Every finding on record at Legacy Nursing and Rehabilitation of Lafourche

Based on observation, interviews, and record review, the facility failed to ensure the kitchen's walk-in cooler was maintained in a sanitary manner. Findings: Review of the facility's undated Food Safety and Sanitization policy and procedure revealed, in part, stored food was to have been protected from contamination and growth of any pathogenic organisms. Review of the facility's undated Dietary Manager job description revealed, in part, the duties and responsibilities of the Dietary Manager included ensuring the kitchen was maintained as required by state and federal governing agencies regulations and standards, keeping the kitchen clean and organized, and keeping the work areas clean. Review of the facility's February 2026 Dietary Cleaning Schedule revealed, in part, floors of the cooler should be checked for food and/or spills, and mopped. Observation of the kitchen's walk-in cooler on 02/23/2026 at 8:45AM revealed 3 decomposing tomatoes, one brown decomposing lemon like fruit, a discolored milk carton laying on its side sitting in an unknown white curdled substance, and an unknown brown liquid on the floor underneath the raised storage racks. Observation of the kitchen's walk-in cooler on 02/24/2026 at 11:10AM with S4Dietary Manager revealed 3 decomposing tomatoes, one brown decomposing lemon like fruit, a discolored milk carton laying on its side sitting in an unknown white curdled substance, and an unknown brown liquid on the floor underneath the raised storage racks. In an interview on 02/24/2026 at 11:15AM, S4Dietary Manager indicated the above mentioned lemon on the ground in the walk in cooler was brown and decomposing, the above mentioned tomatoes were rotten with mold growth, and the above mentioned milk carton was leaking and disintegrating. S4Dietary Manager further indicated the floors in the cooler were not kept in a sanitary manner and should have been.

Based on interviews and record reviews, the facility failed to ensure staff immediately consulted a physician regarding a resident's change of condition for 1 (Resident #52) of 1 sampled residents reviewed for notification of change. Findings:Review of the facility's undated Incident and Accident policy and procedure revealed, in part, the nurse will conduct an immediate investigation of any incident and accident. Further review revealed all incidents that occurred in the building required an incident report regardless of how minor the incident may have been. Review of the facility's undated Certified Nursing Assistant (CNA) job description revealed, in part, CNA duties and responsibilities included informing the assigned nurse and/or nursing management of a change in the resident's condition. On 02/24/2026 at 1:00PM, S2Director of Nursing (DON) was presented with a request for any and all documents related to the incident on 02/18/2026 involving Resident #52. Review of the facility's incident report, dated 02/18/2026 at 4:00PM, revealed, in part, Resident #52's right 4th and 5th digit were bruised. Further review revealed Resident #52 indicated his pinky finger was bruised and the incident occurred this morning (02/18/2026) during a transfer from the bed to the wheelchair. Review of Resident #52's right hand x-ray results, dated 02/19/2026 at 4:38PM, revealed, in part, Resident #52 had an a diagnosis of an acute appearing fracture of the base of the fifth proximal phalanx (bone in a finger). Further review revealed there was a mild displacement of the distal fragment (the broken piece of bone located further away from the bodies center.) Review of Resident #52's record revealed, in part, no documentation Resident #52's physician was consulted the morning of 02/18/2026 when the above mentioned incident occurred. In an interview on 02/24/2026 at 9:49AM, S5Licensed Practical Nurse (LPN) indicated she was the nurse assigned to Resident #52 during the 6:00AM to 2:00PM shift on 02/18/2026. S5LPN further indicated Resident #52's right hand had gotten caught in his wheelchair during a mechanical lift transfer on the morning shift (6:00AM to 2:00PM) of 02/18/2026. S5LPN further indicated S7Certified Nursing Assistant (CNA) did not report the above mentioned incident to her until the following day, 02/19/2026. In an interview on 02/24/2026 at 1:32PM, S7CNA indicated she was the CNA assigned to Resident #52 during the 6:00AM to 2:00PM shift on 02/18/2026. S7CNA further indicated when she lowered Resident #52 down into his wheelchair using the mechanical lift, Resident #52's right hand had gotten caught in the wheelchair. S7CNA indicated she did not report the above mentioned incident to S5LPN until 02/19/2026. S7CNA further indicated she did not report the above mentioned incident to S5LPN or the facility's administration when it occurred on 02/18/2026 and should have. In an interview on 02/26/2026 at 10:45AM, S2DON confirmed Resident #52's incident occurred at 9:00AM on 02/18/2026 and was not reported by S7CNA until the following day, 02/19/2026. S2DON further indicated she was unaware S7CNA knew that Resident #52's hand was caught in the wheelchair at the time of the above mentioned incident on 02/18/2026. In an interview on 02/26/2026 at 12:10AM, S1Administrator was presented with the above mentioned findings. S1Administrator indicated she was unaware S7CNA had not notified the nurse and/or completed an incident report on 02/18/2026 but should have.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident's catheter was maintained in a sanitary condition for 1 (Resident #8) of 2 residents investigated for urinary catheter usage.Review of Resident #8's medical record revealed, in part, Resident #8 was admitted to the facility on [DATE] with diagnoses, which included, obstructive uropathy (a blockage that restricts the flow of urine), and benign prostatic hyperplasia (a condition where to prostate grows larger and restricts the flow of urine). Review of Resident #8's Minimum Data Set with an Assessment Reference Date of 01/08/2026 revealed, in part, Resident #8 had a Brief Interview for Mental Status score of 15, which indicated Resident #8 was cognitively intact. Review of Resident #8's care plan with a goal date of 04/14/2026 revealed, in part, Resident #8 had a suprapubic catheter, and staff were to ensure Resident #8's catheter was secured appropriately. Review of Resident #8's February 2026's physician's orders revealed, in part, an order to ensure Resident #8's suprapubic catheter was hanging freely off of the floor. Observation on 02/24/2026 at 1:36PM revealed Resident #8's catheter bag, which was inside a privacy bag, was hanging on the back of Resident #8's wheelchair and was touching the floor. Further observation revealed the bottom of Resident #8's privacy bag was soiled with an unknown black/gray substance. Observation on 02/25/2026 at 10:55AM revealed Resident #8's catheter bag, which was inside a privacy bag, was hanging on the back of Resident #8's wheelchair and was touching the floor. Further observation revealed the bottom of Resident #8's privacy bag was soiled with an unknown black/gray substance. In an interview on 02/26/2026 at 9:18AM, S5Licensed Practical Nurse indicated Resident #8's catheter bag should hang freely off of the floor, and confirmed Resident #8's catheter bag should not be touching the floor. In an interview on 02/26/2026 at 10:10AM, S2Director of Nursing indicated Resident #8's urinary catheter bag was touching the floor, and it should have been freely hanging off the floor as ordered. In an interview on 02/26/2026 at 10:43AM, S1Administrator confirmed the above deficient practice.

Based on observations, interviews, and record reviews, the facility failed to ensure:1. Staff followed enhanced barrier precautions when providing care to residents with an indwelling catheter (Resident #8, Resident #65); and,2. Staff performed hand hygiene between glove changes (Resident #65).This deficient practice was identified for 2 (Resident #8, Resident #65) of 2 sampled residents observed for catheter care. Findings:1. Review of the facility's undated Enhanced Barrier Precautions (EBP) Policy and Procedure revealed, in part, EBP to have been used during high-contact care activities for residents with indwelling medical devices, regardless of their multidrug resistance status. Further review revealed EBP should be used when the staff was performing high-contact resident care activities, such as, when providing hygiene, and when caring for a urinary catheter device. Further review revealed personal protective equipment (PPE) of a gown and gloves were to be applied prior to performing the high-contact resident activity. Resident #8 Review of Resident #8's Minimum Data Set (MDS) with an Assessment Reference Data (ARD) of 01/08/2026 revealed, in part, Resident #8 had an indwelling catheter. Review of Resident #8's care plan revealed, in part, Resident #8 required EBP related to a suprapubic catheter with a target date of 04/14/2026. Further review revealed, in part, staff would wear PPE during care of an indwelling medical device. Review of Resident #8's February 2026 physician orders revealed, in part, staff were to implement EBP related to Resident #8's suprapubic catheter. Observation on 02/24/2026 at 1:40PM revealed S7Certified Nursing Assistant (CNA) provided catheter care to Resident #8 without wearing a gown. In an interview on 02/24/2026 at 1:44PM, S7CNA indicated Resident #8 was on EBP, and she did not wear a gown while providing catheter care for Resident #8 and should have. In an interview on 02/25/2026 at 9:23AM, S2Director of Nursing (DON) indicated S7CNA should have worn a gown while providing catheter care to Resident #8 who was on EBP, and S7CNA did not. In an interview on 02/25/2026 at 9:25AM, S1Administrator confirmed S7CNA should have worn a gown while providing catheter care for Resident #8 who was on EBP, and S7CNA did not. Resident #65 Review of Resident #65's MDS with an ARD of 12/24/2025 revealed, in part, Resident #65 had an indwelling catheter. Review of Resident #65's care plan with a target date of 03/30/2026 revealed, in part, Resident #65 required EBP related to an indwelling catheter. Further review revealed staff would wear PPE during care of an indwelling medical device. Review of Resident #65's February 2026 physician orders revealed, in part, staff were to implement EBP related to Resident #65's indwelling catheter. Observation on 02/24/2026 at 2:09PM revealed S10Certified Nursing Assistant (CNA) provided incontinence care and catheter care to Resident #65 without wearing a gown. In an interview on 02/24/2026 at 2:09PM, S10CNA indicated Resident #65 was on EBP; therefore, she should have worn a gown and gloves per the requirements. In an interview on 02/24/2026 at 3:08PM, S2Director of Nursing (DON) was notified of the above findings. S2DON indicated S10CNA should have worn a gown while performing incontinence care and catheter care on a resident who required EBP. 2. Review of the facility's undated Hand Hygiene Policy and Procedure revealed, in part, hand hygiene would be performed by staff involved in direct resident contact consistent with accepted standards of practice, to reduce the spread of infections and prevent cross contamination. Further review revealed hand hygiene would be performed via hand sanitizer or hand washing before and after direct resident contact and after removing gloves. Resident #65 Observation on 02/24/2026 at 2:09PM revealed S10CNA applied gloves, opened Resident #65's incontinence brief, and then cleaned feces from Resident #65's perineal area. Further observation revealed, S10CNA then moved Resident #65's blanket removed her gloves and applied a new gloves without performing hand hygiene. Further observation revealed S10CNA then continued to finish wiping Resident #65's perineal area, removed her gloves, applied new gloves, and touched Resident #65's blanket without performing hand hygiene. Further observation revealed S10CNA again removed her gloves, applied new glove, turned Resident #65 to her side, and finished cleaning Resident #65's perineal area without performing hand hygiene. Observation revealed S10CNA did not perform hand hygiene between any glove changes or before touching items in Resident #65's environment during the above mentioned perineal care. In an interview on 02/24/2026 at 2:09PM, S10CNA indicated she should have performed hand hygiene between each glove change, and after any contact with items in Resident #65's environment. In an interview on 02/24/2026 at 3:08PM, S2DON was notified of the above findings. S2DON indicated S10CNA should have performed hand hygiene between all the glove changes and before any contact with items in Resident #65's environment.

Based on observation, interviews, and record reviews, the facility failed to provide adequate supervision to prevent a fall for 1 (Resident #65) of 3 (Resident #44, Resident #55, Resident #65) sampled residents reviewed for falls. This deficient practice resulted in an Immediate Jeopardy situation on 01/17/2025 at 6:35AM, when Resident #65, who required supervision with showers/bathing and had diagnoses, which included, osteoporosis, dementia, and a traumatic brain injury, was able to enter shower room A unattended due to S3Certified Nursing Assistant (CNA) leaving the door propped opened. Resident #65 was found on the floor in shower room A after an unwitnessed fall and had sustained an injury resulting in a C7 (7th cervical vertebrae in the neck) displaced fracture. Resident #65 was required to wear a cervical collar (a device to maintain neck alignment), experienced increased neck pain, depression, decreased mobility and decreased independence as a result of the fall. S1Administrator (ADM) and S2Director of Nursing (DON) were notified of the Immediate Jeopardy on 03/10/2025 at 12:04PM. The Immediate Jeopardy was removed on 03/11/2025 at 3:39PM, after it was verified through observations, interviews, and record reviews, the provider implemented an acceptable Plan of Removal prior to the survey exit. This deficient practice had the likelihood to cause more than minimal harm to the 24 current residents who were assessed by the facility to be at high risk for falls and were able to ambulate and/or self-propel themselves in a wheelchair. Findings: Review of the facility's undated Resident Bathing/Shower Policy and Procedure, revised in 11/2024, revealed, in part, the facility staff should never leave a resident unattended in the tub or the shower room. Review of Resident #65's medical record revealed, in part, Resident #65 was admitted to the skilled nursing facility on 03/26/2024 with a diagnoses of osteoporosis, dementia, and traumatic brain injury. Review of Resident #65's Annual Minimum Data Set with an Assessment Reference Date of 12/12/2024 revealed, in part, Resident #65 had a Brief Interview for Mental Status score of 12, which indicated Resident #65 had mild cognitive impairment. Further review revealed Resident #65 required staff supervision during showers/baths. Review of Resident #65's Fall Risk assessment dated [DATE] revealed, in part, Resident #65 had a score of 18, which indicated Resident #65 was at high risk for falls. Review of Resident #65's progress note dated 01/17/2025, revealed, in part, on 01/17/2025 at 6:35AM, further review revealed Resident #65 was found on the floor of shower room A. Further review revealed Resident #65's right eyelid was swollen with a laceration to the right eyebrow that was actively bleeding. Review of the facility's Incident, Investigation, and Follow-up report dated 01/17/2025 revealed, in part, on 01/17/2025, S3CNA left shower room A unattended and unsupervised. Further review revealed Resident #65 entered the unsupervised shower room A and was found on the shower room floor. Review of Resident #65's hospital record dated 01/17/2025 revealed, in part, Resident #65 was diagnosed with a C7 displaced fracture. Further review revealed an order for Resident #65 to keep the cervical collar on at all times. Review of Resident #65's Physical Therapy Screening dated 01/20/2025 revealed, in part, Resident #65 required increased assistance with Activities of Daily Living (ADLs) following her fall on 01/17/2025 compared to before the fall. Review of Resident #65's electronic Medication Administration Records (eMAR) revealed, in part, Resident #65 had 11 instances of mild to moderate pain after the fall on 01/17/2025 and required administration of acetaminophen (a medication used to treat pain) 650 milligrams (mg) 2 325 mg tablets by mouth on the following dates and times: -01/19/2025 at 9:29AM; -01/19/2025 at 3:09PM; -01/21/2025 at 1:47AM; -01/23/2025 at 11:09AM; -01/28/2025 at 5:17PM; -01/29/2025 at 4:39AM; -01/30/2025 at 5:57AM; -02/05/2025 at 7:33AM; -02/05/2025 at 7:33AM; -02/13/2025 at 8:51AM; -02/15/2025 at 5:47AM; and, -02/17/2025 at 1:57PM. Review of Resident #65's eMAR revealed, in part, Resident #65 had 3 instances of severe pain after the fall on 01/17/2025 and required a Norco (an opioid medication used to treat severe pain) 7.5-325 mg tablet by mouth to be administered on the following dates and times: -02/09/2025 at 10:36PM for a pain scale of 5/10; -02/12/2025 at 5:37AM for a pain scale 5/10; and, -02/17/2025 at 2:58AM for a pain scale 5/10. Review of Resident #65's Psychiatric Progress Note dated 01/29/2025, revealed, in part, Resident #65 experienced depression related to the fall that occurred on 01/17/2025, which resulted in a C7 neck fracture requiring Resident #65 to wear a neck brace for 6 weeks. In an interview on 02/17/2025 at 9:30AM, Resident #65 indicated she was independent with most ADLs until she sustained a fall in the shower on 01/17/2025. Resident #65 further indicated that as a result of her C7 fracture, she had to wear a cervical collar and had not been able to ambulate as she did before the fall on 01/17/2025. In an interview on 02/18/2025 at 8:45AM, Resident #65 indicated she had experienced increased pain in her head and neck since the fall on 01/17/2025. In an interview on 02/19/2025 at 2:50PM, S6Registered Nurse (RN) MDS Coordinator indicated Resident #65 had a significant change in status due to Resident #65's increased need for assistance with ADLs and mobility following Resident #65's fall on 01/17/2025. In an interview on 02/19/2025 at 2:58PM, S2DON indicated the facility's practice was to ensure residents were not left unattended in the shower room. In an interview on 02/19/2025 at 3:16PM, S5LPN confirmed Resident #65 had multiple complaints of pain in her head and neck during the evening shift after her fall on 01/17/2025. In an interview on 02/19/2025 at 3:21PM, S2DON confirmed at the time of Resident #65's fall on 01/17/2025, Resident #65 was unattended in shower room A and should have been supervised with baths and showers. In an interview on 02/19/2025 at 3:23PM, Resident #65 indicated she did not want to be alone, participate in activities, and get up to go to the bathroom independently since the fall that occurred on 01/17/2025. Resident #65 further indicated she was afraid to ambulate out of fear of falling again. Resident #65 also indicated she felt embarrassed to wear the cervical collar. In an interview on 02/19/2025 at 3:41PM, S8Rehabilitation Director indicated before Resident #65's fall on 01/17/2025, Resident #65 was mobile for long distances using her wheelchair, could mobilize short distances by walking, and was able to transfer with little to no assistance. S8Rehabilitaion Director further indicated since Resident #65's fall on 01/17/2025 and her use of a cervical collar, Resident #65 required increased mobility assistance from staff and had become more rigid. In an interview on 02/19/2025 at 4:02PM, S9Restorative Aide indicated Resident #65 had a decline in her mobility and had become more rigid, as a result of wearing a neck brace and Resident #65's fear of falling. In a telephone interview on 02/19/2025 at 4:15PM, S3CNA indicated she was working on 01/17/2025 when Resident #65 was ready to take a shower. S3CNA indicated she rolled another resident out of shower room A, leaving the door to shower room A propped open and unsupervised. S3CNA indicated Resident #65 entered the unsupervised shower room A through the propped open door. S3CNA further indicated S3CNA heard a loud crashing sound which caused her to enter shower room A, S3CNA indicated she then found Resident #65 lying on the floor of shower room A. S3CNA confirmed Resident #65 was in shower room A unsupervised and should not have been. In an interview on 03/10/2025 at 11:22AM, S8Rehabilitation Director indicated Resident #65's fear of falling resulted in Resident #65's decreased independence and mobility. A Plan of Removal was accepted on 03/10/2025 at 12:04PM, which included the following actions to correct the deficient practice: All residents had the potential to be affected by this incident. All residents involved in a major incident would be assessed for psychosocial wellbeing post incident. On 01/17/2025 at 6:35AM, Resident #65 was discovered on the floor in shower room A. The nurse conducted a head-to-toe assessment, neuro checks were initiated, Resident #65's physician was notified, and an order was obtained to send Resident #65 to the emergency room (ER) for evaluation and treated as indicated. Resident #65's responsible party was notified of the incident and the physician's orders. Resident #65 left the facility via ambulance in stable condition. Upon return from the ER, acute charting (clinical documentation by the staff nurse of the resident's condition in relation to the cervical fracture every shift) on Resident #65 continued for 72 hours. The interventions implemented as a result of Resident #65's fall on 01/17/2025 were effective due to no additional incidents in the shower or for Resident #65. On 01/31/2025, all Shower Aides and CNAs on shift were in-serviced on revisions to the Policy and Procedure related to changes on showers/whirlpools' doors. Resident #65 was seen by the Psychiatric Nurse Practitioner (NP) on 01/29/2025. A behavioral health facility was contacted on 03/10/2025 to conduct a follow-up visit regarding information from 01/29/2025 and was provided with Resident #65's medication list for review. On 02/12/2025, upon completion of Resident #65's Social Services quarterly note, there were no indicated changes in Resident #65's mood status, social interaction, and no changes related to the rejection of care or resident choices. On 02/13/2025, an Activity Assessment was completed for Resident #65. S7Activities Director discussed alternative options to provide meaningful social, spiritual, recreational, and leisure activities to prevent loneliness and boredom. S7Activities Director offered Resident #65 the following in-room activities: word searches, word puzzles, color by number, adult coloring sheets, reading material (books, magazines, spiritual literature), daily newspaper, music on iPods, bedside games and cards, spot the different sheets, busy booklets, 1 on 1 visits, reminiscing time and pet therapy. On 02/19/2025, all shower/whirlpool room doors were evaluated for proper function, no issues were identified. On 02/20/2025, the facility revised a Policy and Procedure on Resident Bathing/Shower as it related to shower room doors. On 02/24/2025 at 8:15AM, door audits were initiated by S1ADM or a designee at least 5 times per week for four weeks, monitoring for proper function and adherence to the policy and procedure, and documented on the Bathroom Door Random Audit form. Once the daily audits were completed, S2DON, S11Assistant Director of Nursing (ADON), or designee would conduct audits as needed to assure compliance. On 03/10/2025 at 2:00PM, an in-service was initiated by the facility leadership to ensure that all staff (all departments) were educated on the Policy and Procedure on Resident Bathing/Shower. In-servicing with all scheduled staff would have been educated in person and/or via telephone and witnessed by two staff members, or prior to the next scheduled shift. The in-servicing of staff would have been completed on 03/10/2025. The Policy and Procedure on Resident Bathing/Shower would have been included during the new hire orientation. On 03/10/2025 at 4:00PM, S12Maintenance Supervisor visually inspected all shower/whirlpool doors to assure that all doors were functioning properly. No issues were identified. On 03/10/2025 at 2:30PM, the Incident/Accident policy and procedure were revised to include the psychosocial aspect of residents post incident. On 02/10/2025 at 2:30PM, a post-incident QA initiated related to psychosocial monitoring was created, and education was provided to staff on recognizing psychosocial changes. In-services were initiated on Identifying Residents with Psychosocial Status Changes with staff. In-servicing with all scheduled staff would have been educated in person and/or via telephone or prior to the next scheduled shift. The in-services of staff would be completed on 02/11/2025. The Identifying Residents with Psychosocial Status Changes in-service of staff would have been included during the new hire orientation. All data and findings will be reviewed by the QAPI committee as necessary. The facility asserted the likelihood for serious harm to any recipient no longer existed effective 03/11/2025 at 12:30PM.

Based on interviews and record reviews, the facility failed to develop a plan of care after a fall for 1 (Resident #55) of 3 (Resident #44, Resident #55, Resident #65) sampled residents investigated for falls. Findings: Review of Resident #55's Minimum Data Set with an Assessment Reference Date of 12/26/2024 revealed, in part, a Brief Interview for Mental Status assessment score of 11, which indicated moderate cognitive impairment. Further review revealed Resident #55 had recent falls. Review of Resident #55's Nursing Progress note dated 01/10/2025 at 2:38PM revealed, in part, a Certified Nursing Assistant (CNA) reported to the nurse that Resident #55 was found lying on the floor near Resident #55's recliner, on his back. Review of Resident #55's Plan of Care with a goal date of 05/12/2025 revealed, in part, Resident #55 was at risk for falls related to weakness, use of psychotropic (medications that affect mental status) medications, impaired safety awareness, cognitive impairments, lacks safety awareness and awareness of his own physical limitations, forgetful and confused at times. Further review of Resident #55's Plan of Care revealed no new intervention was developed for the fall dated 01/10/2025. In an interview on 02/18/2025 at 11:52AM, S4Minimum Data Set/Licensed Practical Nurse indicated Resident #55 had a fall on 01/10/2025 from his recliner. S4Minimum Data Set/Licensed Practical Nurse further indicated Resident #55's plan of care was not updated to include an intervention for his fall on 01/10/2025, and should have been. In an interview on 02/18/2025 at 12:15PM, S2Director of Nursing indicated Resident # 55's Plan of Care should have been updated with a fall intervention after his fall on 01/10/2025, but had not been updated as required.

Based on interviews and record review, the facility failed to immediately notify the resident's Responsible Party (RP) after a resident sustained a fall for 1 (Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for falls. Findings included: Review of the facility's incident log dated 10/27/2024 at 12:40AM, revealed, in part, Resident #3 was found sitting on the floor next to her bed with no visible injuries noted. Further review revealed Resident #3's RP was notified on 10/27/2024 at 6:00AM. In an interview on 11/15/2024 at 11:26AM, Resident #3's RP indicated that the facility staff did not notify her that Resident #3 had a fall on 10/27/2024. Resident #3's RP further indicated that she was the person who was notified via telephone or in person of any changes in Resident #3's condition. Resident #3's RP further indicated that she did not know Resident #3 had a fall on 10/27/2024 until today, 11/15/2024. In an interview on 11/15/2024 at 11:36AM, S2Director of Nursing (DON) indicated S3Agency Licensed Practical Nurse (LPN) attempted to contact Resident #3's RP about the fall without success. In a telephone interview on 11/15/2024 at 11:40AM, S3Agency LPN indicated she was unable to reach Resident #3's RP to inform him/her of the fall when she attempted to call. In an interview on 11/15/2024 at 1:35PM, S1Administrator and S2DON indicated Resident #3's Responsible Party was not notified verbally of Resident #3's fall on 10/27/2024, and should have been.

Based on observation and interview, the facility failed to ensure incontinence care was provided in a timely manner for residents who required assistance with personal hygiene. This deficient practice was identified for 2 (Resident #2 and Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) and 1 randomly sampled resident (Resident R1). Findings: Resident #2: Review of Resident #2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/31/2023, in part, revealed Resident #2 required extensive assistance of 1 person for toilet use. Observation on 10/03/2023 at 6:18 a.m., revealed Resident #2's adult brief was saturated with urine which went through her adult brief and onto a pad that was placed beneath her. Resident #3: Review of Resident #3's MDS with an ARD of 09/07/2023, in part, revealed Resident #3 required extensive assistance of 2 or more staff members for toilet use. Observation on 10/03/2023 at 6:45 a.m., revealed Resident #3's adult brief was saturated with urine which went through her adult brief and onto a pad that was placed beneath her. Resident R1: Review of Resident R1's MDS with an ARD of 08/31/2023 revealed, in part, Resident R1 required limited assistance of 1 person for toilet use. Observation on 10/03/2023 at 05:36 a.m., revealed Resident R1 had on an adult brief and an adult pull up. Observation further revealed Resident R1's adult brief and adult pull up was saturated with urine which went through her adult brief and adult pull up onto a pad that was placed beneath her. In an interview on 10/03/2023 at 11:45 a.m., S3Certified Nursing Assistant (CNA) stated resident's adult briefs should not have been soaked through to the pad. In an interview on 10/03/2023 at 12:36 p.m., S2CNA stated that sometimes the residents are saturated with urine and their pad placed beneath them is also wet with urine when she comes to work. S2CNA further stated some of the residents tell her that a staff does not come check on them and provide incontinence care at night. In an interview on 10/03/2023 at 1:02 p.m., S4CNA stated residents should not have on an adult brief and an adult pull up. S4CNA further stated Random Resident #1 should not have had on a pull up brief and a diaper and she should not have wet through to the pad. In an interview on 10/03/2023 at 12:45 p.m. S5CNA stated that she comes on in the morning and sometimes resident's adult briefs are saturated with urine that has gone through to the pad. S5CNA further stated resident's adult briefs should not be saturated in urine that has leaked through to the pad. In an interview on 10/03/2023 at 1:52 p.m. S6CNA stated she comes to work in the morning and sometimes residents have dried feces on them and the diapers are soaked through to the pad to where the entire bed has to be changed. S6CNA further stated that this should not happen. In an interview on 10/04/2023 at 1:42 p.m. S7Licensed Practical Nurse stated she has arrived for her shift in the morning and has received complaints from the CNAs about residents being saturated in urine. S7LPN further stated the residents should not be saturated in urine. In an interview on 10/04/2023 at 10:02 a.m. S1Director of Nursing (DON) stated residents should not be in urine to where it comes through the diapers onto the pads. S1DON confirmed CNAs should make more frequent rounds to see if residents need incontinence care.

Based on interviews, observation, and record review, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to have a system in place to prevent and control the transmission of COVID-19 infections in the facility by: 1.) failing to ensure staff used personal protective equipment (PPE) with COVID-19 positive residents (Resident #44, Resident#47, Resident #55 and Resident #66); 2.) failing to ensure staff quarantined and immediately tested residents (Resident #22 and Resident #46) who displayed symptoms of COVID-19; and 3.) failing to ensure COVID-19 screenings for signs and symptoms were completed by visitors and staff. This deficient practice resulted in an Immediate Jeopardy situation on 02/13/2023, when the facility identified Resident #6, Resident #14, Resident #44, Resident #47, Resident #55, and Resident #66 tested positive for COVID-19. The facility failed to utilize proper PPE (KN95 or N95 masks) and to quarantine Resident #22 and Resident #46 displayed signs and symptoms of COVID-19 on 02/15/2023. The facility failed to immediately test Resident #22 and Resident #46 who had symptoms of COVID-19. The facility failed to ensure staff and visitors were screened for signs and symptoms of COVID-19 prior to entering the facility. The facility's failure to implement infection control measures, resulted in Resident #43 and Resident #53 testing positive for COVID-19 on 02/15/2023. As of 02/15/2023, there were 8 active resident COVID-19 cases. S1Adminisistrator was notified of the Immediate Jeopardy situation on 02/15/2023 at 2:42 p.m. This deficient practice continued at more than minimal harm and had the potential to cause serious injury, harm or death for the remaining 63 non-positive COVID-19 residents residing in the facility that were at risk for contracting COVID-19. The facility presented the following Plan of Removal on 02/16/2023 at 4:30 p.m.: There were eight active COVID-19 resident cases and two active COVID-19 staff cases in the facility. This had the potential to affect any of the 63 non-COVID-19 positive residents who resided in the facility. Resident #43 and Resident #53 were affected by the deficient practice and tested positive for COVID-19 on 02/15/2023. All remaining 63 non-COVID-19 residents were at potential risk for COVID-19. The residents and staff (who were at the facility for his or her scheduled shift) were tested on [DATE] at 5:30 p.m. for COVID-19. From the testing conducted on 02/15/2023, two new resident (Resident #43 and Resident #53) cases were identified. The confirmed cases were placed on isolation precautions immediately after positive results on 02/15/2023. On 02/15/2023 at 8:15 p.m., the staff who were not tested on [DATE] were notified by phone that he or she will need to be tested at the facility on 02/16/2023 or prior to his or her next scheduled shift. The facility implemented a policy and procedure on the proper usage and application of PPE with a COVID-19 positive resident. On 02/15/2023 at 6:30 p.m. an in-service with return demonstration was conducted with staff (direct hire, contract, hospice, other) on the proper procedure for applying and removing PPE with a COVID-19 positive and removing PPE with a COVID-19 positive resident. Staff in-service were completed on 02/16/2023 at 12:30 p.m. The Director of Nursing (DON), Assistant Director of Nursing (ADON), or designee would conduct evaluations on random staff (one from each department) from each shift with return demonstration on proper application and removal of personal protective equipment twice per week for two weeks beginning 02/15/2023 and ending 03/15/2023, then once per week for two weeks beginning 03/06/2023 and ending 03/19/2023. Staff (one from each department) from each shift would perform return demonstration on proper application and removal of personal protective equipment twice a month for one month beginning on 03/20/2023 and ending 04/16/2023, then once a month for four months beginning 04/17/2023 and ending 08/06/2023 (one from each department). A form had been created that would be completed with each evaluation. All staff (direct hire, contract, hospice, other) would be educated/re-educated on the facility's policy and procedure on the proper usage and application of personal protective equipment with a COVID-19 positive resident on hire, annually, and as needed. On 02/15/2023 at 6:30 p.m. the facility implemented a policy and procedure on how to identify residents with signs and symptoms of COVID-19, reporting, and testing. All staff (direct hire, contract, hospice, other) were in-serviced on the proper procedures on who to notify when signs and symptoms were identified and completed on 02/16/2023 at 12:30 p.m. Resident #22 and Resident #46 exhibited signs and symptoms of having COVID-19 and were not tested or isolated. Resident #46 was tested on [DATE] at 12:30 p.m. and tested negative. Resident #22 was tested on [DATE] at 12:35 p.m. and tested positive. Resident #22 was placed on isolation. The DON, ADON, or designee would re-educate and evaluate three random staff members per shift (direct hire, contract, hospice, other) on the identification of signs and symptoms of COVID-19, reporting, and testing twice per week for two weeks beginning 02/15/2023 and ending on 03/05/2023, then once per week for two weeks beginning 03/06/2023 and ending 03/19/2023. Staff (one from each department) from each shift would be evaluated on proper identification, reporting, and testing procedures twice a month for one month beginning on 03/20/2023 and ending 04/16/2023, then once a month for four months 04/17/2023 and ending 08/06/2023 (one from each department). A competency form has been created and will be completed with each evaluation of staff. All staff (direct hire, contract, hospice, other) would be educated/re-educated on the facility's policy and procedure on how to identify residents with signs and symptoms of COVID-19, reporting, and testing on hire, annually, and (as needed) such as an outbreak. On 02/14/2023 a designated administrative staff will be present at all times to instruct visitors on proper screening procedures. Upon entering the facility all visitors must take their temperature and answer the signs and symptoms questionnaire. On 02/15/2023 at 7:00 p.m., an email/phone calls were sent out to the responsible parties as a reminder of the procedure. All email/phone calls were completed on 02/15/2023 at 7:30 p.m. by the administrative staff. On 02/16/2023 at 3:30 p.m., all staff were re-educated on the process of taking his or her temperature and answering the signs and symptoms questionnaire prior to entering the facility. The staff were also re-educated on the signs and symptoms of COVID-19 per Centers for Disease Control and Prevention (CDC) guidelines. If any staff's temperature is below 100 degrees and none of the signs and symptoms are present on the questionnaire, the staff may report to work. Beginning on 02/16/2023, the DON, ADON, or designee would monitor the questionnaire for completion daily for two weeks, then twice a week for two weeks. On 02/15/2023, A COVID-19 Action Plan was implemented to designate administrative staff of specific job duties in the event of a COVID-19 outbreak. The administrator would be notified immediately of a resident or staff positive COVID-19 result. The administrator, DON, or designee will be responsible for notifying the Medical Director, Facility Board of Directors, and Region 3 Office of Public Health (OPH). On 02/16/2023 at 2:30 p.m., S1Administrator, S2Director of Nursing, S3Assistant Director of Nursing held a telephone conference with the Facility's President of the Board. The deficient practices cited on the plan removal was discussed detailing the submitted corrective actions submitted for approval. The topics discussed was the current status of COVID-19 in the building, surveillance policy, isolation policy, identification of COVID-19 signs and symptoms, future plans to update and implement the Infection Prevention Program. The teleconference was completed on 02/16/2023 at 3:30 p.m. The Board President would monitor the plan of removal implemented by the facility for compliance starting on 02/16/2023. The Board President, Administrator, DON, and ADON will meet once a week for two months ending 04/16/2023, then once every other week for a month beginning 04/17/2023 ending 05/14/2023. Afterwards monthly, they would meet for three months, beginning 05/15/2023 ending 08/06/2023. The Immediate Jeopardy was removed on 02/16/2023 at 6:47 p.m., when the provider presented an acceptable plan of removal. Through observations, interviews, and record reviews, it was determined the facility implemented an acceptable Plan of Removal, prior to the survey exit. Findings: Cross reference F880 and F882. In an interview on 02/15/2023 at 11:25 a.m., S1Administrator confirmed signs and symptoms of COVID-19 and temperatures had not been checked when all visitors entered the facility. S1Administrtor further stated visitor sign in log should be completed for all visitors who enter the facility. In an interview on 02/15/2023 at 11:35 a.m., S2Director of Nursing (DON) stated and confirmed that staff should have used PPE to include gowns, KN95 masks or N95 masks, surgical mask to cover the KN95 masks or N95 masks, face shields or goggles, and shoe covers when in the room of a COVID-19 positive resident and they were not. S2DON further stated and confirmed this also applied to housekeeping staff who cleaned the rooms of a COVID-19 positive residents. In an interview on 02/16/2023 at 5:15 p.m., S1Administrator confirmed she did not ensure the facility used its resources to effectively prevent the spread of COVID-19 in the facility.

45877 Based on interviews, observation, and record review, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to have a system in place to prevent and control the transmission of COVID-19 infections in the facility by: 1.) failing to ensure staff used personal protective equipment (PPE) with COVID-19 positive residents (Resident #44, Resident#47, Resident #55 and Resident #66); 2.) failing to ensure staff quarantined and immediately tested residents (Resident #22 and Resident #46) who displayed symptoms of COVID-19; and 3.) failing to ensure COVID-19 screenings for signs and symptoms were completed by visitors and staff. This deficient practice resulted in an Immediate Jeopardy situation on 02/13/2023, when the facility identified Resident #6, Resident #14, Resident #44, Resident #47, Resident #55, and Resident #66 tested positive for COVID-19. The facility failed to utilize proper PPE (KN95 or N95 masks) and to quarantine Resident #22 and Resident #46 who displayed symptoms of COVID-19 on 02/15/2023. The facility failed to immediately test Resident #22 and Resident #46 who had symptoms of COVID-19. The facility failed to ensure staff and visitors were screened for signs and symptoms of COVID-19 prior to entering the facility. The facility's failure to implement infection control measures, resulted in Resident #43 and Resident #53 testing positive for COVID-19 on 02/15/2023. As of 02/15/2023, there were 8 active resident COVID-19 cases. S1Adminisistrator was notified of the Immediate Jeopardy situation on 02/15/2023 at 2:42 p.m. This deficient practice continued at more than minimal harm and had the potential to cause serious injury, harm or death for the remaining 63 non-positive COVID-19 residents residing in the facility that were at risk for contracting COVID-19. The facility presented the following Plan of Removal on 02/16/2023 at 4:30 p.m.: 1. Resident #43 and Resident #53 were affected by the deficient practice by testing positive for COVID-19. 2. Resident #43 and Resident #53 were then put on isolation precautions. 3. All the remaining 63 COVID-19 negative residents were at risk for the potential to become positive with COVID-19. All staff were required to wear KN95 masks at all times, except when eating or drinking. Staff that were directly caring for COVID-19 positive residents were required to wear a N95 mask. Residents were encouraged to wear surgical masks when in common areas. All visitors were required to wear a mask. A sign was posted at the entrance of the facility on how to properly wear a mask. Visitation and Staff Log On 02/15/2023 a designated administrative staff will be present at all times to direct the visitors on the proper procedure. Upon entering the facility all visitors must take their temperature and answer the signs and symptoms questionnaire. On 02/15/2023 at 7:00 p.m., an email/phone call was sent out to the responsible parties as a reminder of the procedure. All email/phone calls were completed on 02/15/2023 at 7:30 p.m. by the Administrative staff. On 02/16/2023 at 3:30 p.m., all staff were re-educated on the process of taking his or her temperature and answering the signs and symptoms questionnaire, prior to entering the facility. The staff were also re-educated on the signs and symptoms of COVID-19 per Center for Disease Control guidelines. If any staff's temperature was below 100 degrees and none of the signs and symptoms were present, the staff will be able to report to work. Effective on 02/16/2023, S2Director of Nursing (DON), S3Assistant Director of Nursing/Infection Preventionist (ADON/IP) or designee will monitor the signs and symptoms questionnaire for completion daily for two weeks, then twice a week for two weeks. The residents and staff (ones who were at the facility for his or her scheduled shift) were tested on [DATE] at 5:30 p.m. for COVID-19 due to the identification of a potential risk of spreading COVID-19. From the testing conducted on 02/15/2023, two new resident cases (Resident #43 and Resident #53) were identified. The confirmed cases were placed on isolation precautions immediately after positive results on 02/15/2023. On 02/15/2023 at 8:15 p.m., the staff who were not tested on [DATE] were notified by phone that he or she would need to be tested at the facility on 02/16/2023 prior to his or her next scheduled shift. The facility implemented a policy and procedure on the proper procedure for usage and application of PPE with a COVID-19 positive resident. On 02/15/2023 at 6:30 p.m., an in-service with return demonstration was conducted with staff (direct hire, contract, hospice, other) on the proper procedure for applying and removing personal protective equipment with a COVID-19 positive resident. In-servicing with all staff was completed on 02/16/2023 at 12:30 p.m. S2DON, S3ADON/IP, or designee will conduct evaluations on random staff (one from each department) from each shift with return demonstration on proper application and removal of personal protective equipment twice per week for two weeks beginning 02/15/2023 and ending 03/05/2023, then once per week for two weeks beginning 03/06/2023 and ending 03/19/2023. Staff (one from each department) from each shift will perform return demonstration on proper application and removal of personal protective equipment twice a month for one month beginning on 03/20/2023 and ending 04/16/2023, then once a month for four months beginning 04/17/2023 and ending 08/06/2023 (one from each department). A form has been created that will be completed with each evaluation. All staff (direct hire, contract, hospice, other) will be educated/re-educated on facility's policy and procedure on the proper procedure for usage and application of personal protective equipment with a COVID-19 positive resident on hire, annually, and as needed if there is an outbreak. On 02/15/2023 at 6:30 p.m., the facility implemented a Policy and Procedure on how to identify residents with signs and symptoms of COVID-19, reporting, and testing, All staff (direct hire, contract, hospice, other) were in-serviced on the proper procedures on who to notify when these signs are identified and completed on 02/16/2023 at 12:30 p.m. The DON, ADON/IP, or designee will re-educate and evaluate three random staff members per shift (direct hire, contract, hospice, other) on the identification of signs and symptoms, reporting, and testing twice per week for two weeks beginning 02/15/2023 and ending 03/05/2023, then once per week for two weeks beginning 03/06/2023 and ending 03/19/2023. Staff (one from each department) from each shift will be evaluated on proper identification, reporting, and testing procedures twice a month for one month beginning on 03/20/2023 and ending 04/16/2023, then once a month for four months 04/17/2023 and ending 08/06/2023 (one from each department). A competency form has been created that will be completed with each evaluation of staff. All staff (direct hire, contract, hospice, other) will be educated/re-educated on the facility's policy and procedure on how to identify residents with signs and symptoms of COVID-19, reporting, and testing on hire, annually, and (as needed) if there is an outbreak. On 02/15/2023, the facility failed to quarantine and test Resident #22 and Resident #46 who exhibited signs and symptoms of COVID-19. The residents who exhibited signs and symptoms were tested for COVID-19. Once it was confirmed that Resident #22 tested positive, she was placed on isolation precautions per facility protocol. On 02/15/2023, education was conducted with the nurses on the importance of immediate action, following identification of a resident with signs and symptoms of COVID-19 to prevent the transmission of the virus. The nurses were instructed to immediately place the resident in his or her room if signs and symptoms were exhibited, perform COVID-19 testing immediately, and place on surveillance list if negative or isolation precautions if positive. On 02/15/2023, education on proper use and applying/removing personal protective equipment when in contact with a COVID-19 resident was conducted with staff. In-services and education were completed with all staff on 02/16/2023 at 12:30 p.m. If a resident exhibits signs and symptoms of COVID-19, it should be reported to the nurse immediately. If the resident is in a general area of the facility, he or she will be placed in his or her room for testing. If the results are negative, the resident will be placed on a surveillance list for five days for continued monitoring. Nurses will monitor for worsening signs and symptoms. Nurses will assess and document on these residents every shift while on the surveillance list. The residents on the surveillance list will be retested on day three. If a resident's symptoms worsen prior to next the next scheduled test date, he or she will be tested immediately. Residents who test positive will be placed on isolation precautions per facility protocol. Testing will be performed on residents and staff who exhibit signs and symptoms of COVID-19. If any resident or staff test results are positive for COVID-19, the facility will test all residents and staff as soon as possible on the same day to prevent transmission of COVID-19. The facility will test in accordance with CDC guidelines. In the event that there are new cases identified prior to the next scheduled testing day, all resident and staff will be tested as soon as possible on that same day due to the identification of potential risks of spreading COVID-19. Signs are placed on the entrance doors to inform visitors and staff that the facility has a current outbreak of COVID-19. These signs include education on identifying signs and symptoms of COVID-19, hand hygiene, and how to properly wear face masks. The Immediate Jeopardy was removed on 02/16/2023 at 6:47 p.m., when the provider presented an acceptable plan of removal. Through observations, interviews, and record reviews, it was determined the facility implemented an acceptable Plan of Removal, prior to exit. Findings: 1. Review of the facility's Personal Protective Equipment Policy, revealed, in part, 3. Protective clothing provide to our employees includes but is not necessarily limited to: a. Gowns (disposable); b. Gloves (sterile, non-sterile); c. Masks; d. Eyewear (disposable glasses, goggles and/or face shields); and e. Shoe covers (disposable). Review of the facility's Isolation Transmission Base Precautions Policy, revealed, in part 4.a. Ensure that protective equipment (i.e. gloves, gowns, masks, etc.) is maintained near the resident's room so that everyone entering the room can access what they need. Review of Resident #47's Nurse's Notes dated 02/13/2023 at 2:29 p.m., revealed Resident #47 tested positive for COVID-19 and was moved to an isolation room. Review of Resident #44's Nurse's Notes dated 02/13/2023 at 6:17 p.m., revealed Resident #44 tested positive for COVID-19 was placed in quarantine. Review of Resident #55's Nurse's Notes dated 02/13/2023 at 6:14 p.m., revealed Resident #55 tested positive for COVID-19 and placed in quarantine and droplet/contact precautions initiated. Review of Resident #6's Nurse's Notes dated 02/13/2023 at 6:16 p.m., revealed Resident #6 tested positive for COVID-19 and place in quarantine and droplet/contact precautions initiated. Review of Resident #14's Nurse's Notes dated 02/13/2023 at 6:19 p.m., revealed Resident #14 tested positive for COVID-19 and placed in quarantine and droplet/contact precautions initiated. Review of Resident #66's Nurse's Notes dated 02/13/2023 at 6:18 p.m., revealed Resident #66 tested positive for COVID-19 and placed in quarantine and droplet/quarantine precautions initiated. Observation on 02/14/2023 at 10:37 a.m., revealed S12Certified Nursing Assistant (CNA) put on PPE and entered Resident #47's room COVID-19 isolation Room c without a face shield or googles. In an interview on 02/14/2023 at 10:38 a.m., S12Certified Nursing Assistant stated that she did not wear a face shield or goggles in COVID-19 isolation Room b, COVID-19 isolation Room d, or COVID-19 isolation Room c. Observation on 02/14/2023 at 10:55 a.m., revealed S22Housekeeper did not have a KN95 mask on and entered isolation room c. Observation on 02/14/2023 at 10:59 a.m. revealed, S22Housekeeper exited room 'g which contained a COVID-19 positive resident with contaminated shoe covers, gown, face shield, gloves, surgical masks, and hair cover. In an interview on 02/14/2023 at 11:06 am. S22Housekeeper confirmed she exited room g with shoe covers, gown face shield, gloves, surgical masks and hair cover on. S22 Housekeeper further state she was only going to her cart and not down the hall. Observation on 02/14/2023 at 11:11 a.m., revealed S22Housekeeper entered COVID-19 isolation room b without and N95 Mask on or shoe covers on. Observation further revealed S22Houskeeper to have on two surgical masks. Observation on 02/14/2023 at 11:19 a.m., revealed S22Housekeeper exited COVID-19 Isolation room b with no mask and entered COVID-19 isolation room d with a surgical mask in place. In an interview on 02/14/2023 at 2:36 p.m., S3ADON/IP stated staff should put on shoe covers, face shields, hair nets, gowns, and surgical mask to cover KN95 masks prior to entering COVID-19 isolation rooms. S3ADON/IP further stated visitors should wear surgical masks and complete screening questions regarding sign and symptoms of COVID-19, along with taking temperatures prior to entering the facility. In an interview on 02/14/2023 at 5:05 p.m., S13Dietary Manager stated that she did not need to wear PPE because she was not going into Resident #44's room and was only in her doorway. In an interview on 02/15/2023 at 11:35 a.m., S2Director of Nursing stated that staff should be in full personal protective equipment, including eye protection when going into COVID-19 positive rooms or when cleaning a room after a COVID-19 positive resident has been moved. 2. Review of the facility's COVID-19 Test Frequency for Residents and Staff Policy, revealed, in part, residents with signs or symptoms of COVID-19 should be tested immediately and be placed on transmission-based precautions until test results are obtained. In an interview on 02/14/2023 at 2:36 p.m., S3Assistant Director of Nursing (ADON) stated COVID-19 testing was completed on 02/13/2023 and would not be completed again until 02/17/2023. In an interview on 02/15/2022 at 8:15 a.m., Resident #22 stated that she vomited yesterday and she had not been tested for COVID-19 since 02/13/2023. Observation on 02/15/2022 at 8:15 a.m. revealed Resident #22 was not on isolation precautions at this time. In an interview on 02/15/2023 at 9:37 a.m., Resident #46 stated she was very nauseous this morning and she had not been tested for COVID-19 since 02/13/2023. Observation on 02/15/2023 at 9:45 a.m. revealed Resident #22 in the facility chapel with her mask underneath her chin with other residents present. In an interview on 02/15/2023 at 10:50 a.m., S7LPN confirmed that both Resident #22 and Resident #46 were having GI issues such as nausea this morning. Observation on 02/15/2023 at 11:26 a.m., revealed Resident #43 sitting in the Minimum Data Set (MDS) Coordinator's office, with her mask sitting underneath her nose, while awaiting to be tested due to symptoms of COVID-19. Observation further revealed S11MDS Coordinator, S17MDS Coordinator, and S18Transportation Driver in the office without a gown, gloves, eye protection nor shoe covers. In an interview on 02/15/2023 at 11:51 a.m., S1Administrator stated that Resident #43 tested positive for COVID-19. S1Administrator confirmed that Resident #43 should have been wearing her mask over her nose and mouth and that staff should have used PPE while in the room with Resident #43. In an interview on 02/15/2023 at 12:25 p.m., S23Medical Director stated residents who are positive for COVID-19 should be contained in their rooms. S23 Medical Director further stated a COVID-19 test should be performed immediately after symptom onset and that residents with symptoms should be quarantined as soon as possible until a test is performed to confirm if they are COVID-19 positive or COVID-19 negative. S23Medical Director further stated the facility did not consult with him in regards to when COVID-19 testing should be performed. S23Medical Director further recommended COVID-19 testing be performed on 02/16/2023. In an interview on 02/15/2023 at 1:00 p.m., S7LPN stated that both Resident #22 and Resident #46 were having symptoms of COVID-19 since the beginning of the shift and should have been tested for COVID-19. 3. Review of the facility's visitor screening log for 02/13/2023 revealed, in part, signs and symptoms of COVID-19 were not monitored for 68 of 134 visitors. Further review of the facility's visitor sign in log revealed temperatures were not taken for 16 of 134 visitors. Review of the facility's visitor screening log for 02/14/2023 revealed, signs and symptoms of COVID-19 were not monitored for 68 of 73 visitors. Further review of the facility's visitor sign in log revealed temperatures were not taken for 15 of 73 visitors. Review of the facility's staff screening log for 02/14/2023 revealed, signs and symptoms of COVID-19 were not monitored for 20 of 47 staff members that worked that day. Further review of the facility's staff screening log for 02/14/2023 revealed, temperatures were not taken for 6 of 47 staff members that worked that day. Review of the facility's visitor screening log for 02/15/2023 revealed, signs and symptoms of COVID-19 were not monitored for 8 of 21 visitors. Further review of the facility's visitor sign in log revealed temperatures were not taken for 4 of 21 visitors. Review of the facility's staff sign in log for 02/15/2023 revealed, signs and symptoms of COVID-19 were not monitored for 20 out of 45 staff members that worked that day. Further review of the facility's staff sign in log for 02/15/2023 revealed, temperatures were not taken for 9 out of 45 staff members that worked that day. Observation on 02/15/2023 at 11:01 a.m., revealed a visitor did not use hand sanitizer after signing in and continuing into facility. Observation further revealed facility staff did not stop the visitor to inquire about symptoms or encourage the visitor to use alcohol sanitizer. In an interview on 02/15/2023 at 11:23 a.m., S21Accounts Payable stated she is responsible for monitoring the family/visitor sign in log and ensuring temperatures are taken. S21 Accounts Payable confirmed she did not always ensure the visitor sign in log was filled out in completion. In an interview on 02/15/2023 at 11:25 a.m., S1Administrator confirmed signs/symptoms of COVID-19 and temperatures had not been checked when all visitors entered the facility and they should have. In an interview on 02/15/2023 at 11:30 a.m., S2ADON/IP confirmed staff had not answered the screening questions for signs and symptoms of COVID-19 nor had their temperatures taken and they should have prior to entering the facility. 47487

Based on observation, interview and record review, the facility failed to ensure the Infection Preventionist established and maintained an effective infection prevention and control program to prevent the transmission of COVID-19 infections in the facility by: 1.) failing to ensure staff used personal protective equipment (PPE) with COVID-19 positive residents (Resident #44, Resident#47, Resident #55 and Resident #66); 2.) failing to ensure staff quarantined and immediately tested residents (Resident #22 and Resident #46) who displayed symptoms of COVID-19; and 3.) failing to ensure COVID-19 screenings for signs and symptoms were completed by visitors and staff. This deficient practice resulted in an Immediate Jeopardy situation on 02/13/2023, when the facility identified Resident #6, Resident #14, Resident #44, Resident #47, Resident #55, and Resident #66 tested positive for COVID-19. The facility failed to utilize proper PPE (KN95 or N95 masks) and to quarantine Resident #22 and Resident #46 who displayed symptoms of COVID-19 on 02/15/2023. The facility failed to immediately test Resident #22 and Resident #46 who had symptoms of COVID-19. The facility failed to ensure staff and visitors were screened for signs and symptoms of COVID-19 prior to entering the facility. The facility's failure to implement infection control measures, resulted in Resident #43 and Resident #53 testing positive for COVID-19 on 02/15/2023. As of 02/15/2023, there were 8 active resident COVID-19 cases. This deficient practice had the likelihood to cause serious harm, injury, or death to the remaining 63 residents identified by the facility to be negative for COVID-19. S1Adminisistrator was notified of the Immediate Jeopardy situation on 02/15/2023 at 2:42 p.m. This deficient practice continued at more than minimal harm and had the potential to cause serious injury, harm or death for the remaining 63 non-positive COVID-19 residents residing in the facility that were at risk for contracting COVID-19. The facility presented the following Plan of Removal on 02/16/2023 at 4:30 p.m.: The Infection Preventionist failed to do the following: perform resident and staff testing, complete a surveillance list, complete identification, reporting, testing, education, implement proper usage of person protective equipment, monitor visitation and staff log, and ensure rooms were cleaned properly. On 02/15/2023, there were eight active resident cases and two active staff cases of COVID-19 in the facility. This deficient practice had the potential to affect any of the 63 COVID-19 negative residents residing in the facility. 1. Resident and Staff Testing Resident #43 and Resident #53 were affected by the deficient practices. The residents and staff were tested on [DATE] at 5:30 p.m. for COVID-19 due to the identification of potential risk of spreading COVID-19. From this testing on 02/15/2023, two (2) new resident cases were identified. The confirmed cases were placed on isolation precautions on 02/15/2023. On 02/15/2023 at 8:15 p.m., the staff who had not been tested on [DATE] were notified by phone that he or she will need to be tested at the facility on 02/16/2023 or prior to working their next scheduled shift. The facility implemented a Policy and Procedure on how to identify residents with signs and symptoms of COVID-19, reporting, and testing. The staff (direct hire, contract, hospice, other) were in-serviced on the proper procedures on who to notify when these signs and symptoms are identified. CDC possible symptoms include fever, cough, fatigue, shortness of breath, vomiting and loss of taste or smell. 2. Surveillance List Resident #22 and Resident #46 were observed to have signs and symptoms of COVID-19. Resident #46 was tested on [DATE] and the test result was negative. Resident #22 was tested on [DATE] and the result was positive and was immediately placed on isolation. The residents who were identified with signs and symptoms of COVID-19 were placed on a surveillance list for continued monitoring of signs and symptoms of COVID-19. This list was updated every shift by the nurses. The nurses monitored for worsening of signs and symptoms. If the signs and symptoms worsened, the resident was retested on Day 3 (or prior if needed). The nurses assessed and documented the resident's condition every shift. The surveillance was monitored daily by the Infection Preventionist or designee. On 02/15/2023 at 5:30 p.m. the residents that were identified with signs and symptoms of COVID-19 remained on the surveillance for 5 days from the start date of 02/15/2023. 3. Identification, Reporting, Testing Education On 02/15/2023 at 6:30 p.m., the facility implemented a Policy and Procedure on how to identify residents with signs and symptoms of COVID-19, reporting, and testing per CDC guidelines. In the event of multiple positives before the next scheduled round of testing, the residents and staff will be tested immediately. On 02/15/2023 at 6:30 p.m., the staff (direct hire, contract, hospice, other) who were present during the assigned shift were in-serviced on the proper procedure on who to notify when these signs were identified. The in-service on the proper procedure on how to identify residents with signs and symptoms of COVID-19 was completed on 02/16/2023 at 12:30 p.m. Attached are the CDC possible symptoms. 4. Personal Protective Equipment On 02/15/2023, the facility implemented a Policy and Procedure on the proper usage of personal protective equipment with a COVID-19 positive resident. On 02/15/2023 at 6:30 p.m., the staff (direct hire, contract, hospice, other) were educated on when to use a KN95 or a N95 while in the facility. The staff who were assigned to work with the COVID-19 positive residents were to wear a N95 with a surgical mask while providing direct care. On 02/15/2023, one CNA and one nurse was assigned to the identified COVID-19 positive residents. The staff were educated on how to properly wear masks and to keep masks on unless eating or drinking. Beginning on 02/15/2023, the Director of Nursing (DON), Assistant Director of Nursing (ADON), or designee re-educated and re-evaluated the staff on all shifts (direct hire, contract, hospice, other) on the identification of signs and symptoms, reporting, and testing twice a week for two weeks on all shifts, then once a week for two weeks. After four weeks of conducting education and evaluation with random staff (one from each department) for each shift will be evaluated on proper identification, reporting and testing procedure, twice a month for one month and once a month for four months (one from each department). 5. Visitation and Staff Log On 02/14/2023 a designated administrative staff was present at all times to direct the visitors on the proper procedure. Upon entering the facility, visitors must take their temperature and complete the signs and symptoms questionnaire. On 02/15/2023 at 7:00 p.m., an email/phone calls were sent out to the responsible parties as a reminder of the procedure. All email/phone calls were completed 02/15/2023 at 7:30 p.m. by the Administrative staff. On 02/16/2023 at 3:30 p.m., all staff were re-educated on the process of taking his or her temperature and completing the signs and symptoms questionnaire prior to entering the facility. The staff were also re-educated on the signs and symptoms of COVID-19 per CDC guidelines. If any staff's temperature was below 100 degrees and none of the sign and symptoms were present on the questionnaire, the staff reported to work. Beginning on 02/16/2023, the DON, ADON or designee will monitor the questionnaire for completion daily for two weeks, then twice a week for 2 weeks. 6. Proper Cleaning of Rooms On 02/16/2023 at 7:30 a.m., the housekeepers were trained on the proper procedure for cleaning rooms of residents who tested positive for COVID-19 (See attached). The housekeepers were also trained on the proper usage of PPE. The Service Administrator/Designee will monitor daily for 10 days (beginning on 02/16/2023), which may be extended based on COVID-19 status in facility. In the event of a new COVID outbreak, the housekeepers will be re-educated on the proper procedure with monitoring. The staff (direct hire, contact, hospice, other) will be re-educated on this upon hire, annually, and as needed (such as an outbreak). 7. Infection Preventionist On 02/16/2023 at 3:37 p.m., the Infection Preventionist was re-educated on the key components of an effective Infection Prevention and Control Program. On 02/16/2023, the DON will monitor the Infection Preventionist starting on 02/16/2023, the Infection Preventionist and DON will meet once a week for two months with an end date of 04/15/2023, then once every other week for a month beginning 04/17/2023, then once every other week for a month beginning 04/17/2023 with an end date of 05/14/2023. Afterwards monthly, they will meet for three months, beginning 05/15/2023 with an end date of 08/06/2023. Infection prevention and control program revealed the Infection Preventionist responsibilities included the following: quality assessment and performance improvement integration, infection surveillance, outbreaks, principles of standard precautions, principles of transmission-based precautions, hand hygiene, injection safety, respiratory hygiene and cough etiquette, device (i.e. indwelling urinary and central venous catheters) and wound management, Point of care blood testing, reprocessing reusable resident care equipment, environmental cleaning, water management program, linen management, preventing respiratory infections, tuberculosis prevention, occupational health considerations, antibiotic stewardship, and care transitions. The staff (direct hire, contract, hospice, other) will be re-educated on this upon hire, annually, and as needed (such as an outbreak). The Immediate Jeopardy was removed on 02/16/2023 at 6:47 p.m. when the provider presented an acceptable plan of removal. Through observations, interviews, and record reviews, it was determined the facility implemented an acceptable Plan of Removal. Findings: Cross reference F880. In an interview on 02/14/2023 at 2:36 p.m., S3Assistant Director of Nursing/Infection Preventionist (ADON/IP) stated staff should use shoe covers, face shields, hair nets, gowns, and surgical mask to cover KN95 masks prior to entering COVID-19 isolation rooms. S3ADON/IP confirmed staff were not wearing all components of PPE. In an interview on 02/15/2023 at 9:50 a.m., S3ADON/IP stated residents should be tested for COVID-19 if they have symptoms such as cough, fever, shortness of breath, or any gastrointestinal issues. S3ADON/IP confirmed residents with gastrointestinal symptoms were not tested for COVID-19 and should have been. In an interview on 02/14/2023 S3ADON/IP stated visitors should wear surgical masks and complete the screening questionnaire regarding signs and symptoms of COVID-19, as well as have their temperatures taken upon entrance to the facility. S3ADON/IP confirmed screenings were not being done consistently. In an interview on 2/15/2023 at 11:25 a.m., S1Administrator confirmed S3ADON/IP should have ensured staff were monitoring visitors for signs/symptoms of COVID-19 and temperatures were obtained when visitors entered the facility and staff wore all components of PPE. S1Administrator confirmed she did not.

Based on observations and interviews the facility failed to store a Continuous Positive Airway Pressure (CPAP) mask in a plastic bag as a preventative measure for infection control. (CPAP is a non-invasive ventilation machine that involves the administration of air usually through the nose by an external device at a predetermined level of pressure). This deficient practice was identified for 1 resident (Resident #58) of 2 residents sampled for respiratory care in a total sample of 21 residents. Findings: Observation on 02/13/2023 at 9:15 a.m. revealed Resident #58's CPAP mask was uncontained on the top of Resident #58's dresser. Observation on 02/14/2023 at 9:58 a.m. revealed Resident #58's CPAP mask was uncontained on the top of Resident #58's dresser. Observation on 02/14/2023 at 10:20 a.m. revealed Resident #58's CPAP mask was uncontained on the top of Resident #58's dresser. In an interview on 02/14/2023 at 10:25 a.m., Resident # 58 stated that he wears his CPAP at night time. In an interview on 02/14/2023 at 11:25 a.m., S8Licensed Practical Nurse stated that Resident #58's CPAP mask should be contained in a plastic bag when the night shift staff that takes the mask off of him to make sure the mask does not get any dirt or germs on it. In an interview on 02/14/2023 at 1:55 p.m., S9Certified Nursing Assistant stated that Resident #58's CPAP mask was not covered with a plastic bag this morning. In an interview on 02/15/2023 at 2:35 p.m., S2Director of Nursing stated that Resident #58 should have his CPAP mask stored in a plastic bag. Observation on 02/16/2023 at 1:57 p.m. revealed Resident #58's CPAP mask was uncontained on the top of Resident #58's dresser.

Based on observation and interviews the facility failed to discard a used vial of insulin (a medication used to treat diabetes and lower blood sugar) that was expired on a medication cart. This deficient practice was identified for 1 medication cart (medication cart g) of 2 medication carts for a total of 2 medication carts in the facility. Findings: Observation on [DATE] at 11:20 a.m. revealed Insulin Lispro was located on Medication Cart g. Further observation revealed [DATE] was written on the box of Insulin Lispro. In an interview on [DATE] at 11:22 a.m., S7Licensed Practical Nurse (LPN) stated that Resident #68's Insulin Lispro was first used on [DATE], which the date was written on the Insulin Lispro box and vial. S7LPN stated the insulin should have been discarded after 30 days. S7LPN further stated the last time the resident was administered Insulin Lispro was on [DATE]. In an interview on [DATE] at 2:00 p.m., S2Director of Nursing stated that Resident #68's insulin should have been discarded after 30 days of [DATE].

Based on observations, record review, and interviews the facility failed to have 2 refrigerators working with proper control temperatures that stored medication and residents' food items that were not dated and labeled with a resident's name. This deficient practice was identified for 2 refrigerators (Refrigerator on Hall A and refrigerator in medication room a) out of 3 refrigerators. Findings: Observation on 02/15/2023 at 9:30am revealed the refrigerator in Medication Room a' thermometer read 52 degrees Fahrenheit. Further observation revealed Trulicity and Novolog Insulin was in the refrigerator in Medication Room a. Review of Trulicity and Novolog Insulins package instructions revealed the medications should be stored between 36 and 46 degrees Fahrenheit. Review of the temperature log revealed, in part, if the temperature in the refrigerator is out of 36-40 degrees fahrenheight range to readjust temperature and recheck the temperature in 15 minutes and if temperature not correct notify maintenance. In an interview on 02/15/2023 at 9:35 a.m., S6Licensed Practical Nurse (LPN) confirmed the temperatures in both refrigerators were above 40 degrees fahrenheight which was too hot. Observation on 02/15/2023 at 9:36 a.m. revealed the refrigerator on Hall A revealed the refrigerator temperature was 48 degrees fahrenheight. Observation revealed there was food in a plastic container dated 02/11/2023 for Resident #68. Observation further revealed an opened and unlabeled container of a strawberry banana drink. In an interview on 02/15/2023 at 9:38 a.m., S6LPN confirmed the temperature of the Hall A refrigerator temperature was too high at 48 degrees fahrenheight, and Resident #68 remained a resident in the facility. S6LPN stated that the strawberry banana drink had some of its contents consumed, and it should have been labeled and dated. Observation on 02/15/2023 at 11:40 a.m. revealed the refrigerator on hall A was 46 degrees fahrenheight, and the temperature of the refrigerator in Medication Room a was 52 degrees fahrenheight. In an interview on 02/15/2023 at 11:43 a.m., S7LPN confirmed the refrigerator on Hall A was 46 degrees fahrenheight and the temperature of the Medication Room a was 52 degrees fahrenheight. In an interview on 02/15/2022 at 11:47 a.m., S7LPN stated the medication refrigerator in medication room a was turned up to its maximum cool, and the consumable food and beverage refrigerator was turned up to almost the maximum setting earlier when it was brought to her attention by the surveyor. Observation on 02/15/2023 at 1:52 p.m. revealed the Hall A refrigerator temp was 42 degrees fahrenheight, and the medication room a refrigerator's temperature was 52 degrees fahrenheight. In an interview on 02/15/2023 at 1:54 p.m., S7LPN stated that the above temperatures were still above the normal range for both of the above refrigerators. In an interview on 02/15/2023 at 2:00 p.m., S2Director of Nursing stated that the two refrigerators were out of range by being too hot, and the drink in the refrigerator should have been dated and labeled with resident's name.

Based on record review and interview, the facility failed to follow their abuse and neglect policy and procedure by failing to complete a thorough background check for a direct care employee that had criminal charges on her record. This deficient practice had the potential to affect all 71 residents who reside in the facility as documented on the Resident Censes and Conditions of Residents Form, CMS-672. Findings: Review of the facility's Abuse Policy and Procedure revealed, in part, that the facility would screen all potential new hires with a criminal background check. Review of the facility's new hire list revealed, in part, S6Certified Nursing Assistant was hired on 08/25/2022. Review of S6CNA's personnel file revealed, in part, S6CNA had a background check completed on 08/04/2022 with a charge of aggravated battery from 06/23/2002. Further review of S6CNA's background check revealed S1Administrator's signature. Review of S6CNA's time sheet revealed, in part, S6CNA worked at the facility on 08/25/2022, 08/26/2022, 08/27/2022, 08/28/2022, 09/01/2022, and 09/02/2022. In an interview on 09/08/2022 at 11:42am, S6CNA stated when she was interviewed at the facility, S6CNA was not questioned at any time about the charges on her background check. S6CNA also stated prior to yesterday, she was never asked for documentation regarding her current charges. S6CNA further stated she worked on 08/27/2022 and 08/28/2022 with residents. In an interview on 09/07/2022 at 3:45pm, S3Assistant Administrator stated if Criminal Background checks results revealed charges of aggravated battery she would notify the Administrator and he would request additional documents if needed and makes the final decision on hiring the individual. S3Assistant Administrator stated a disposition for the aggravated battery charge was not obtained prior to S6CNA being hired or working with residents. S3Assistant Administrator confirmed S6CNA worked as a CNA on 08/27/2022 and 08/28/2022. In an interview on 09/07/2022 at 3:50pm, S1Administrator stated he did sign off on S6CNA's background check because he did not see the aggravated battery charge when he reviewed it. S1Administrator stated he did not request additional documents from S6CNA upon hire.

Based on record review and interview the facility failed to ensure or complete abuse and neglect training for contract staff. This deficient practice had the potential to affect all 71 residents who reside in the facility as documented on the Resident Censes and Conditions of Residents Form, CMS-672. Findings: Review of the facility's Abuse Policy revealed that staff were to receive training on abuse and abuse reporting, on hire, annually and on an ongoing basis by the abuse coordinator. Review of the facility's list of Agency staff and last date work form revealed, in part 7 Licensed Practical Nurses worked at the facility without documentation of Abuse, Neglect, or Exploitation training. Review of the facility staffing schedules revealed, in part, Agency Staff worked at the facility on the following dates: S5 License Practical Nurse (LPN)-04/02/2022; S6LPN-04/22/2022; S7LPN-09/02/2022, 09/05/2022; S8LPN-07/11/2022; S9LPN-09/05/2022; S10LPN-09/01/2022, 09/04/2022, 09/05/2022, 09/09/2022, 09/10/2022, 09/11/2022, 09/13/2022; and S11LPN-09/07/2022. In an interview on 09/08/2022 at 11:39am, S2Director of Nursing (DON) stated she had never checked to see if the direct care contracted staff received abuse training prior to working with the facility's residents. S2DON further stated she was unaware it was her responsibility to ensure the agency staff were trained properly.

Based on record review, observation and interview the facility failed to have a medication available for administration for 1 (Resident #55) of 32 residents reviewed in the investigative stage. This deficient practice had the potential to affect any of the 58 residents who resided in the facility as documented on the facility's Resident Census and Condition of Residents Form CMS-672. Findings: Resident #55 was admitted to the facility on [DATE] with a diagnoses of Anxiety. Review of Resident #55's April 2021 Physician Orders revealed, in part, [MEDICATION(S)] 0.25mg 1 by mouth every day. Review of Resident #55's April 2021 electronic Medication Administration Record (eMAR) revealed, in part, [MEDICATION(S)] 0.25mg was not administered as ordered on 04/23/2021, 04/24/2021, 04/25/2021, 04/26/2021 and 04/27/2021. Observation on 04/28/2021 at 10:44am revealed S2LicensedPracticalNurse(LPN) was unable to locate Resident #55's [MEDICATION(S)] 0.25mg tablet in the medication cart. S2LPN stated when a medication is not available for administration the nurse should call the pharmacy, notify the Director of Nurses (DON) or Assistant Director of Nurses (ADON) and document in the nurses notes. S2LPN reviewed Resident #55's Nurses Notes and stated there was no documentation regarding the failure to administer Resident #55's [MEDICATION(S)] on 04/23/2021, 04/24/2021, 04/25/2021, 04/26/2021 and 04/27/2021. In an interview on 04/28/2021 at 10:48am, S1DON stated she was not aware Resident #55 was out of [MEDICATION(S)] on 04/23/2021, 04/24/2021, 04/25/2021, 04/26/2021 and 04/27/2021. In a telephone interview on 04/28/2021 at 10:50am, a Pharmacist from the facility's contracted pharmacy stated Resident #55 [MEDICATION(S)] was last ordered on 04/10/2021 with a delivery date of 04/11/2021. The pharmacist further stated the next refill request was made by telephone on 04/28/2021 at 10:50am. In a telephone interview on 04/28/2021 at 1:40pm, S3LPN stated she was Resident #55's nurse on 04/23/2021, 04/24/2021, 04/25/2021, 04/26/2021 and 04/27/2021. S3LPN confirmed Resident #55's [MEDICATION(S)] 0.25mg was not available on 04/23/2021, 04/24/2021, 04/25/2021, 04/26/2021 and 04/27/2021 for the 8:00pm administration. S3LPN further stated she assumed another nurse had notified the pharmacy; therefore, she did not request a refill for the medicine.

Based on record review and interview the facility failed to: 1. Notify the physician of chest x-ray result of pneumonia; and 2. Notify the physician of a change in resident behaviors in a timely manner. This deficient practice was identified for 2 of 5 residents reviewed for nursing services (Resident #3 and Resident #4). This failed practice had the potential to affect any of the 66 residents residing in the facility, which could have a change in condition requiring physician intervention as documented on the facility's Resident Census and Conditions of Residents form (CMS672). Findings: Resident #3 Review of Resident #3's Record revealed Resident #3 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's Nurses Notes dated 10/30/2020 revealed the resident received a new order per the nurse practitioner for a chest x-ray and [MEDICATION NAME] 20mg (milligrams) (steroid, used for inflammation) by mouth daily for 5 days. Review of Resident #3's Physician Telephone Order dated 10/30/2020 revealed okay to chest x-ray. Review of Resident #3's Physician Telephone Order dated 10/30/2020 revealed [MEDICATION NAME] 20mg one tablet give one tablet by mouth daily for 5 days. Review of Resident #3's X-ray Results dated 10/30/2020 revealed moderate patchy bilateral densities compatible with pneumonia, and small bilateral effusions. Further review revealed follow-up up chest x-ray suggested due to in comparison to prior study, findings are new. Review revealed results were faxed on 10/30/2020 to the physician's office with no response noted. Review of Resident #3's Nurses Notes dated 11/02/2020 at 9:14pm Resident remains on [MEDICATION NAME] for a [DIAGNOSES REDACTED]. Review of Resident #3's Nurses Notes dated 11/03/2020 revealed the resident continued on [MEDICATION NAME], with a cough noted. Further review revealed cough medication given. Review of Resident #3's Nurses Notes dated 10/30/2020 at 1:41pm to 11/02/2020 to 9:14pm revealed no mention of an attempt to contact the physician for follow-up orders due to the chest x-ray results from 10/30/2020. Review of Resident #3's Physician's Telephone Order dated 11/05/2020 revealed [MEDICATION NAME] (antibiotic, used to treat infections) 500mg tablet, administer one tablet by mouth daily for 5 days to Resident #3. Review of Resident #3's November 2020 MAR (Medication Administration Record) revealed Resident #3's first dose of [MEDICATION NAME] 500mg was administered on 11/05/2020 at 8pm. In an interview on 11/06/2020 at 10:09am, Resident #3's Nurse Practitioner stated the resident was having complaints of joint pain and a cough. She stated she ordered [MEDICATION NAME] and a chest x- ray. Resident #3's Nurse Practitioner stated reviewing the documents at her office she saw the results were faxed more than once, but she did not get the results and review them until 11/05/2020. Resident #3's Nurse Practitioner stated she did not have any evidence the physician's office was called with the chest x-ray report results and follow-up. Resident #3's Nurse Practitioner stated she would have started antibiotics for Resident #3's community acquired pneumonia immediately had she been aware of results. In an interview on 11/06/2020 at 10:52am, S4LPN (Licensed Practical Nurse) stated her first day back working with Resident #3 was on Wednesday, but did not call the physician's office about the chest x-ray results. In an interview on 11/06/2020 at 1:06pm, S1DON (Director of Nursing) stated the facility was unable to speak to the weekend supervisor, but had no documented evidence of the weekend supervisor contacting the physician of the chest x-ray results. S1DON stated she had spoken with S8LPN, S8LPN stated to the DON on Friday (10/30/2020) she left a message with Resident #3's answering service but did not receive a return call, and she had faxed the report on Monday 11/02/2020. S1DON stated the nurse stated she never spoke to anyone at the office to confirm the receipt of results of the chest x-ray and follow-up orders. In an interview on 11/06/2020 at 2:26pm, S1DON confirmed the facility failed to ensure the physician was aware of the chest x-ray results; and therefore failed to notify the physician timely. S1DON stated the facility had no further evidence to present of the physician having been notified of results timely. Resident #4 Review of Resident #4's Record revealed the resident was admitted [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's Nurses Notes dated 10/02/2020 at 4:44am revealed the resident was yelling at this time help, help, help go into the room she states they have an alligator in my room and it's 6 feet, it's big, the girl just ran out of here because she seen it too. Review revealed the nurse told the resident she (the nurse) did not see it, but she said, I know what an alligator looks like I'm from _____. The nurse called the CNA (Certified Nursing Assistant) into the room so the CNA could keep her occupied because the resident said she was going to get out of bed. Review of Resident #4's Nurse's Notes dated 10/02/2020 at 5:38am revealed the resident walked to chapel because she stated there was a snake in her room. Review revealed the resident then stated the snake was in the chapel. The CNA brought the resident to the dayroom by nurse's station. Further review revealed the nurse will send SBAR (Situation, Background, Assessment, Recommendation) (screen to identify infections) to the physician. Review of Resident #4's Nurses Notes dated 10/02/2020 at 5:46am revealed the nurse sent SBAR (Situation, Background, Assessment, Recommendation) (screen to identify infections) to Resident #4's physician, suspected urinary tract infection (bladder infection). Review revealed confusion noted all night and resident had lower back pain. Further review revealed report given to ongoing nurse. Review of Resident #4's Nurses Notes dated 10/02/2020 at 11:16am Resident #4 was transported to the emergency room post fall. Review of Resident #4's Social Services Notes dated 10/02/2020 at 2:10pm revealed the resident was transported to the hospital per ambulance earlier today and remains in emergency room at this time. Review revealed the resident was found on floor in the hallway, on her left side with her arm under her. Resident #4 had stated she was trying to get the lady out of her room because of the snakes. Review revealed a head to toe assessment was completed and pain was noted to the left hip/upper leg area. Review of Resident #4's Record revealed no documented evidence of the nurse having spoken with the physician regarding Resident #4's change in condition between 10/02/2020 at 4:44pm and the time of Resident #4's fall. In an interview on 11/06/2020 at 1:06pm, S1DON stated upon looking into Resident #4's case she spoken with S9LPN. S1DON stated S9LPN confirmed she had not called the physician with the resident's new hallucinations, and had only faxed the physician's office and was awaiting a response. S1DON stated the nurse should have ensured the physician was notified of Resident #4's change in condition in a timely manner.

Based on interview and record review, the facility failed to prevent an accident when staff did not turn a resident in bed in accordance with professional standards. This deficient practice was identified for 1 of 5 sampled residents (Resident #1), but had the potential to affect any of the 65 residents who require assistance and/or was totally dependent on staff for Activities of Daily Living (ADL) as documented on the facility's Resident Census and Conditions of Residents CMS Form-672. Findings: Review of Resident #1's clinical record revealed, in part, Resident #1 was receiving hospice services, and had a [DIAGNOSES REDACTED]. Review of Resident #1's clinical record revealed, in part, that on 05/14/2020 at 12:30pm, Resident #1 complained of pain and was asked where the pain was, Resident #1 pointed to her left hip. Resident #1's left hip was assessed, with no irregularities noted, and Tylenol 650mg (medication used for pain) was administered as ordered. In interview on 11/05/2020 at 1:44pm, S4Licensed Practical Nurse (LPN) indicated S7Certified Nursing Assistant (CNA) reported her left hip hurt, so I went in Resident #1's room, Resident #1 said her left hip hurt. S4LPN further indicated she assessed Resident #1's left hip visually then palpated the left hip, and nothing was out the ordinary upon palpation. Resident #1 was not screaming in pain, but just had a basic complaint of mild pain. Nothing was seen or heard that would raise a red flag or concern, but since Resident #1 complained of pain, Tylenol was administered as ordered which was effective because she was resting well afterwards. Review of Resident #1's Departmental Notes dated 05/14/2020 at 9:30pm revealed, in part, S6CNA (Resident #1's CNA the shift after S7CNA) reported to S5LPN (Resident #1's LPN the shift after S4LPN) that she noticed bruising on Resident #1's left inner knee when she removed a pillow which was placed between her knee. Further review revealed S5LPN assessed Resident #1's knee and noted bruising, swelling, and a complaint of pain when nurse attempted to move leg. Further review revealed Resident #1 was sent to the hospital for evaluation and x-ray. Review of Resident #1's 05/14/2020 emergency room assessment revealed, in part, that extremities had no [MEDICAL CONDITION], but tenting around left knee. Resident #1 denied pain, and the impression was a fractured femur, age related debility, and encounter for palliative care/hospice care. Review of Resident #1's 05/14/2020 emergency room x-ray revealed, in part, that Resident #1's femur showed [MEDICAL CONDITION] and an acute posttraumatic displaced [MEDICAL CONDITION] left femur. Review of S7CNA's written statement related to Resident #1's above mentioned incident revealed, in part, that S5CNA had turned Resident #1 in bed on her left side while her legs were crossed at which time Resident #1 complained of her left knee or leg hurting. Further review revealed S7CNA reported Resident #1's complaint to S4LPN. In interview on 11/06/2020 at 1:22pm, S1Director of Nursing (DON) indicated staff were to follow the guidelines for turning residents that S3Occupational Therapist (OT) provides and gives in-services on. Review of the facility's professional standards guidelines for the Proper Alignment/Hand Placement during ADL care revealed, in part, that staff were to ensure arms and legs were not intertwined, and free from bed rails and sheets prior to movement. In interview on 11/06/2020 at 1:24pm, S3Occupational Therapist (OT) indicated CNA staff should not turn a resident with legs crossed and/or with bed sheets/covers on.

Based on observation, record review, and interviews, the facility failed to: 1) ensure [MEDICAL CONDITION] (Continuous Positive Air Pressure) and BPAP (Bi-level Positive Airway Pressure) equipment and supplies were properly cleaned for 2 (#6, #47) of 2 residents reviewed for [MEDICAL CONDITION] and BPAP machines, and 2) failed to ensure staff followed correct procedures for sanitizing the shower/bath area and equipment. This deficient practice had the potential to affect all 70 residents as identified on the Resident Census and Conditions of Residents, Form CMS-672. Findings: 1) Failed to ensure [MEDICAL CONDITION] and BPAP equipment and supplies were properly cleaned: Resident #6 An observation on 07/22/19 at 2:00 p.m. revealed Resident #6 had a BPAP (Bi-level Positive Airway Pressure) machine at the bedside. In an interview with Resident #6, she stated she had never observed any staff member cleaning the mask. Review of the medical record revealed the resident was admitted to the facility on [DATE]. Review of the MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 04/22/19 revealed Resident #6 had a BIMS (Brief Interview for Mental Status) score of 15 indicating Resident #6 was cognitively intact. Review of the physician orders [REDACTED]. Clean mask/nose piece with soap and water and dry. Clean water reservoir with white vinegar, then rinse every week if being used (1/12/19). Change headgear, tubing, non-disposable filters and humidifier chamber every 6 months (Jan - July): check disposable filter and if grey or discolored (6/15/19). Review of the MAR (Medication Administration Record) revealed Resident #6 was compliant with using the BPAP nightly as ordered. Review of the TAR (Treatment Administration Record) revealed there was no documented evidence the hose used for the BPAP was cleaned weekly. Resident #47 In an observation/interview on 07/22/19 during the screening of Resident #47, she stated she came into the facility with her [MEDICAL CONDITION], and she has just started using the [MEDICAL CONDITION] prior to admission at the facility. Resident #47 indicated she had never seen anyone take the [MEDICAL CONDITION] mask/tubing and clean it since she has been residing at the facility. Review of the medical record revealed Resident #47 was admitted to the facility on [DATE]. Review of the MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 06/18/19 revealed Resident #47 had a BIMS (Brief Interview for Mental Status) score of 15 indicating Resident #47 was cognitively intact. Review of the physician's orders [REDACTED]. Review of the TAR (Treatment Administration Record) revealed no documented evidence the hose used for the [MEDICAL CONDITION] was cleaned weekly with soap and water. In a telephone interview in the presence of S2DON (Director of Nursing) and S4ADON (Assistant Director of Nursing) on 07/25/19 at 11:30 a.m., S3RN (Registered Nurse) indicated she was responsible for cleaning the [MEDICAL CONDITION] and BPAP supplies and equipment weekly. Surveyor asked S3RN to explain how she cleans the equipment and supplies, and she stated she wipes down the hose on the outside and wipes out the mask and nose piece with an antimicrobial wipe. S3RN confirmed she did not soak the tubing in warm soapy water to cleanse the inside of the hose, and she did not clean the mask and nose piece with soap and water as per the physician's orders [REDACTED]. S3RN stated she had not received any in-services on how to properly clean a [MEDICAL CONDITION] and BPAP machine and equipment. S3RN indicated she went by the physician's orders [REDACTED]. In an interview on 07/25/19 at 11:20 a.m., S4ADON (Infection Control Nurse) indicated they use the physician's orders [REDACTED]. S4ADON confirmed the facility did not have any policy/procedure or instructions from the manufacturers for the proper cleaning of [MEDICAL CONDITION]/BPAP equipment and supplies. S4ADON confirmed the facility had not provided any in-services on how to properly clean [MEDICAL CONDITION]/BPAP supplies. 2) failed to ensure staff followed correct procedures for sanitizing the shower/bath area and equipment Review of the manufacturer's instructions for disinfecting the shower/bath areas and equipment revealed that the correct surface contact time was 10 minutes. In an interview on 07/25/19 at 10:40 a.m., S4ADON indicated the surface contact time was 10 minutes. In an interview on 07/25/19 at 10:55 a.m., S5CNA (Certified Nursing Assistant) indicated she leaves the disinfecting solution on the surfaces in the bath/shower rooms and equipment for about 3 to 5 minutes. Surveyor asked her what was the maximum time she was supposed to leave the disinfecting solution on the surfaces before she rinses it off, and S5CNA stated about 5 minutes.