, 10 residents tested positive for COVID and received their results between 12/13/2020 and 12/17/2020. All residents resided on the North side (COVID negative unit) of the building. - on 12/15/2020 CNA A tested positive for COVID and received her results on 12/16/2020. - on 12/18/2020, 9 residents tested positive for COVID and received their results on 12/21/2020. 8 of the residents resided on the North side (COVID negative unit) of the building. LVN H tested positive for COVID and received her results on 12/18/2020. LVN C tested positive for COVID and received her results on 12/21/2020. ADON B tested positive for COVID and received her results on 12/22/2020. - on 12/21/2020, 7 residents tested positive for COVID and received their results on 12/24/2020. All residents resided on the North side (COVID negative unit) of the building. CNA D tested positive for COVID. - on 12/23/2020, 7 residents tested positive for COVID and received their results on 12/26/2020. 3 of the residents resided on the North side (COVID negative unit) of the building. NA E tested positive for COVID and received her results on 12/25/2020. The surveyor made multiple attempts to contact the DON and was unsuccessful. On 12/29/2020 at 5:27 p.m., the RDO and corporate RN were notified of the Immediate Jeopardy (IJ) situation, a completed IJ template was provided to the facility for the above failures, and a Plan of Removal was requested. On 12/30/2020 at 8:37 a.m., the RDO and corporate RN were notified the facility's Plan of Removal was accepted and included: 1. Notify Medical Director of Immediate Jeopardy status. Complete - MD notified at 6:55pm 12/29/20. 2. Notify Regional Director of Clinical Services of Immediate Jeopardy status. Corporate RN notified along with RDO at 12/29/20 @ 5:25 pm. 3. Notify Regional Director of Operations of Immediate Jeopardy status. RDO notified by surveyor at 5:25pm 12/29/20. 4. Notify Administrator and DON - Administrator and Director of Nurses both notified at 6:15PM 12/29/20. 5. CNA A was taken off the schedule on 12/15/20 and has not returned to work since the time of this plan. 6. ADON B was taken off the schedule 12/18/20 and has since returned to work asymptomatic. 7. LVN C was taken off the schedule on 12/21/20 and has returned to work asymptomatic. 8. CNA D was taken off the schedule on 12/16/20 and remains off facility schedule. 9. The front desk worker (NA E) was taken off the schedule on 12/25/20 and remains off work. 10. COVID-19 Respiratory Virus Screening Tools for employees who worked in the facility on 12/29/20 were reviewed by the Regional Nurse Consultant for completeness and indications of positive symptoms. Corporate RN started at 6:00pm and completed at 6:45pm 12/29/20. 11. COVID-19 Respiratory Virus Screening Tools that were incomplete or not completed will have follow up with identified employee and tool completed by nursing management. Started at 6:03pm 12/29/20. 12. Facility residents were evaluated/assessed by licensed nursing staff for COVID-19 signs and symptoms, starting 7:20pm 12/29/20. 13. Facility staff will be provided education on 12/29/20 by ADON/designee beginning at 6:15pm on the following topics: - COVID-19, Prevention and Control Policy and Procedure - Screening Procedures - Completion of Screening Tool - Notification to Supervisor/Administrator of any signs or symptoms of COVID-19 14. Employees who may be assigned to complete screening tools will be provided education including a competency evaluation by ADON/Designee of screening procedures and completion of COVID-19 Respiratory Virus Screening Tool. Started 7:00pm 12/29/20. 15. Compliance will be monitored through: - A review of COVID-19 Respiratory Virus Screening Tool by Administrator/Designee with corrective actions taken for identified concerns. - Observation and completion of COVID-19 competency evaluation twice per week by nursing management with corrective action taken for identified concerns. Audits for compliance will be reviewed by the facility QAPI Committee on a monthly basis for any additional actions if indicated. On 12/30/2020 the surveyor confirmed the facility implemented their plan of removal (POR) sufficiently to remove the IJ by: During an interview on 12/30/2020 at 8:37 a.m., NA M said if anyone has any symptoms marked on the screening log they are to wait outside until a nurse can evaluate them. She said she was trained on the screening process, infection control, and COVID-19. During an interview on 12/30/2020 at 9:26 a.m., RN L said she was trained on screening procedures, infection control, and COVID-19 yesterday and was told to not work if you have or report symptoms. During an interview on 12/30/2020 at 9:37 a.m., LVN N said she was trained on COVID-19, screening procedures, and infection control before she started her shift this morning. During an interview on 12/30/2020 at 9:40 a.m., CNA O said she was trained this morning on screening processes and COVID-19. She said if an employee reports symptoms and is made to work they are to notify the administrator to review the screening sheet. During an interview on 12/30/2020 at 10:00 a.m., the Admin said she is unsure why the DON was having people work with symptoms. She said their policy is to send someone home if they have any symptoms that are not chronic issues such as migraines or allergies [REDACTED]. She said she has her phone number posted throughout the facility for staff to get into contact with her easier. A Record of In-Service form titled COVID-19 Screening Proficiency/Procedure dated 12/29/2020 included facility policy on the employee screening process, a copy of the employee screening tool, and a copy of the COVID-19 screener proficiency test. A Record of In-Service form titled COVID-19 prevention and Control dated 12/29/2020 included the facility COVID-19 prevention and control policy. Staff were given copies for future reference. A Record of In-Service form titled Screening Procedures dated 12/29/2020 indicated any staff that that report symptoms are to be sent home even if their supervisor tell them to work. They are to report any concerns to the administrator. COVID-19 Screener Proficiency tests initiated 12/29/2020 and completed 12/30/2020. Staff responsible for screening other employees met all competency areas. On 12/30/2020 at 10:45 a.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a level of actual harm with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.