Every finding on record at Life Care Center of Citrus County

Based on interview and record review, the facility failed to ensure each resident received an accurate assessment reflective of the resident status for 1 of 5 residents, Resident #65, reviewed for medication management.Findings include:Review of Resident #65's Minimum Data Set titled Modification of Quarterly/Medicare-5 Day dated 1/22/2026 read, N0300. Injections. Enter Days: 6. Record the number of days that injections of any type were received during the last 7 days or since admission/entry or reentry if less than 7 days. N0350. Insulin. Enter Days: 5. A. Insulin Injections. Record the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry if less than 7 days.Review of Resident #65's physician order dated 1/20/2026 read, Insulin Glargine Subcutaneous Solution Pen-Injector 100 Unit/ML [milliliter] (Insulin Glargine) inject 40 unit subcutaneously at bedtime for Diabetes.Review of Resident #65's physician order dated 1/20/2026 read, Novolog Solution 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 0 - 200 = 0 units; 201 - 250 = 3 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 9 units; 401+ = 0 units Call MD [Medical Doctor], subcutaneously before meals and at bedtime for diabetes.Review of Resident #65's Medication Administration Record for the month of January 2026 documented only three days where the resident received an injection of insulin.During an interview on 2/11/2026 at 10:20 AM the Registered Nurse Minimum Data Set Coordinator stated, After reviewing [Resident #65's name] medication record for the look back period, the injections number was incorrect and needs to be modified. Review of the facility policy and procedure titled Resident Assessment Instrument and Care Plan Development with a review date of 8/29/2025 read, Policy: The facility will follow the procedures set forth in the Resident Assessment Instrument (RAI) User's Manual 3.0 when completing the MDS, Care Area Assessment, and Comprehensive Care Plan.

Based on observation, interview, and record review the facility failed to maintain dignity for a resident who needed assistance with dining for 1 of 5 residents, Resident #6, reviewed for dining.Findings include:During an observation on 2/9/2026 at 11:52 AM Staff C, Certified Nursing Assistant (CNA) was seated bedside Resident #6 in a side-to-side position and was not facing the resident during the meal. Staff C was observed feeding Resident #6 over her shoulder rather than directly facing Resident #6. Between spoonfuls of food, Staff C picked up her cellphone resting it on her lap and was observed scrolling on the device. This occurred between each spoon feeding. There was no verbal interactions or engagement noted between Staff C and Resident #6 during the dining process. After completing the meal, Staff C stood up and exited the room with the meal tray.Review of Resident #6's Minimum Data Set titled Annual dated 12/24/2025 documented resident was dependent for eating. During an interview on 2/11/2026 at 12:50 PM Staff C, CNA, stated, I should not have had my phone out. I should have fed [Resident #6's name] paying attention and focusing on him.During an interview on 2/11/2026 at 1:36 PM Staff B Unit Manager/Licensed Practical Nurse stated, Staff should converse with residents and be focused completely on the resident making sure all dietary needs are met. Cell phones are not allowed in patient care areas.During an interview on 2/11/026 at 1:40 PM the Director of Nursing stated, Staff should sit at eye level and provide sips of liquids in between the meal. The staff should be facing the resident and giving the resident one-to-one patient interaction. There should be no phones in the resident areas.Review of the facility policy and procedure titled Cell Phone Use with a last review date of 4/8/2025 read, Policy. The facility will ensure the appropriate usage of cell phones to safeguard patient privacy and to ensure the provision of high-quality patient care. Procedure: 1. Associates should refrain from using cell phones in patient care areas at all times.

Based on interview and record review the facility failed to ensure physician prescribed orders were followed for blood pressure medication for 1 of 9 residents, Resident #35, reviewed for medication management.Findings include:Review of Resident #35's physician order dated 2/3/2026 read, Clonidine HCI [Hydrochloride] Oral Tablet 0.1 MG [milligram] (Clonidine HCI) give 1 tablet by mouth every 8 hours as needed for SBP [systolic blood pressure] >150 mmHg [greater than 150] Notify MD [Medical Doctor] if ineffective.Review of Resident #35's blood pressure record for the month of February 2026 documented on 2/4/2026 at 0800 [8:00 AM] SBP was 159, on 2/6/2026 at 2000 [8:00PM] SBP was 158, and on 2/7/2026 at 2000 SBP was 163.Review of Resident #35's Medication Administration Record for the month of February 2026 did not document Clonidine 0.1mg as administered on 2/4/2026, 2/6/2026, and 2/7/2026 as order by the physician.Review of Resident #35's physician order dated 11/7/2025 read, Clonidine HCI Oral Tablet 0.1 mg (Clonidine HCI) give 1 tablet by mouth every 8 hours as needed for HTN [hypertension] give if SBP is 150 or above.Review of Resident #35's blood pressure record for the month of January 2026 documented on 1/2/2026 at 2000 [8:00 PM] SBP was 155, on 1/16/2026 at 2000 SBP was 160, and on 1/21/2026 at 2000 SBP was 161.Review of Resident #35's Medication Administration Record for the month of January 2026 did not document Clonidine 0.1mg as administered on 1/2/2026, 1/16/2026, and 1/21/2026 as ordered by the physician.During an interview on 2/11/2026 at 1:24 PM Staff D, Licensed Practical Nurse (LPN) stated, I do not remember having the medication [Clonidine] on her [Resident #35] MAR [medication administration record]. I don't remember, it has been some time. If it is not documented on the MAR as given, I probably did not give the medication.During an interview on 2/11/2026 at 1:29 PM Staff E, LPN, stated, I don't remember that day if she [Resident #35] had a prn [as needed] order for clonidine. I should have administered the medication. I don't remember that specific situation.During an interview on 2/11/2026 at 1:34 PM Staff F, LPN stated, I no longer work in that facility. [Resident #35's name] is familiar but I don't recall the resident having a prn order for Clonidine.During an interview on 2/11/2026 at 12:32 PM the Advance Practice Registered Nurse #1 stated, The resident has been stable, she has had elevated blood pressure but has not had to be sent out to the hospital. The staff are expected to follow parameters included in the MD orders. I have not gotten any calls from staff informing me the medication was not given per the parameters.During an interview on 2/12/2026 at 8:15 AM the Director of Nursing stated, Nurses need to follow the parameters and physician orders.Review of the facility policy and procedure titled Administration of Medications with a review date of 9/9/2025 read, Policy: The facility will ensure medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms.

Based on interview and record review the facility failed to ensure physician ordered parameters were followed for blood pressure medications resulting in the administration of unnecessary medications for 4 of 9 residents, Residents #19, #92, #35 and #17, reviewed for unnecessary medications.Findings include: 1. Review of Resident #19's admission record documented diagnosis to include displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with healing, encounter for other orthopedic aftercare, history of falling, essential (primary) hypertension, hyperlipidemia unspecified, gastroesophageal reflux disease without esophagitis, type 2 diabetes mellitus with diabetic neuropathy unspecified, and hypothyroidism unspecified. Review of Resident #19's physician order dated 4/29/2025 read, Metoprolol Tartrate Oral Tablet 25 MG [milligrams] (Metoprolol Tartrate) Give 1 tablet by mouth two times a day for HTN [hypertension] Hold for SBP [systolic blood pressure] less than 100 and HR [heart rate] < [less than] 60. Notify MD [Medical Doctor] if HR less than 50. Review of Resident #19's February Medication Administration Record (MAR) documented Metoprolol Tartare was administered on 2/6/2026 at 0800 (8:00 AM) with a heart rate of 57, at 1900 (7:00 PM) with a heart rate of 59, and on 2/7/2026 at 0800 with a Heart rate of 59. Review of Resident #19's MAR for January 2026 documented Metoprolol Tartare was administered on 1/1/2026 at 0800 with a heart rate of 51, at 1900 with a heart rate of 56, on 1/15/2026 at 0800 with a heart rate 52, on 1/19/2026 with a heart rate of 59, on 1/23/2026 at 0800 with a heart rate of 55, at 1900 with a heart rate of 55, on 1/26/2026 at 1900 with a heart rate of 58, and on 1/28/2026 at 1900 with a heart rate of 59. Review of Resident #19's MAR for December 2025 documented Metoprolol Tartare was administered on 12/20/2025 at 0800 with a heart rate of 59, on 12/27/2025 at 1900 with a heart rate of 58, on 12/31/2025 at 0800 with a heart rate of 51, and at 1900 with a heart rate of 51. During an interview on 2/11/2026 at 12:47 PM Staff I, Licensed Practical Nurse (LPN) stated, I should not have given that medication. I did administer it. I did not realize I shouldn't. I should have followed the doctor's orders. During an interview on 2/12/2026 at 8:40 AM Staff R, LPN stated, I should have held the medication. I should have followed the doctor's order. 2. Review of Resident #92's admission record documented diagnosis to include essential (primary) hypertension, hyperlipidemia unspecified, major depressive disorder single episode unspecified, unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, dizziness and giddiness, adult failure to thrive, wedge compression fracture of first lumbar vertebra, wedge compression fraction of third lumbar vertebra, disorder of thyroid, other specified persistent mood disorders, other specified anxiety disorder, primary insomnia, and unspecified protein calorie malnutrition. Review of Resident #92's physician order dated 5/22/2025 read, Lisinopril Oral Tablet 40 MG (Lisinopril) Give 1 tablet by mouth one time a day for HTN HOLD FOR SBP < 120. Review of Resident #92's MAR for December 2025 documented Lisinopril was administered at 0800 (8:00 AM) on 12/20/2025 with a blood pressure (B/P) of 114/46, on 12/17/2025 with a B/P of 116/50, on 12/19/2025 with a B/P of 114/60, and on 12/20/2025 with a B/P of 118/64. Review of Resident #92's MAR for January 2026 documented Lisinopril was administered at 0800 on 1/5/2026 with a B/P of 97/51 on 1/8/2026 with a B/P of 118/45, on 1/19/2026 with a B/P of 110/58, and on 1/23/2026 with a B/P of 112/56. Review of Resident #92's physician order dated 2/4/2026 read, Lisinopril Oral Tablet 40 MG (Lisinopril) Give 1 tablet by mouth one time a day for HTN [hypertension] Hold for SBP <110 or DBP [diastolic blood pressure] <90. Review of Resident #92's MAR for February 2026 documented Lisinopril was administered at 0800 on 2/5/2026 with a B/P of 114/52, on 2/6/2026 with a B/P of 114/52, on 2/7/2026 with a B/P of 145/84, on 2/9/2026 with a B/P of 142/62 and on 2/10/2026 with a B/P of 142/58. During an interview on 2/11/2026 at 9:45 AM Staff A, LPN stated, I did not see the diastolic blood pressure parameters and I did administer those [medication]. I should have followed the orders and held the medication. This order just changed and I didn't notice it. During an interview on 2/11/2026 at 9:00 AM the Director of Nursing (DON) stated, All physician orders should be followed for administering medications. The parameters should be followed. 3. Review of Resident #35's physician order dated 2/3/2026 read, Losartan Potassium Tablet 100 MG give 100 mg by mouth one time a day for HTN hold if SBP <100 or DBP < 90. Review of Resident #35's MAR for the month of February 2026 documented Losartan Potassium 100 mg was administered on 2/4/2026 at 0900 [9:00 AM] with a diastolic blood pressure of 68, on 2/5/2026 at 0900 with a diastolic blood pressure of 75, on 2/8/2026 at 0900 with a diastolic of 80, on 2/9/2026 at 0900 with a diastolic of 69, and on 2/11/2026 at 0900 with a diastolic of 63. Review of Resident #35's physician order dated 2/3/2026 read, Carvedilol Tablet 3.125 MG give 1 tablet by mouth two times a day for htn hold if SBP <100 or DBP <60 or HR [Heart Rate] <60. Review of Resident #35's MAR for the month of February 2026 documented Carvedilol 3.125 mg was administered on 2/9/2026 at 0800 [8:00AM] with a heart rate of 59 and at 2000 [8:00 PM] with a diastolic blood pressure of 58. Review of Resident #35's physician order dated 12/3/2025 read, Carvedilol Tablet 3.125mg give 1 tablet by mouth two times a day for htn hold if SBP <100 and/or apical pulse <60 bpm [beats per minute]. Review of Resident #35's MAR for the month of January 2026 documented Carvedilol 3.125 mg was administered on 1/1/2026 at 0800 with a pulse of 56, on 1/2/2026 at 2000 with a pulse of 58, on 1/19/2026 at 0800 with a pulse of 59, and on 1/24/2026 at 0800 with a pulse of 55. During an interview on 2/11/2026 at 10:13 AM Staff A, LPN, stated, We have always been told about the top number and the heart rate not to give if the top number is less than 110 or heart rate less than 60. I did not know when they put in orders for the bottom [diastolic] order parameters. If I do not give her blood pressure medication if the systolic is not less than 110 then her blood pressure will skyrocket. I want to talk to the provider about that order because she has high blood pressure if the medication is not given to her, her blood pressure goes up. If there is a check mark it means I have given the medication. We get so used to the residents, but I will be checking parameters. During an interview on 2/11/2026 at 1:24 PM Staff D, LPN, stated, A check mark documented on the medication record normally means that the medication was given. I don't remember it's been some time. If I marked it off, I probably gave the medication. During an interview on 2/11/2026 at 12:32 PM the Advance Practice Registered Nurse #1 stated, [Resident#35's name] has been stable she has had elevated blood pressure but has not had to be sent out to the hospital. The staff are expected to follow parameters included in the md [medical doctor] orders. I have not gotten any calls from staff informing me the medication was not given when out of the parameters. During an interview on 2/12/2026 at 8:15 AM the Director of Nursing stated, Nurses need to follow the parameters and nursing orders. 4. Review of Resident #17's admission record documented diagnosis that include cognitive communication deficit, dysarthria and anarthria, protein calorie malnutrition, pain in unspecified knee, chronic viral Hepatitis C, major depressive disorder, insomnia and lymphedema. Review of Resident #17's physician orders dated 1/20/2026 read, Metoprolol Tartrate Oral Tablet 50 MG (Metoprolol Tartrate) Give 1 tablet by mouth two times a day for HTN Hold for SBP 110 or below OR HR below 60 contact MD for HR below 50. Review of Resident #17's MAR for February 2026 documented Metoprolol was administered outside of physician ordered parameters on 02/01/2026 at 0800 (8:00 AM) HR 52, documented by LPN Staff K, on 02/01/2026 at 8:00 PM HR 58, documented by LPN Staff J, on 02/07/2026 at 8:00 AM HR 58, documented by LPN Staff Q, on 02/11/2026 at 8:00 PM BP 108/49 and HR 56, documented by LPN Staff P. During an interview on 2/12/2026 at 11:23 AM Staff K, LPN stated I do see in the MAR on 2/1/2026 at 8 AM that I signed and the HR was 52. The order stated hold if HR is less than 60 so I agree that the vitals are out of parameters. I should have notified the MD and at that time discussed the next protocol for the resident. I should have held the medication and made a progress note. During interview on 2/12/2026 at 9:02 AM Staff J, LPN stated, I did give [Resident #17's name] blood pressure medications out of parameter on 2/1/2026 at 8 PM, but I didn't look at any other months. I should have notified the MD that his pulse was under 60 and then the MD would have advised me further on the next step.

Based on observation, interview, and record review the facility failed to prevent the possible spread of infection and communicable diseases by failing to ensure staff used appropriate Personal Protective Equipment (PPE) for residents on enhanced barrier precautions and failing to perform hand hygiene. Findings include: 1. During an observation of medication administration on 2/12/2026 at 5:00 AM Staff I, Licensed Practical Nurse (LPN) did not perform hand hygiene, donned gloves, and assembled the supplies needed to complete an accucheck [a test to obtain blood sugar value results], removed the gloves and did not perform hand hygiene. Staff I, entered Resident #34's room, did not perform hand hygiene, donned gloves, and completed the accucheck. Staff I, LPN doffed the gloves, did not perform hand hygiene, and returned to the medication cart. Staff I did not perform hand hygiene, unlocked the medication cart, activated the computer, and removed insulin from the medication cart. Staff I, LPN entered Resident #34's room did not perform hand hygiene, did not don gloves, and administered the insulin via injection to Resident #34. Staff I, LPN washed her hands, exited the room, returned to the medication cart and began preparing medications for another resident. At 5:05 AM, Staff I, LPN unlocked the medication cart, activated and typed on the computer, did not perform hand hygiene, and prepared medications for Resident #35. Staff I entered Resident #35's room did not perform hand hygiene and administered the medications. Staff I did not perform hand hygiene, exited the resident's room, and returned to the medication cart. At 5:11 AM Staff I unlocked the medication cart, activated and typed on the computer, assembled the supplies to perform an accucheck, did not perform hand hygiene, and donned gloves. Staff I entered Resident #24's room, did not perform hand hygiene, completed the accucheck, doffed the gloves, did not perform hand hygiene, and returned to the medication cart. Staff I, LPN did not perform hand hygiene, unlocked the medication cart, activated and typed on the computer, and removed the insulin injection. Staff I returned to Resident #24's room performed hand hygiene, did not don gloves, and administered the insulin via injection to Resident #24. During an interview on 2/12/2026 at 5:18 AM Staff I, LPN stated, I didn't realize that I needed to put on gloves to give insulin. I should have used hand sanitizer more frequently. Review of Resident #82's admission record documented diagnosis that include atherosclerotic heart disease of native coronary artery without angina pectoris (chest pain), essential (primary) hypertension, hematuria (blood in the urine), unspecified, and obstructive and reflux uropathy, unspecified. Review of Resident #82's physician order dated12/3/2025 read, Indwelling catheter to straight drainage. Size:18 F [French] Bulb:10 cc [cubic centimeters]. Change for infection, obstruction or when the closed system is compromised. Review of Resident #82's physician order dated 8/21/2025 read, Enhanced Barrier Precautions [infection control measure requiring staff to wear gowns and gloves during contact care, such as dressing, transferring, changing linens] r/t [related to] indwelling medical device. During an observation of urinary catheter care for Resident #82 on 2/12/2026 at 9:41 AM, Staff N, Certified Nursing Assistant (CNA) performed hand hygiene donned personal protective equipment (PPE) of a gown and gloves. Staff N, CNA assembled supplies and entered Resident #82's room placing the supplies on the overbed table. Staff N, CNA then exited Resident #82's room with the PPE on, went out to the supply room, obtained a plastic pad, and returned to Resident #82's room without changing the PPE of the gown and gloves. The plastic pad fell onto the floor and Staff CNA picked it up off the floor with gloved hands and placed the plastic pad under Resident #82. Staff N, CNA obtained wipes and provided catheter care wiping from front to back using one wipe each time and cleaning down the catheter. Staff N, CNA repositioned Resident #82, removed the gown and gloves, did not perform hand hygiene, and exited the room. During an interview on 2/12/2026 at 1:18 PM Staff N, Certified Nursing Assistant (CNA) stated, I would change a lot about that observation. I should have had everything ready, so I didn't leave the room with my gown and gloves on. I should have changed them. I shouldn't have picked up the plastic pad from off the floor and then done her catheter care. During an interview on 2/12/2026 at 1:21 PM the Director of Nursing (DON) stated, Staff should follow all infection control standards for enhanced barrier precautions and for changing PPE and gloves. They should perform hand hygiene when donning or doffing gloves. Review of the policy and procedure titled, Hand Hygiene with a last review date of 7/7/2025 read, Policy: The facility has adopted the CDC (Center for Disease Control) Core Infection Prevention and Control Practice for safe healthcare delivery in all settings for indications of hand hygiene that are generally consistent with the WHO (World Health Organization) 5 moments for hand hygiene. Procedure: 2. Associates perform hand hygiene (even if gloves are used) in the following situations: a. Before and after contact with the resident; b. After contact with blood, body fluids, or visibly contaminated surfaces; c. After contact with objects and surfaces in the resident's environment; d. After removing personal protective equipment (e.g., gloves, gown, eye protection facemask). 2. During an observation on 2/9/2026 at 10:39 AM Staff G, Certified Nursing Assistant (CNA) was changing Resident #74's bed linens. Staff G had donned gloves and no gown. Staff G wheeled Resident #74 to the shower room. Resident #74's door had an enhanced barrier precaution sign and personal protective equipment outside of the room door. During an observation on 2/9/2026 at 10:55 AM in the shower room, Staff G came around the corner of the curtain and was observed not wearing a protective gown while assisting Resident #74 with a shower. Review of Resident #74's physician order dated 12/22/2025 read, Enhanced Barrier Precautions Diagnosis: history of MDRO [Multidrug Resistant Organisms] every shift. During an observation on 2/9/2026 at 4:02 PM Staff G, CNA and Staff H, CNA, entered Resident #65's room. Resident #65's room door had an enhanced barrier precaution sign and personal protective equipment outside of the room. Staff G and Staff H were observed to go into the resident's room without donning a gown. When entry into the room was requested by this writer, Staff G CNA pulled the curtain back and stated patient care while disposing of a soiled brief. Staff G and Staff H were observed to be wearing gloves but no gowns. Review of Resident #65's physician orders dated 1/22/2026 read, Enhanced Barrier Precaution Diagnosis: MRSA [Methicillin-resistant Staphylococcus aureus] in nares every shift. During an interview on 2/11/2026 at 1:20 PM Staff H, CNA stated, I did not put a gown on because I was not aware that [Resident #65's name] had enhanced barrier precaution orders. During an interview on 2/12/2026 at 10:14 AM Staff G, CNA stated, I was moving too fast and did not gown when helping [Resident 74's name]. I thought I had gowned for [Resident #65's name].

Based on observation, interview, and record review the facility failed to prevent the possible spread of infection when staff failed to implement infection prevention measures while assisting 1 of 3 residents, Resident #19, observed for infection control practices. Findings include: On 9/10/2024 at 12:45 PM, Staff B, Certified Nursing Assistant, picked Resident #19's hearing aids up off of Resident #19's bedside table with her hands to insert into Resident #19's ears. Staff B did not wash/sanitize her hands or don gloves before she picked up Resident #19's hearing aids and attempted to insert one hearing aid into Resident #19's left ear. On 9/10/2024 at 12:48 PM, Staff C, Certified Nursing Assistant, entered Resident #19's room. Staff B requested that Staff C assist her to insert the hearing aids into Resident #19's ear. Staff C responded by telling Staff B that she should have sanitized her hands and donned gloves before picking up Resident #19's hearing aids and attempting to insert the hearing aids into Resident #19's ears. During an interview on 9/10/2024 at 12:49 PM, Staff B confirmed she had not washed/sanitized her hands and donned gloves before she picked up Resident #19's hearing aids and attempted to insert the hearing aids into Resident #19's ears. During and interview on 9/11/2024 at 7:57 AM, the Director of Nursing stated Staff B should have sanitized her hands and donned gloves before she picked up Resident #19's hearing aids and attempted to insert the hearing aids into Resident #19's ears. She stated that Staff B should have then assisted Resident #19 to insert the hearing aids, doffed her gloves and washed her hands with soap and water. Review of the document titled Hearing Aid Care, reviewed 5/20/2024, read Implementation: Gather and prepare the necessary equipment and supplies. Perform hand hygiene. Confirm the patient's identity using at least two identifiers. Provide privacy. Raise the bed to waist level before providing care to prevent caregiver back strain. Perform hand hygiene. Review of the policy and procedure titled Hand Hygiene, reviewed 6/3/2024, read 2. Associates perform hand hygiene (even if gloves are used) in the following situations: a. Before and after contact with the resident; b. After contact with blood, body fluids, or visibly contaminated surfaces; c. After contact with objects and surfaces in the resident's environment; d. After removing personal protective equipment (e.g., [for example] gloves, gown, eye protection, facemask); and e. Before performing a procedure such as an aseptic task (e.g., [for example] insertion of an invasive device such as a urinary catheter, manipulation of a central venous catheter, and/or dressing care).

Based on interview and record review, the facility failed to transmit accurate and complete Minimum Data Sets (MDS) for 2 of 3 discharged residents, Residents #117 and #118). Findings include: 1. Review of the medical record for Resident #117 documented the resident was discharged on [DATE] to short term general hospital. Review of Resident #117's MDS (Minimum Data Set) Discharge-Return Not Anticipated, dated 7/29/2024, read, (Section A 0310 Discharge assessment- return not anticipated). Review of Resident 117's physician orders read, Physician order Late entry 7/30/24 at 6:34 AM send resident to ER [emergency room ] for eval/tx [evaluation/treatment] During an interview on 9/11/24 at 12:07 PM the MDS Coordinator stated, There is an error with the discharge assessment. It should have been return anticipated. 40559 2. Review of the medical record for Resident #118 documented the resident was admitted to the facility on [DATE] and discharged on [DATE] to [Name of Hospital]. Review of Resident #118's physician order dated 6/21/24 read, D/C [discharge] to [Name of Hospital] per residents request for 6/24/2024. During an interview on 09/11/24 at 12:54 PM, the Director of Nursing confirmed Resident #118 had an order per her choice to discharge to [Name of Hospital]. Review of Resident #118's Minimum Data Set (MDS) Assessment discharge return not anticipated dated 6/21/24 documented resident as an unplanned discharge to inpatient rehab facility. During an interview on 09/11/24 at 12:07 PM the MDS Coordinator, stated, Resident #118's MDS Assessment was inaccurately coded as unplanned and due to Resident #118 having a physician order for discharge, it should have been coded as a planned discharge. A copy of the policy and procedure was requested. The MDS Coordinator stated, we follow the RAI [Resident Assessment Instrument].

Based on record review and interview the facility failed to ensure the physician/prescriber documented a rationale for declining a pharmacist's recommendation in a timely manner for 1 of 5 residents, Resident #20, reviewed for unnecessary medications. Findings include: Review of Resident #20's medication regimen review (MRR), dated 11/13/2023, showed the pharmacist had recommended [Resident's Name] has received a non sedating antihistamine routinely, LORATADINE 10 MG [milligrams] DAILY for NASAL DRIP since 12-4-2020. Recommendation: Please discontinue LORATADINE. Resident #20's MRR, dated 11/13/2023, showed the Advanced Practitioner Registered Nurse (APRN) had declined the pharmacist's recommendation to discontinue Loratadine. Resident #20's MRR failed to show the APRN had included a rationale for their decision to decline the pharmacist's recommendation. During an interview on 9/11/2024 at 8:31 AM, the Director of Nursing confirmed the APRN had not documented a rationale for declining the pharmacist's 11/13/2023 recommendation in a timely manner. She confirmed the APRN had not prepared a statement that explained her decision to decline the pharmacist's 11/13/2023 recommendation. Review of the policy and procedure titled Medication Regimen Review, last reviewed 1/25/2024, read 8. Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRR and the Director of Nursing to act upon the recommendations contained in the MRR. 8.1 For those issues that require Physician/Prescriber intervention, Facility should encourage Physician/Prescriber to either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected. 8.2.1 If the attending physician has decided to make no change in the medication, the attending physician should document the rationale in the resident's health record.

Based on observation, interview, and record review the facility failed to follow/implement the facility's policy and procedures and Centers for Disease Control (CDC) guidelines for Transmission Based Precautions to prevent the possible spread of infection to staff, visitors, and residents. The facility failed to ensure appropriate visual alerts were posted outside of the memory care unit and on the 200 Hall when residents were identified to be COVID-19 (Coronavirus 2019) positive. The facility failed to maintain contact/droplet precautions by not donning appropriate Personal Protective Equipment (PPE) to include N95 respirators, gowns, gloves, and eye protection when in close and prolonged contact with COVID-19 positive residents on the memory care unit, and would exit the unit, walk through the facility to clock out at the end of the shift. On 5/11/2023, the facility had a total of 28 COVID-19 positive residents out of a census of 109 residents. This failure has the likelihood for serious harm, serious impairment or death for people [AGE] years of age or older, people who have a severe underlying medical condition, and people who live in nursing homes are at higher risk for developing serious complications from COVID-19 illness. Individuals who are infected might develop serious diseases with difficulty breathing. Some individuals might require intensive care for the treatment of multi organ failure, respiratory failure, and septic shock. COVID-19 infection can lead to death. Findings include: During an observation on 5/8/2023 at 8:45 AM, the facility's main entrance did not have visual alerts posted to inform visitors and staff of an infection outbreak. There were surgical masks in a box on the receptionist desks. There was no other PPE observed in the lobby for visitors and staff to don prior to entering the facility. During an observation on 5/8/2023 beginning at 9:45 AM of the Memory Care Unit entrance double doors, there were no visuals alerts posted to inform visitors and staff of an identified infection outbreak. There was no signage of the need to don PPE before entering the unit and there was no personal protective equipment at the entry to indicate the need for donning PPE prior to entering. After entering the unit, there were two rooms observed to have bins containing PPE consisting of gowns, gloves, N95 respirators, and face shields for Residents #45, #60, #42, and #72's rooms. There were no visual postings on the doors for Residents #45, #60, #42, and #72 to inform visitors or staff of the need to see the nurse prior to entering the room or the need to don PPE prior to entering the rooms. Staff A, Licensed Practical Nurse (LPN), was observed wearing an N95 respirator, and another staff member was observed wearing a surgical mask. Neither staff member was wearing a gown, gloves, or eye protection. Three residents were observed in the dining room and five residents were observed in the common living area of the Memory Care Unit. During an observation on 5/8/2023 at 9:45 AM, Staff A, LPN, exited the nursing station and administered medications to a resident sitting in the dining room of the Memory Care Unit. During an observation on 5/8/2023 at 9:46 AM, Staff E, Certified Nursing Assistant (CNA), was observed exiting a resident's room toward the end of the hallway and entered the living area where the five residents were sitting. Staff E was observed to be wearing a surgical mask, and was not wearing a gown, gloves, or eye protection. During an observation on 5/8/2023 at 9:46 AM, Staff C, CNA, was wearing an N95 respirator in the dining room area. A resident stood up and Staff C assisted the resident back to a sitting position in a chair. Observations were made of the remaining rooms on the unit that did not have a storage bin in front of the rooms. During an observation on 5/8/2023 at 10:10 AM, Staff B, Director of Central Supply, and Staff C, CNA, were wearing N95 respirators, and Staff E, CNA, was wearing a surgical mask. Staff B, Staff C, and Staff E were not wearing gowns, gloves, or eye protection. Staff B, Staff C, and Staff E were placing Contact Precautions signs on multiple room doors of the Memory Care Unit. During an interview on 5/8/2023 at 10:10 AM on the Memory Care Unit, Staff A, LPN, stated, [Resident #94's name] is COVID positive. That is why the room door has a contact precaution sign posted. This is the sign we use for COVID positive. During an observation on 5/8/2023 at 10:11 AM, Residents #26, #70, #58, #157, #71, #69, #45, #60, #42, #72, #53, #99, #76, #61, #52, #85, #13, #88, #94, and #37's room doors had signage which read, Contact Precautions. Review of the COVID-19 Line List documented as of 5/4/2023 revealed the facility had a total of 7 COVID-19 positive residents. Four (4) of the 7 positive residents resided on the Memory Care Unit. Review of the COVID-19 Line List documented as of 5/7/2023 revealed the facility had a total of 16 COVID-19 positive residents. Twelve (12) of the 16 positive residents resided on the Memory Care Unit. Review of the COVID-19 Line List documented as of 5/8/2023 revealed the facility had a total of 21 COVID-19 positive residents. Fourteen (14) of the 21 positive residents resided on the Memory Care Unit. During an observation on 5/8/2023 at 9:53 AM of Residents #92 and #50's rooms, which were located on the 200 Hall, there was a visual posting that read, Contact Precaution. During an interview on 5/8/2023 at 9:55 AM, Staff D, Registered Nurse (RN), stated, Both of the residents in the room had tested positive last Thursday [Resident #92 tested positive on 5/5/2023 and Resident #50 tested positive on 5/8/2023]. We use masks, gowns, gloves, and face shields. Both residents are in isolation and cannot come out until they are negative. During an interview on 5/8/2023 at 10:27 AM, the Infection Preventionist stated, [Resident #50's name] is negative as of right now. [Resident #92's name] tested COVID positive on Saturday [5/6/2023]. [Resident 92's name] son came into the building to visit, and he tested COVID positive. Both [Resident #50's name and Resident #92's name] are sharing a room since they are both isolated due to the exposure. I recommended that they share a room due to the level of their exposure. We will test [Resident #50's name] today and again tomorrow. The Memory Care Unit census is 20 residents, and 12 residents are positive as of 5/8/2023. These residents are severely cognitively impaired, and the approach was to isolate the entire wing. We have residents who wander into other residents' rooms. They are exit seekers and at risk for elopement and we cannot move them anywhere else safely. Memory care should have Personal Protective Equipment (PPE) outside of the double doors to Serenity [Memory Care Unit name]. I cannot say that is in place now. I tested positive on 5/2/2023 and I am not sure where it came from. My symptoms started late Monday afternoon. I did the 5-day quarantine and returned today [5/8/23]. The Serenity Unit has only contact precaution signs and not droplet precautions [signs]. I came back to work using the CDC criteria and came back due to 'crisis staffing criteria' as I was needed to come back in to work. The Memory Care Unit staff started testing positive on 5/4/2023. We had a staff member who tested positive on 5/1/2023 [The Activity Director]. Her last day working in the facility was 4/28/2023. She worked on all three units. Our community rate was low enough that we were not wearing masks. We started wearing masks on 5/1/2023. We have three staff members out due to COVID. We are testing staff twice a week on Tuesday and Thursday. We last tested residents on 5/4/2023. We will be testing residents again tomorrow. During an observation on 5/8/2023 at 10:45 AM, the Memory Care Unit entrance double doors had no visual posting to alert visitors and staff before entering the unit with instructions about current infection prevention and control recommendations for the unit. No personal protective equipment was observed outside of the doors. During an observation on 5/8/2023 at 10:45 AM, in the Memory Care Unit, Staff A, LPN, was assisting residents and was wearing an N95 respirator, and was not wearing a gown, gloves, or eye protection. During an observation on 5/8/2023 at 10:46 AM, Staff C, CNA, was supervising a resident in the dining area. Staff C was wearing an N95 respirator and was not wearing a gown, gloves, or eye protection. During an observation on 5/8/2023 at 10:46 AM, Staff E, CNA, was supervising a resident in the dining area. Staff C was wearing a surgical mask, not an N95 respirator, and was not wearing a gown, gloves, or eye protection. During an interview on 5/8/2023 at 10:46 AM in the Memory Care Unit, the Infection Preventionist stated, All rooms in the locked memory care unit were incorrectly labeled with contact precaution signs and the signs should say droplet and contact precautions. Signs should be posted on residents' doors as soon as the test results come in. During an observation on 5/8/2023 at 12:03 PM, Staff E, CNA, was passing out lunch trays to the residents in the Memory Care Unit. Staff E was wearing a surgical mask, not an N95 respirator, and was not wearing a gown, gloves, or eye protection. Coming in close contact, she placed each food tray on the table in front of each resident. During an interview on 5/8/2023 at 12:15 PM, Staff A, LPN, stated, I was not here over the weekend. What I did when I came back to work was to do my own report and test all the residents again to make sure what their COVID status was at this time. I had the staff take all the signs down. That is why when you entered the unit, some rooms did not have signs posted on the doors. The Infection Preventionist was out due to COVID and [Staff F, LPN's name] took over. The girls [Certified Nursing Assistants assigned to the Memory Care Unit] were helping me put the signs back on the doors after the COVID test results came back. Normally if a resident tested positive for COVID, we will move the resident out of the room to a single room or if two residents are positive, we will double them up in the same room. This is the memory care unit, and we need to be careful that the residents do not get out of the unit making it harder to arrange room changes. We were all off this weekend and I had the signs being copied to place on the doors. We had bins outside some rooms. This was sporadic. I stopped everything after I received the shift report and started testing all the residents from scratch since we have agency staff working in the unit. We were not aware we needed to wear gowns and gloves on the unit. The Infection Preventionist informed us we needed to wear proper PPE after you had been on the unit. [Staff E, CNA's name] was the staff who didn't have the N95 mask on while on the unit. We all found out we needed to wear gowns in the halls and only N95 mask afterwards. The Infection Preventionist came into the unit and provided the correct signs for all the rooms. We were using the contact signs because that was what we had at that time. I had sent a text message to [Staff F, LPN's name] at 9:22 AM stating some rooms had signs and some did not. She replied that we needed to have signage on resident doors for contact/droplet precautions and since I was off during the weekend that is why I decided to do my own report since I did not know when those signs went on the doors. I am the primary nurse on the unit and do my own thing due to the agency staff that work the unit. During an interview on 5/8/2023 at 1:01 PM, Staff C, CNA, stated, I was off during the weekend and just came back to work today. We get report on the unit at 6:45 AM. Residents were starting to come up positive for COVID. [Staff A, LPN's name] decided to recheck to make sure [to determine if additional residents were positive]. We were not aware we needed to wear a gown and gloves while working on the unit. I know as you go into the room you wear a face shield, N95 mask, gloves, and gown. This unit is different. COVID positive residents are outside of the rooms. We had contact precaution signs on the doors. Contact precautions is pretty much used for everything. [Staff A, LPN's name] never mentioned that the signs provided were not the correct ones. During an interview on 5/8/2023 at 1:21 PM, Staff E, CNA, stated, I was wearing a surgical mask because that was what we were supposed to do until they told us to wear N95 masks later on 5/8/2023. [Staff A, LPN's name] told us to put up the contact precaution signs on the COVID positive resident doors. Nobody told us that we needed to include droplet precautions. I worked Friday and rooms for [Residents #70, #42, #37 and #94's names] all had contact precaution signs on the door. I was wearing only a surgical mask while in contact with two COVID positive residents that were sitting in the living room area. The residents were not wearing masks. It is hard for them to keep the masks on. I did not know we had to wear gowns while in the common area. During an interview on 5/8/2023 at 1:31 PM, Staff B, Director of Central Supply, stated, On Friday night, three residents tested positive for COVID and I posted the signs I had available. Monday, [Staff A, LPN's name] said to make copies. It was the same two signs. One said, 'stop see the nurse' and the other one 'contact precautions.' I went and got the copies. That is when you saw us posting the signs on the doors. Later that day, I saw the Infection Preventionist hanging the other signs which basically say the same things as the other ones. When [Staff A, LPN's name] asked me to make copies and hang the signs, she never mentioned they were not appropriate [signs]. I placed the signs on Friday before I left, so at least the people entering would at least stop at the door [resident's door]. I think we use the same protocol for all, the same precautions. I did not have a gown when entering the Memory Care Unit. I was not going in the rooms. I was just hanging signs on the resident rooms. I did hear some more residents tested positive but I'm not familiar with their faces. I was not aware the residents that were COVID positive were in the common areas in the Memory Care Unit. For contact precautions, I would say we use a blue mask [surgical mask], gown, and gloves. If it is droplet, we are expected to wear a face shield, N95, and gown. When I exited the Memory Care Unit, I went around the facility and made sure all PPE bins were fully stocked. During an interview on 5/8/2023 at 1:45 PM, the Director of Nursing (DON) stated, As far as monitoring infection control, I do it with the Infection Preventionist. We collaborate on how we are going to move forward. Residents who test negative for COVID should be removed from COVID positive rooms. Signage should be on the door as well as personal protective equipment. I do not know what happened with [Resident #92's name]. I reached out to the nurse that worked that weekend and she has not reached out back. I round daily regarding education on PPE. I am in the middle of my infection control training. Staff should wear appropriate PPE when in contact with positive residents. I went to the memory care unit on 5/4/2023 and again on 5/5/2023 and I was wearing an N95 and face shield. I was not wearing a gown since I was only at the nursing station and hallway. The staff were informing me of a COVID positive resident, and I then informed my boss and the Infection Control Preventionist. Staff was instructed to notify the physician, family, and follow orders. They were also instructed to isolate residents as much as they can. I would say I oversee infection prevention when the Infection Preventionist is not available. During an observation on 5/9/2023 at 12:32 PM of the Memory Care Unit double door entrance, there was a sign, which read, STOP! You are entering a COVID-19 Positive Unit. Associates must wear the following at all times in this unit: Eye Protection, Respirator or surgical face mask. Associates must wear the following when entering resident rooms: Gown, Gloves. During a telephonic interview on 5/9/2023 at 2:33 PM, Staff F, LPN/Infection Prevention Trainee, stated, I would keep communication via phone with Infection Preventionist, Administrator and DON for guidance as to my role I wasn't sure. I tested positive on the 3rd [May] showing symptoms. When I spoke to [Staff A, LPN's name], I told them to follow normal protocol which include signs, carts with PPE, and wearing proper PPE. There was a lot of texting back and forth, a lot of the guidance came from the Infection Control Preventionist. Staff needed to make sure that signs stated droplet and contact if I am not mistaken. Via text, I was notified that Sunday [5/7/2023], 10 residents tested positive for COVID. I did not give any guidance. It was pretty much the DON and Administrator who were going back and forth providing guidance. Last time I was in the building was Wednesday [5/3/2023] until 4 PM. When the Infection Preventionist is not available, the DON and the Regional Clinical Consultant were responsible. During a telephonic interview on 5/9/2023 at 2:55 PM, the Medical Director stated, I was not aware of the COVID-19 outbreak status in the facility. I have been the Medical Director since January. No one contacted me in the last two weeks concerning the COVID-19 outbreak status at the facility. My expectation was for residents who have a roommate and test positive for COVID, the positive resident should be put in a room with others who are positive. The roommate would generally be placed or transferred with patients with a negative test result. I would have expected the resident who tested negative to be removed from the room of the one who tested positive. During an interview on 5/11/2023 at 12:15 PM, Staff E, CNA, stated, I do not take lunch in the breakroom. I go outside using the back door. We are allowed to use the employee breakroom for lunch if we want. When my shift is over, I exit the unit and walk through the facility to clock out. During an interview on 5/11/2023 at 12:16 PM, Staff G, CNA, stated, I work all over the facility. Last time I worked in the Memory Care Unit was last Thursday or Friday [5/4/2023 or 5/5/2023]. I worked with [Staff E, CNA's name] and we were only wearing surgical face masks while taking care of the residents in the Memory Care Unit. Residents were already coming up positive and I didn't know I was supposed to wear an N95. During an interview on 5/11/2023 at 12:20 PM, Staff H, LPN, stated, I only work in the Memory Care Unit and worked last Sunday [5/7/2023]. I wore an N95 mask. I did not leave the unit on Sunday for lunch or break. I exit the unit and walk through the facility to clock out. During an interview on 5/11/2023 at 12:50 PM, Staff I, CNA, stated, I do not remember what rooms I was assigned to. I think I worked in the back hall of the 200 Hall. On Monday, I was wearing a surgical mask when I came in, then we were told to wear an N95 mask when you guys showed up. Review of the COVID-19 Line List documented as of 5/11/2023 revealed the facility had a total of 28 COVID-19 positive residents. During an interview conducted on 5/12/2023 at 8:49 AM, the Administrator stated, Biggest thing was on 5/1/2023 when residents started testing positive for COVID. I sat down with my Director of Nursing (DON) and Infection Preventionist (IP) and referred back to our policies and procedures. I had the DON and IP come up with a clinical procedure and isolation and personal protective equipment to go into place. We had an Ad Hoc meeting on 5/1/2023, got the isolation signs and continued to test. We reviewed residents and patient care and began putting a plan in place. I took the clinical piece and had my DON and IP work together. The Medical Director was aware of the policies we have in place, but he was not involved in the meeting held on 5/1/2023. The DON provided coverage while the Infection Preventionist was out. My Infection Preventionist tested positive on 5/2/2023. The DON was responsible for overseeing infection control in the facility. With COVID positive [residents], we need to have droplet and contact precautions. The signs [visual alerts] should have been posted. I became aware the COVID Unit [Memory Care Unit] was not on isolation on 5/8/2023. COVID positives are not allowed to cohort with non-positive residents. They are not allowed to remain in the same room. When this was brought to my attention, we separated them on 5/8/2023 [Residents #92 and #50]. It was my understanding that staff were wearing the appropriate personal protective equipment and appropriate signage was posted. The DON was here on Friday [5/5/2023] and she was here on [5/6/2023] on Saturday. The signage was provided to her and put in place. The DON notified me on 5/7/2023 of the COVID positives and it was my understanding that we had made the Memory Care Unit a red unit [COVID Unit]. During an interview on 5/12/2023 at 8:50 AM, the Regional [NAME] President stated, As long as the staff is properly donning and doffing their PPE and handwashing before they exit the unit, they are able to go through the facility to clock out. During an interview on 5/12/2023 at 8:57 AM, the Regional Director of Clinical Services stated, I personally provided the correct signs on 5/4/2023. I know the two signs on Serenity [Memory Care Unit] signs were not on the doors on Monday morning [5/8/2023]. The CDC wants correct singular signs of contact and droplet precaution signs versus a combined sign. I knew the individual rooms in the Serenity Unit did not have signs posted. I was not aware of the incident in the C-wing [200 Hall where Residents #92 and #50 reside]. I was not aware of the room in the C-wing [200 Hall, having the wrong sign]. On 5/4/2023, signage was identified as a concern and I personally placed a color sign on the A-wing [100 Hall] and provided two signs to the DON to place on the Serenity doors. The plan we had in place was not working. I provided correct signs, and the facility was not using them. On Monday morning [5/8/2023] when I showed up, I realized that signs had not been posted. On 5/4/2023, a cover message was sent out to all staff stating to wear eye protection and N95 mask for the A-wing and Serenity Unit [100 Hall and Memory Care Unit]. A request was made for documentation of all staff having received and read the cover message. No documentation was provided. During an interview on 5/12/2023 at 10:30 AM, the Regional Director of Clinical Services stated, The incorrect signage [in the Memory Care Unit] on 5/4/2023 was corrected immediately and didn't warrant follow up. It was a singular incident. No performance plan was needed. We would not evaluate at a later date. The signage was incorrect on the entrance of Serenity on that day [5/4/2023]. I did not enter the Serenity Unit; less people is better. The signage on the outside was what was observed. I was not notified that the facility had positives in the building over the weekend. If I had that information as a Clinical Leader, I would have come into the facility. Especially with a cluster as big as seven. I would have come in, the Director of Nursing and/or the Infection Preventionist facilitated the room changes, notifications, and process. I would not say it was a systemic break, it was the action of employees regardless of the education provided. The system was in place but not followed. The process broke. There was a hole, definitely a gap. I did not put in a root cause analysis. I had included it in my notes and dealt with it appropriately. The expectation is that PPE and handwashing are followed. They are allowed to come into facility to exit [to clock out]. I was not aware that staff was not using the appropriate PPE, but I can prove that 128 staff members received the message sent regarding the PPE to wear. I am not able to say if the Director of Nursing went into the Memory Care Unit to verify staff were following instructions on PPE. The audits [5/1/2023 and 5/3/2023] do not have to do with the current issue. Currently, we suspended the Director of Nursing for failure to follow clinical direction and follow the clinical policy in relation to infection control. A request was made for documentation of all staff having received and read the cover message. No documentation was provided. Review of Resident #26's admission record documented the resident was [AGE] years old with diagnoses to include congestive heart failure, chronic kidney disease, stage III and age-related cognitive decline. Review of Resident #26's progress note dated 5/4/2023 documented, Resident COVID tested with positive result. Resident placed on transmission-based precautions. Review of Resident #94's admission record documented the resident was [AGE] years old with diagnoses to include urinary tract infection, hypertensive, chronic kidney disease, neoplasm of uncertain behavior of prostate, chronic kidney disease, and cognitive communication deficit. Review of Resident #94's progress note dated 5/4/2023 documented, Resident noted with head congestion. States he does not feel well. Temp. [temperature] 99.6. Covid test positive. Residents are [Sic.] placed in transmission-based precautions. Review of Resident #42's admission record documented the resident was [AGE] years old with diagnosis to include chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease, and dementia. Review of Resident #42's progress note dated 5/4/2023 documented, Resident with positive covid test. Noted with temp 99.5. No cough or congestion noted. Notified [Physician Assistant's name] PA, resident placed on transmission-based precautions. Review of Resident #72's admission record documented the resident was [AGE] years old with diagnosis to include chronic obstructive pulmonary disease, type II diabetes mellitus, viral hepatitis C, and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of Resident #72's progress note dated 5/4/2023 documented, Resident with positive covid test. Afebrile, no cough or congestion noted. Notified [Physician Assistant's name] PA, resident placed on transmission-based precautions. Review of Resident #92's admission record documented the resident was [AGE] years old with diagnoses to include hypertension, depression, osteoarthritis, repeated falls, dementia, and dysphagia. Review of the progress note dated 5/5/2023 for Resident #92, who resided on the 200 Hall in a semi-private room with Resident #50, documented, Pt [patient] experiencing SOB [shortness of breath], shallow respirations, tachypnea. 114/60 [blood pressure] 92P [pulse] 98.4T [temperature] 24R [respirations] 95% RA [oxygen saturation on room air]. Lungs have crackles in bilateral lower lobes. Blood glucose 156. Covid + [positive] rapid test. PCP [Primary Care Physician] contacted, new orders for Paxlovid BID x 5 days [twice a day times 5 days, an antiviral pill that reduces the amount of the virus that cause COVID-19 in the body and prevents symptoms from getting worse], Son notified of covid+ status and informed that he recently has gotten over covid and would like to know if a mask needs to be worn while visiting his mother. Son educated on proper PPE. Review of the admission record for Resident #50 documented the resident was [AGE] years old with diagnosis to include chronic kidney disease, stage 3, type II diabetes mellitus, and cognitive communication deficit and resided on the 200 Hall in a semi-private room with Resident #92. Review of Resident #61's admission record documented the resident was [AGE] years old with diagnosis to include atrial fibrillation, altered mental status, chronic obstructive pulmonary disease, and dementia. Review of Resident #61's progress notes dated 5/7/2023 documented, Resident tested for covid due to other residents' positive status. Resident tested positive. Review of the medical record for Resident #61 did not provide on order to place the resident on transmission-based precautions dated 5/7/2023. Review of Resident #45's admission record documented the resident was [AGE] years old with diagnosis to include hypertensive chronic kidney disease, Alzheimer's Disease with early onset, squamous cell carcinoma of skin of left upper limb, type 2 diabetes, and unspecified dementia. Review of Resident #45's progress note dated 5/8/2023 documented, Resident tested this morning for COVID positive. [Doctor's name] PA [Physician Assistant's name] was notified, waiting for response. Asked to advise for any orders. Waiting for response from [Physician Assistant's name] PA. Review of Resident #58's admission record documented the resident was [AGE] years old with diagnosis to include dementia, hypertensive chronic kidney disease stage IV, and personal history of tuberculosis. Review of the Line Listing dated 5/7/2023 documented Resident #58 tested positive. Review of the medical record for Resident #58 did not provide documentation of the resident having tested positive for COVID-19. Review of Resident #99's admission record documented the resident was [AGE] years old with diagnosis to include dementia and mood affective disorder. Review of Resident #99's progress note dated 5/7/2023 documented, Resident tested for covid d/t [due to] other residents' positive status. Residents tested positive. Review of Resident #13's admission record documented the resident was [AGE] years old with diagnosis to include chronic kidney disease, heart failure, dementia, and type II diabetes mellitus. Review of Resident #13's progress note dated 5/7/2023 documented, Resident noted with mild symptoms, runny nose. tested for covid, positive result. Review of Resident #85's admission record documented the resident was [AGE] years old with diagnosis to include hypertensive heart disease, dementia, and cognitive communication deficit. Review of Resident #85's progress note dated 5/8/2023 documented, Resident was tested this morning with results of COVID positive. Called [Physician Assistant's name] PA with [Doctor's name] asking to advise for any new orders. Waiting for response. Review of Resident #69's admission record revealed the resident was [AGE] years old with diagnosis to include paranoid schizophrenia, dementia, bipolar disorder, and anxiety. Review of Resident #69's progress note dated 5/7/2023 documented, Resident tested for covid due to positive status of other residents. Resident with positive result. Review of Resident #60's admission record documented the resident was [AGE] years old with diagnosis to include dementia, pseudo bulbar, and cognitive communication. Review of Resident #60's progress note dated 5/7/2023 documented, Resident with mild cold symptoms. tested for covid, results positive. Review of Resident #53's admission record documented the resident was [AGE] years old with diagnosis to include dementia, COPD (chronic obstructive pulmonary disease), Alzheimer's Disease, and palliative care. Review of Resident #53's progress note dated 5/9/2023 documented, Spoke with son, [Resident #53 son's name] of mother testing positive for COVID. Review of Resident #88's admission record documented the resident was [AGE] years old with diagnosis to include Alzheimer's Disease and schizoaffective. Review of Resident #88's progress note dated 5/8/2023 documented, Attempted to contact family message left with family of mother positive results when tested this afternoon for COVID. Review of Resident #59's admission record documented the resident was [AGE] years old with diagnosis to include cognitive communication deficit, allergic rhinitis, and other idiopathic peripheral autonomic neuropathy. Review of Resident #59's progress noted dated 5/8/2023 documented, Resident COVID positive. Review of Resident #76's admission record documented the resident was [AGE] years old with diagnosis to include unspecified dementia, chronic kidney disease, other disorders of lung, and elevation od levels of live [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure their quality assessment and assurance committee developed and implemented appropriate plans of action to investigate, develop and implement an effective performance improvement plan (PIP) for the prevention of the possible spread of infection, when a COVID-19 outbreak was identified in the facility. The facility failed to ensure appropriate visual alerts were posted outside of the memory care unit and on the 200 Hall related to identified COVID-19 (Coronavirus Disease 2019) outbreak. The facility failed to implement monitoring to maintain contact/droplet precautions to ensure the donning appropriate Personal Protective Equipment (PPE) to include N95 respirators, gowns, gloves, and eye protection when in close and prolonged contact with COVID-19 positive residents on the memory care unit. On 5/11/2023, the facility had a total of 28 COVID-19 positive residents out of a census of 109 residents. This failure has the likelihood for serious harm, serious impairment or death for people [AGE] years of age or older, people who have a severe underlying medical condition, and people who live in nursing homes are at higher risk for developing serious complications from COVID-19 illness. Individuals who are infected might develop serious diseases with difficulty breathing. Some individuals might require intensive care for the treatment of multi organ failure, respiratory failure, and septic shock. COVID-19 infection can lead to death. Findings include: During an interview on 5/8/2023 at 1:45 PM, the Director of Nursing (DON) stated, As far as monitoring infection control, I do it with the Infection Preventionist. We collaborate on how we are going to move forward. Residents who test negative for COVID should be removed from COVID positive rooms. Signage should be on the door as well as personal protective equipment. I do not know what happened with [Resident #92's name]. I reached out to the nurse that worked that weekend and she has not reached out back. I round daily regarding education on PPE. I am in the middle of my infection control training. Staff should wear appropriate PPE when in contact with positive residents. I went to the memory care unit on 5/4/2023 and again on 5/5/2023 and I was wearing an N95 and face shield. I was not wearing a gown since I was only at the nursing station and hallway. The staff were informing me of a COVID positive resident, and I then informed my boss and the Infection Control Preventionist. Staff was instructed to notify the physician, family, and follow orders. They were also instructed to isolate residents as much as they can. I would say I oversee infection prevention when the Infection Preventionist is not available. During an interview conducted on 5/12/2023 at 8:49 AM, the Administrator stated, Biggest thing was on 5/1/2023 when residents started testing positive for COVID. I sat down with my Director of Nursing (DON) and Infection Preventionist (IP) and referred back to our policies and procedures. I had the DON and IP come up with a clinical procedure and isolation and personal protective equipment to go into place. We had an Ad Hoc meeting on 5/1/2023, got the isolation signs and continued to test. We reviewed residents and patient care and began putting a plan in place. I took the clinical piece and had my DON and IP work together. The Medical Director was aware of the policies we have in place, but he was not involved in the meeting held on 5/1/2023. The DON provided coverage while the Infection Preventionist was out. My Infection Preventionist tested positive on 5/2/2023. The DON was responsible for overseeing infection control in the facility. With COVID positive [residents], we need to have droplet and contact precautions. The signs [visual alerts] should have been posted. I became aware the COVID Unit [Memory Care Unit] was not on isolation on 5/8/2023. COVID positives are not allowed to cohort with non-positive residents. They are not allowed to remain in the same room. When this was brought to my attention, we separated them on 5/8/2023 [Residents #92 and #50]. It was my understanding that staff were wearing the appropriate personal protective equipment and appropriate signage was posted. The DON was here on Friday [5/5/2023] and she was here on [5/6/2023] on Saturday. The signage was provided to her and put in place. The DON notified me on 5/7/2023 of the COVID positives and it was my understanding that we had made the Memory Care Unit a red unit [COVID Unit]. During an interview on 5/12/2023 at 10:30 AM, the Regional Director of Clinical Services stated, The incorrect signage [in the Memory Care Unit] on 5/4/2023 was corrected immediately and didn't warrant follow up. It was a singular incident. No performance plan was needed. We would not evaluate at a later date. The signage was incorrect on the entrance of Serenity on that day [5/4/2023]. I did not enter the Serenity Unit; less people is better. The signage on the outside was what was observed. I was not notified that the facility had positives in the building over the weekend. If I had that information as a Clinical Leader, I would have come into the facility. Especially with a cluster as big as seven. I would have come in, the Director of Nursing and/or the Infection Preventionist facilitated the room changes, notifications, and process. I would not say it was a systemic break, it was the action of employees regardless of the education provided. The system was in place but not followed. The process broke. There was a hole, definitely a gap. I did not put in a root cause analysis. I had included it in my notes and dealt with it appropriately. The expectation is that PPE and handwashing are followed. They are allowed to come into facility to exit [to clock out]. I was not aware that staff was not using the appropriate PPE, but I can prove that 128 staff members received the message sent regarding the PPE to wear. I am not able to say if the Director of Nursing went into the Memory Care Unit to verify staff were following instructions on PPE. The audits [5/1/2023 and 5/3/2023] do not have to do with the current issue. Currently, we suspended the Director of Nursing for failure to follow clinical direction and follow the clinical policy in relation to infection control. A request was made for documentation of all staff having received and read the cover message. No documentation was provided. During an observation on 5/8/2023 at 8:45 AM, the facility's main entrance did not have visual alerts posted to inform visitors and staff of an infection outbreak. There were surgical masks in a box on the receptionist desks. There was no other PPE observed in the lobby for visitors and staff to don prior to entering the facility. During an observation on 5/8/2023 beginning at 9:45 AM of the Memory Care Unit entrance double doors, there were no visuals alerts posted to inform visitors and staff of an identified infection outbreak. There was no signage of the need to don PPE before entering the unit and there was no personal protective equipment at the entry to indicate the need for donning PPE prior to entering. After entering the unit, there were two rooms observed to have bins containing PPE consisting of gowns, gloves, N95 respirators, and face shields for Residents #45, #60, #42, and #72's rooms. There were no visual postings on the doors for Residents #45, #60, #42, and #72 to inform visitors or staff of the need to see the nurse prior to entering the room or the need to don PPE prior to entering the rooms. Staff A, Licensed Practical Nurse (LPN), was observed wearing an N95 respirator, and another staff member was observed wearing a surgical mask. Neither staff member was wearing a gown, gloves, or eye protection. Three residents were observed in the dining room and five residents were observed in the common living area of the Memory Care Unit. During an observation on 5/8/2023 at 9:45 AM, Staff A, LPN, exited the nursing station and administered medications to a resident sitting in the dining room of the Memory Care Unit. During an observation on 5/8/2023 at 9:46 AM, Staff E, Certified Nursing Assistant (CNA), was observed exiting a resident's room toward the end of the hallway and entered the living area where the five residents were sitting. Staff E was observed to be wearing a surgical mask, and was not wearing a gown, gloves, or eye protection. During an observation on 5/8/2023 at 9:46 AM, Staff C, CNA, was wearing an N95 respirator in the dining room area. A resident stood up and Staff C assisted the resident back to a sitting position in a chair. Observations were made of the remaining rooms on the unit that did not have a storage bin in front of the rooms. During an observation on 5/8/2023 at 10:10 AM, Staff B, Director of Central Supply, and Staff C, CNA, were wearing N95 respirators, and Staff E, CNA, was wearing a surgical mask. Staff B, Staff C, and Staff E were not wearing gowns, gloves, or eye protection. Staff B, Staff C, and Staff E were placing Contact Precautions signs on multiple room doors of the Memory Care Unit. During an interview on 5/8/2023 at 10:10 AM on the Memory Care Unit, Staff A, LPN, stated, [Resident #94's name] is COVID positive. That is why the room door has a contact precaution sign posted. This is the sign we use for COVID positive. During an observation on 5/8/2023 at 10:11 AM, Residents #26, #70, #58, #157, #71, #69, #45, #60, #42, #72, #53, #99, #76, #61, #52, #85, #13, #88, #94, and #37's room doors had signage which read, Contact Precautions. Review of the COVID-19 Line List documented as of 5/4/2023 revealed the facility had a total of 7 COVID-19 positive residents. 4 of the 7 positive residents resided on the Memory Care Unit. Review of the COVID-19 Line List documented as of 5/7/2023 revealed the facility had a total of 16 COVID-19 positive residents. 12 of the 16 positive residents resided on the Memory Care Unit. Review of the COVID-19 Line List documented as of 5/8/2023 revealed the facility had a total of 21 COVID-19 positive residents. 14 of the 21 positive residents resided on the Memory Care Unit. During an observation on 5/8/2023 at 9:53 AM of Residents #92 and #50's rooms, which were located on the 200 Hall, there was a visual posting that read, Contact Precaution. During an interview on 5/8/2023 at 9:55 AM, Staff D, Registered Nurse (RN), stated, Both of the residents in the room had tested positive last Thursday [Resident #92 tested positive on 5/5/2023 and Resident #50 tested positive on 5/8/2023]. We use masks, gowns, gloves, and face shields. Both residents are in isolation and cannot come out until they are negative. During an interview on 5/8/2023 at 10:27 AM, the Infection Preventionist stated, [Resident #50's name] is negative as of right now. [Resident #92's name] tested COVID positive on Saturday [5/6/2023]. [Resident 92's name] son came into the building to visit, and he tested COVID positive. Both [Resident #50's name and Resident #92's name] are sharing a room since they are both isolated due to the exposure. I recommended that they share a room due to the level of their exposure. We will test [Resident #50's name] today and again tomorrow. The Memory Care Unit census is 20 residents, and 12 residents are positive as of 5/8/2023. These residents are severely cognitively impaired, and the approach was to isolate the entire wing. We have residents who wander into other residents' rooms. They are exit seekers and at risk for elopement and we cannot move them anywhere else safely. Memory care should have Personal Protective Equipment (PPE) outside of the double doors to Serenity [Memory Care Unit name]. I cannot say that is in place now. I tested positive on 5/2/2023 and I am not sure where it came from. My symptoms started late Monday afternoon. I did the 5-day quarantine and returned today [5/8/23]. The Serenity Unit has only contact precaution signs and not droplet precautions [signs]. I came back to work using the CDC criteria and came back due to 'crisis staffing criteria' as I was needed to come back in to work. The Memory Care Unit staff started testing positive on 5/4/2023. We had a staff member who tested positive on 5/1/2023 [The Activity Director]. Her last day working in the facility was 4/28/2023. She worked on all three units. Our community rate was low enough that we were not wearing masks. We started wearing masks on 5/1/2023. We have three staff members out due to COVID. We are testing staff twice a week on Tuesday and Thursday. We last tested residents on 5/4/2023. We will be testing residents again tomorrow. During an observation on 5/8/2023 at 10:45 AM, the Memory Care Unit entrance double doors had no visual posting to alert visitors and staff before entering the unit with instructions about current infection prevention and control recommendations for the unit. No personal protective equipment was observed outside of the doors. During an observation on 5/8/2023 at 10:45 AM, in the Memory Care Unit, Staff A, LPN, was assisting residents and was wearing an N95 respirator, and was not wearing a gown, gloves, or eye protection. During an observation on 5/8/2023 at 10:46 AM, Staff C, CNA, was supervising a resident in the dining area. Staff C was wearing an N95 respirator and was not wearing a gown, gloves, or eye protection. During an observation on 5/8/2023 at 10:46 AM, Staff E, CNA, was supervising a resident in the dining area. Staff C was wearing a surgical mask, not an N95 respirator, and was not wearing a gown, gloves, or eye protection. During an interview on 5/8/2023 at 10:46 AM in the Memory Care Unit, the Infection Preventionist stated, All rooms in the locked memory care unit were incorrectly labeled with contact precaution signs and the signs should say droplet and contact precautions. Signs should be posted on residents' doors as soon as the test results come in. During an observation on 5/8/2023 at 12:03 PM, Staff E, CNA, was passing out lunch trays to the residents in the Memory Care Unit. Staff E was wearing a surgical mask, not an N95 respirator, and was not wearing a gown, gloves, or eye protection. Coming in close contact, she placed each food tray on the table in front of each resident. During an interview on 5/8/2023 at 12:15 PM, Staff A, LPN, stated, I was not here over the weekend. What I did when I came back to work was to do my own report and test all the residents again to make sure what their COVID status was at this time. I had the staff take all the signs down. That is why when you entered the unit, some rooms did not have signs posted on the doors. The Infection Preventionist was out due to COVID and [Staff F, LPN's name] took over. The girls [Certified Nursing Assistants assigned to the Memory Care Unit] were helping me put the signs back on the doors after the COVID test results came back. Normally if a resident tested positive for COVID, we will move the resident out of the room to a single room or if two residents are positive, we will double them up in the same room. This is the memory care unit, and we need to be careful that the residents do not get out of the unit making it harder to arrange room changes. We were all off this weekend and I had the signs being copied to place on the doors. We had bins outside some rooms. This was sporadic. I stopped everything after I received the shift report and started testing all the residents from scratch since we have agency staff working in the unit. We were not aware we needed to wear gowns and gloves on the unit. The Infection Preventionist informed us we needed to wear proper PPE after you had been on the unit. [Staff E, CNA's name] was the staff who didn't have the N95 mask on while on the unit. We all found out we needed to wear gowns in the halls and only N95 mask afterwards. The Infection Preventionist came into the unit and provided the correct signs for all the rooms. We were using the contact signs because that was what we had at that time. I had sent a text message to [Staff F, LPN's name] at 9:22 AM stating some rooms had signs and some did not. She replied that we needed to have signage on resident doors for contact/droplet precautions and since I was off during the weekend that is why I decided to do my own report since I did not know when those signs went on the doors. I am the primary nurse on the unit and do my own thing due to the agency staff that work the unit. During an interview on 5/8/2023 at 1:01 PM, Staff C, CNA, stated, I was off during the weekend and just came back to work today. We get report on the unit at 6:45 AM. Residents were starting to come up positive for COVID. [Staff A, LPN's name] decided to recheck to make sure [to determine if additional residents were positive]. We were not aware we needed to wear a gown and gloves while working on the unit. I know as you go into the room you wear a face shield, N95 mask, gloves, and gown. This unit is different. COVID positive residents are outside of the rooms. We had contact precaution signs on the doors. Contact precautions is pretty much used for everything. [Staff A, LPN's name] never mentioned that the signs provided were not the correct ones. During an interview on 5/8/2023 at 1:21 PM, Staff E, CNA, stated, I was wearing a surgical mask because that was what we were supposed to do until they told us to wear N95 masks later on 5/8/2023. [Staff A, LPN's name] told us to put up the contact precaution signs on the COVID positive resident doors. Nobody told us that we needed to include droplet precautions. I worked Friday and rooms for [Residents #70, #42, #37 and #94's names] all had contact precaution signs on the door. I was wearing only a surgical mask while in contact with two COVID positive residents that were sitting in the living room area. The residents were not wearing masks. It is hard for them to keep the masks on. I did not know we had to wear gowns while in the common area. During an interview on 5/8/2023 at 1:31 PM, Staff B, Director of Central Supply, stated, On Friday night, three residents tested positive for COVID and I posted the signs I had available. Monday, [Staff A, LPN's name] said to make copies. It was the same two signs. One said, 'stop see the nurse' and the other one 'contact precautions.' I went and got the copies. That is when you saw us posting the signs on the doors. Later that day, I saw the Infection Preventionist hanging the other signs which basically say the same things as the other ones. When [Staff A, LPN's name] asked me to make copies and hang the signs, she never mentioned they were not appropriate [signs]. I placed the signs on Friday before I left, so at least the people entering would at least stop at the door [resident's door]. I think we use the same protocol for all, the same precautions. I did not have a gown when entering the Memory Care Unit. I was not going in the rooms. I was just hanging signs on the resident rooms. I did hear some more residents tested positive but I'm not familiar with their faces. I was not aware the residents that were COVID positive were in the common areas in the Memory Care Unit. For contact precautions, I would say we use a blue mask [surgical mask], gown, and gloves. If it is droplet, we are expected to wear a face shield, N95, and gown. When I exited the Memory Care Unit, I went around the facility and made sure all PPE bins were fully stocked. During a telephonic interview on 5/9/2023 at 2:33 PM, Staff F, LPN/Infection Prevention Trainee, stated, I would keep communication via phone with Infection Preventionist, Administrator and DON for guidance as to my role I wasn't sure. I tested positive on the 3rd [May] showing symptoms. When I spoke to [Staff A, LPN's name], I told them to follow normal protocol which include signs, carts with PPE, and wearing proper PPE. There was a lot of texting back and forth, a lot of the guidance came from the Infection Control Preventionist. Staff needed to make sure that signs stated droplet and contact if I am not mistaken. Via text, I was notified that Sunday [5/7/2023], 10 residents tested positive for COVID. I did not give any guidance. It was pretty much the DON and Administrator who were going back and forth providing guidance. Last time I was in the building was Wednesday [5/3/2023] until 4 PM. When the Infection Preventionist is not available, the DON and the Regional Clinical Consultant were responsible. During a telephonic interview on 5/9/2023 at 2:55 PM, the Medical Director stated, I was not aware of the COVID-19 outbreak status in the facility. I have been the Medical Director since January. No one contacted me in the last two weeks concerning the COVID-19 outbreak status at the facility. My expectation was for residents who have a roommate and test positive for COVID, the positive resident should be put in a room with others who are positive. The roommate would generally be placed or transferred with patients with a negative test result. I would have expected the resident who tested negative to be removed from the room of the one who tested positive. During an interview on 5/11/2023 at 12:15 PM, Staff E, CNA, stated, I do not take lunch in the breakroom. I go outside using the back door. We are allowed to use the employee breakroom for lunch if we want. When my shift is over, I exit the unit and walk through the facility to clock out. During an interview on 5/11/2023 at 12:16 PM, Staff G, CNA, stated, I work all over the facility. Last time I worked in the Memory Care Unit was last Thursday or Friday [5/4/2023 or 5/5/2023]. I worked with [Staff E, CNA's name] and we were only wearing surgical face masks while taking care of the residents in the Memory Care Unit. Residents were already coming up positive and I didn't know I was supposed to wear an N95. During an interview on 5/11/2023 at 12:20 PM, Staff H, LPN, stated, I only work in the Memory Care Unit and worked last Sunday [5/7/2023]. I wore an N95 mask. I did not leave the unit on Sunday for lunch or break. I exit the unit and walk through the facility to clock out. During an interview on 5/11/2023 at 12:50 PM, Staff I, CNA, stated, I do not remember what rooms I was assigned to. I think I worked in the back hall of the 200 Hall. On Monday, I was wearing a surgical mask when I came in, then we were told to wear an N95 mask when you guys showed up. Review of the COVID-19 Line List documented as of 5/11/2023 revealed the facility had a total of 28 COVID-19 positive residents. During an interview on 5/12/2023 at 8:50 AM, the Regional [NAME] President stated, As long as the staff is properly donning and doffing their PPE and handwashing before they exit the unit, they are able to go through the facility to clock out. During an interview on 5/12/2023 at 8:57 AM, the Regional Director of Clinical Services stated, I personally provided the correct signs on 5/4/2023. I know the two signs on Serenity [Memory Care Unit] signs were not on the doors on Monday morning [5/8/2023]. The CDC wants correct singular signs of contact and droplet precaution signs versus a combined sign. I knew the individual rooms in the Serenity Unit did not have signs posted. I was not aware of the incident in the C-wing [200 Hall where Residents #92 and #50 reside]. I was not aware of the room in the C-wing [200 Hall, having the wrong sign]. On 5/4/2023, signage was identified as a concern and I personally placed a color sign on the A-wing [100 Hall] and provided two signs to the DON to place on the Serenity doors. The plan we had in place was not working. I provided correct signs, and the facility was not using them. On Monday morning [5/8/2023] when I showed up, I realized that signs had not been posted. On 5/4/2023, a cover message was sent out to all staff stating to wear eye protection and N95 mask for the A-wing and Serenity Unit [100 Hall and Memory Care Unit]. A request was made for documentation of all staff having received and read the cover message. No documentation was provided. Review of the facility assessment tool, last reviewed on 3/29/2023, read, Part 2. Resident Support/Care Needs. Specific Care or Practices. Monitoring and maintaining infection control practices. Identification and containment of infections, prevention of infections. Prevent abuse and neglect. Review of the policy and procedure titled Quality Assurance and Performance Improvement Plan lasted reviewed on 4/27/2023 read, Policy: The facility will develop and maintain a written Quality Assurance and Performance Improvement (QAPI) written plan in accordance with state and federal regulation. Definitions: Performance Improvement (PI): PI (also called Quality Improvement-QI) is the continuous study and improvement of processes with the intent to improve services or outcomes, and prevent or decrease the likelihood of problems, by identifying opportunities for improvement, and testing new approaches to fix underlying causes of persistent/systemic problems or barriers to improvement. PI aims to improve facility processes involved in care delivery and enhance resident quality of life. Procedure: 5. The QAPI plan should describe the process for identifying and correcting quality deficiencies. Key components of the process include: a. Tracking and measuring performance; b. Establishing goals and threshold for performance measurement; c. Identifying and prioritizing quality deficiencies; d. Systematically analyzing underlying causes of systemic quality deficiencies; e. Developing and implementing corrective action or performance improvement activities; f. Monitoring or evaluating the effectiveness of the corrective action /performance improvement activities, and revising as needed. Review of the policy and procedure titled Area of Focus: QAA and QAPI Program lasted reviewed on 4/27/2023 read, What: The QAA committee determines what performance date will be monitored and the frequency for monitoring. The QAA committee responsibilities include identifying and responding to quality deficiencies throughout the facility, and oversight of the QAPI program. Additionally, the committee must develop and implement corrective action, and monitor to ensure performance goals or targets are achieved and revising corrective action when necessary. Regulation: 483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program. The committee must: (i) Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues a with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary. (ii) Develop and implement appropriate plans of action to correct identified quality deficiencies; When: The facility may utilize one of the following actions to ensure planned changes are implemented and effective: a. Choose key performance indicators that tie directly to the new changes, b. Conduct on going periodic measurements review to ensure the new changes have been implemented and are effective. C. Based on review, make changes as indicated. Review of the policy and procedure titled Coronavirus (COVID 19) (SARS-CoV-2) [Severe acute respiratory syndrome coronavirus 2] last reviewed on 4/27/2023 read, Policy. The facility will follow the Core Principles of COVID-19 Infection Prevention as outlined below and defined by CMS [Centers for Medicare and Medicaid] and CDC to mitigate COVID-19 entry into the facility. 3. Face covering or well fitted mask (covering mouth or nose) in accordance with CDC guidance. 4. Instructional signage throughout the facility and proper visitor education on COVID19 signs and symptoms, infection control precautions, other applicable facility practices (e.g., use of face covering or mask, specified entries, exits and routes to designated areas, hand hygiene). 6. Appropriate staff use of Personal Protective Equipment (PPE). 7. Effective cohorting or residents (e.g., separate areas dedicated COVID-19 care). Infection Prevention and Control Recommendations. Infection control recommendations include the following: 1. Ensure everyone is aware of recommended IPC [Infection Prevention and Control] practices in the facility. a. Post signs, or posters at the entrance and in strategic places (e.g. waiting areas, elevators) with instructions about current IPC recommendations (e.g., when to use source control and perform hand hygiene). Dating these alerts can help ensure people know that they reflect current recommendations. 6. The facility should provide visitors with education on hand hygiene, limiting surfaces touched, and use of PPE according to current CDC guidelines. Provide Supplies Necessary to Adhere to Recommended Infection Prevention and Control Practices. 4. Personal Protective Equipment (PPE): c. Make necessary PPE available in areas where resident care is provided. Associate Education and Assignment: 2. Ensured that associates are educated, trained, and have practiced the appropriate use of PPE prior to caring for a resident/residents. Bed Management Strategies and Cohorting: COVID-19 Positive Residents. 1. HCP [Health Care Professional] caring for residents with confirmed SARS-CoV-2 infection should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved [The National Institute for Occupational Safety and Health] N95 or equivalent or higher-level respirator) 2. Place a patient with suspected or confirmed SARS-CoV-2 infection in a single person room. The door should be kept closed (if safe to do so). The patient should have a dedicated bathroom. 3. The facility could consider designating entire units within the facility, with dedicated HCP, to care for patients with SARS-CoV-2 infection when the number of patients with SARS-CoV-2 infection is high. Dedicated means that HCP are assigned to care only for these patients during their shifts. Recommendations for Newly Identified Active Cases in the Facility. 1. Because of the high risk of unrecognized infection among residents, a single new case of SARS-CoV-2 infection in any HCP or SARS-CoV-2 infection in a resident should be evaluated as a potential outbreak. 4. HCP should care for residents using N95 or higher-level respirator, eye protection (i.e. goggles or a face shield that covers the front and sides of the face), gloves and gown. 5. The facility will ensure that appropriate PPE is available outside the resident room for any resident who is on isolation unless the resident resides on a dedicated COVID-19 unit. If the facility has COVID-19 positive residents on a dedicated unit, the PPE will be available in designated areas on the unit. Suspected or Confirmed COVID-19 cases on a Memory Care Unit. As it may be challenging to restrict residents to their rooms, the facility should implement the use of eye protection and N95 or other respirators (or facemask if respirators are not available) for all associates when on the unit to address potential for encountering a wandering resident who might have COVID-19. d. Facilities may determine that it is safer to maintain care of residents with COVID-19 on the memory unit with dedicated personnel. Review of the policy and procedure titled Personal Protective Equipment (PPE) for SARS-CoV-2 last reviewed on 4/27/2023 read, Policy. The facility will provide and utilize the appropriate PPE for the care of residents during the COVID-19 Pandemic in accordance with CMS and CDC guidance. The facility will provide and ensure associates use respirators and other PPE for exposure to residents with suspected or confirmed COVID-19. PPE Recommended for Symptomatic, Suspected, or Confirmed COVID-19. HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection. The PPE recommended when caring for a patient with suspected or confirmed COVID-19 includes the following: 1. Respirator: a. Put on an N95 respirator (or equivalent or higher-level respirator) before [TRUNCATED]

Based on observation, interview, and record review, the Administration failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident when failing to follow/implement facility policy and procedures and Centers for Disease Control and Prevention (CDC) guidelines related to transmission-based precautions for the prevention of the possible spread of infection to staff, visitors, and residents. The facility failed to ensure appropriate visual alerts were posted outside of the memory care unit and on the 200 Hall related to identified COVID-19 (Coronavirus Disease 2019) outbreak. The facility failed to maintain contact/droplet precautions by not having the staff donning appropriate Personal Protective Equipment (PPE) to include N95 respirators, gowns, gloves, and eye protection when in close and prolonged contact with COVID-19 positive residents on the memory care unit. On 5/11/2023, the facility had a total of 28 COVID-19 positive residents out of a census of 109 residents. This failure has the likelihood for serious harm, serious impairment or death for people [AGE] years of age or older, people who have a severe underlying medical condition, and people who live in nursing homes are at higher risk for developing serious complications from COVID-19 illness. Individuals who are infected might develop serious diseases with difficulty breathing. Some individuals might require intensive care for the treatment of multi organ failure, respiratory failure, and septic shock. COVID-19 infection can lead to death. Findings include: Review of the job description titled Executive Director (ED) Job Description- Corporate Primary dated 3/13/2023 read, Position Summary: The Executive Director provides leadership and direction for overall facility operations to provide quality patient care in accordance with all laws, regulations, and Life Care standards. Provides oversight of key areas including financial operations, human resources, customer service, business development, and clinical operations. Implements policies pertaining to patient care, caregiving, and support staff, financial control, public relations, and maintenance of physical plant through consultation with the facility management team. Essential Functions: Must ensure patients receive high quality care, Must ensure facility is compliant with all Federal, State, Local, and JCAHO requirements as well as serve as the facility's Compliance and Ethics Liaison. Must ensure facility is clean and safe for the comfort, convenience and safety of patients, families, and staff. Must effectively supervise team. Review of the job description titled Director of Nursing (DON) Job Description Primary dated 4/4/21 read, Position Summary: The Director of Nursing plans, organizes, develops, and directs the overall operation of the Nursing department to assure patient safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each patient in accordance with all applicable laws, regulations, and Life Care Standards. Reports to Executive Director. Must be knowledgeable of nursing administration practices and procedures as well as the laws, regulations, and guidelines governing nursing administration functions in the post-acute facility. Must have the ability to implement and interpret the programs, goals, objectives, policies, and procedures of the nursing administration department. Review of the job description titled LPN [Licensed Practical Nurse] Infection Preventionist (IP) Job Description Primary dated 9/29/2022 read, The LPN Infection Preventionist evaluates the quality of resident care and outcomes as they relate to Healthcare Acquired Infections (HAI) and Community Acquired Infections (CAI) in accordance with all applicable laws, regulations, and Life Care standards. Collects, prepare, and analyzes HAI data. Presents infection data and makes recommendations for actions. Monitors associate compliance with infection control standards through the use of barriers and infection prevention measures. Prepares and presents education for the staff, residents, and families. Serves as a resource to all departments and personnel. Reports to the Director of Nursing (DON). Specific requirements: Serves as the on-site IPC for Covid-19 prevention and response activities, in accordance with current CDC recommendations. Essential functions: Must be able to plan, develop, organize, implement, and evaluate facility-wide systems for the prevention, identification, investigation, and control of infections of residents, staff, and visitors. Must be able to plan, develop, organize, implement, and evaluate a high-quality infection prevention and control program (IPCP) to prevent, recognize, and control the onset and spread of infection to the extent possible. Must be able to serve as the educational resource for ensuring the facility is able to properly educate; residents, families, associates, consultants, contractors, and volunteers on information regarding: COVID-19, infectious disease, outbreaks, and infection control practices the facility uses to mitigate the spread of infection. Review of the Medical Director Agreement dated 4/27/2023 read, 3. Duties of Medical Director. A. Director shall perform such Services and functions as are customary for a Medical Director in a skilled nursing facility comparable in size and scope of services to that of Facility, and to perform such services in accordance will all applicable requirements of Facility policies and federal, state and local laws, rules, and regulations, which shall include but not be limited to full compliance with Title 42, Section 483.75 (h) of the Code of Federal Regulations, the Interpretive Guidelines implementing that regulatory requirement at State Operations Manual, Appendix PP, Guidance to Surveyors for Long Term Care Facilities, F-841, and any applicable state regulations. Director shall on an ongoing basis advise the Executive Director of facility (Executive Director) of the adequacy of Facility's scope of Services, resident care programs, medical equipment, and its professional and support staff. D. In addition, Director shall: 1.1 Assist in coordinating medical care in Facility to ensure that adequate and appropriate medical services are provided to the residents in Facility and making periodic rounds to evaluate the adequacy of nursing care furnished to Facility residents. The Medical Director will collaborate with Facility Leadership, staff, and other practitioners and consultants to help develop, implement and evaluate resident care policies and procedures that reflect current standards of practice. During an observation on 5/8/2023 at 8:45 AM, the facility's main entrance did not have visual alerts posted to inform visitors and staff of an infection outbreak. There were surgical masks in a box on the receptionist desks. There was no other PPE observed in the lobby for visitors and staff to don prior to entering the facility. During an observation on 5/8/2023 beginning at 9:45 AM of the Memory Care Unit entrance double doors, there were no visuals alerts posted to inform visitors and staff of an identified infection outbreak. There was no signage of the need to don PPE before entering the unit and there was no personal protective equipment at the entry to indicate the need for donning PPE prior to entering. After entering the unit, there were two rooms observed to have bins containing PPE consisting of gowns, gloves, N95 respirators, and face shields for Residents #45, #60, #42, and #72's rooms. There were no visual postings on the doors for Residents #45, #60, #42, and #72 to inform visitors or staff of the need to see the nurse prior to entering the room or the need to don PPE prior to entering the rooms. Staff A, Licensed Practical Nurse (LPN), was observed wearing an N95 respirator, and another staff member was observed wearing a surgical mask. Neither staff member was wearing a gown, gloves, or eye protection. Three residents were observed in the dining room and five residents were observed in the common living area of the Memory Care Unit. During an observation on 5/8/2023 at 9:46 AM, Staff E, Certified Nursing Assistant (CNA), was observed exiting a resident's room toward the end of the hallway and entered the living area where the five COVID-19 exposed residents were sitting. Staff E was observed to be wearing a surgical mask, and was not wearing a gown, gloves, or eye protection. During an observation on 5/8/2023 at 9:46 AM, Staff C, CNA, was wearing an N95 respirator in the dining room area. A resident stood up and Staff C assisted the resident back to a sitting position in a chair. Observations were made of the remaining rooms on the unit that did not have a storage PPE bin in front of the rooms. During an observation on 5/8/2023 at 10:10 AM, Staff B, Director of Central Supply, and Staff C, CNA, were wearing N95 respirators, and Staff E, CNA, was wearing a surgical mask. Staff B, Staff C, and Staff E were not wearing gowns, gloves, or eye protection. Staff B, Staff C, and Staff E were placing Contact Precautions signs on multiple room doors of the Memory Care Unit. During an interview on 5/8/2023 at 10:10 AM on the Memory Care Unit, Staff A, LPN, stated, [Resident #94's name] is COVID positive. That is why the room door has a contact precaution sign posted. This is the sign we use for COVID positive. During an observation on 5/8/2023 at 10:11 AM, Residents #26, #70, #58, #157, #71, #69, #45, #60, #42, #72, #53, #99, #76, #61, #52, #85, #13, #88, #94, and #37's room doors had signage which read, Contact Precautions. Review of the COVID-19 Line List documented: 5/4/2023 - 7 COVID-19 positive residents, 4 resided on the Memory Care Unit (MCU); 5/7/2023 - 16 COVID-19 positive residents, 12 resided on the MCU; 5/8/23 - 21 COVID-19 positive residents, 14 residents resided on the MCU. During an observation on 5/8/2023 at 9:53 AM of Residents #92 and #50's rooms, which were located on the 200 Hall, there was a visual posting that read, Contact Precaution. During an interview on 5/8/2023 at 10:27 AM, the Infection Preventionist stated, [Resident #50's name] is negative as of right now. [Resident #92's name] tested COVID positive on Saturday [5/6/2023]. [Resident 92's name] son came into the building to visit, and he tested COVID positive. Both [Resident #50's name and Resident #92's name] are sharing a room since they are both isolated due to the exposure. The Serenity Unit has only contact precaution signs and not droplet precautions [signs]. I came back to work using the CDC criteria and came back due to 'crisis staffing criteria' as I was needed to come back in to work. The Memory Care Unit staff started testing positive on 5/4/2023. We had a staff member who tested positive on 5/1/2023 [The Activity Director]. She worked on all three units. Our community rate was low enough that we were not wearing masks. We started wearing masks on 5/1/2023. We have three staff members out due to COVID. During an observation on 5/8/2023 at 10:45 AM, the Memory Care Unit entrance double doors had no visual posting to alert visitors and staff before entering the unit with instructions about current infection prevention and control recommendations for the unit. No personal protective equipment was observed outside of the doors. During an observation on 5/8/2023 at 10:45 AM, in the Memory Care Unit, Staff A, LPN, was assisting residents and was wearing an N95 respirator, and was not wearing a gown, gloves, or eye protection. During an observation on 5/8/2023 at 10:46 AM, Staff C, CNA, was supervising a resident in the dining area. Staff C was wearing an N95 respirator and was not wearing a gown, gloves, or eye protection. During an observation on 5/8/2023 at 10:46 AM, Staff E, CNA, was supervising a resident in the dining area. Staff C was wearing a surgical mask, not an N95 respirator, and was not wearing a gown, gloves, or eye protection. During an interview on 5/8/2023 at 10:46 AM in the Memory Care Unit, the Infection Preventionist stated, All rooms in the locked memory care unit were incorrectly labeled with contact precaution signs and the signs should say droplet and contact precautions. Signs should be posted on residents' doors as soon as the test results come in. During an observation on 5/8/2023 at 12:03 PM, Staff E, CNA, was passing out lunch trays to the residents in the Memory Care Unit. Staff E was wearing a surgical mask, not an N95 respirator, and was not wearing a gown, gloves, or eye protection. Coming in close contact, she placed each food tray on the table in front of each resident. During an interview on 5/8/2023 at 12:15 PM, Staff A, LPN, stated, I was not here over the weekend. What I did when I came back to work was to do my own report and test all the residents again to make sure what their COVID status was at this time. I had the staff take all the signs down. That is why when you entered the unit, some rooms did not have signs posted on the doors. The Infection Preventionist was out due to COVID and [Staff F, LPN's name] took over. The girls [Certified Nursing Assistants assigned to the Memory Care Unit] were helping me put the signs back on the doors after the COVID test results came back. Normally if a resident tested positive for COVID, we will move the resident out of the room to a single room or if two residents are positive, we will double them up in the same room. This is the memory care unit, and we need to be careful that the residents do not get out of the unit making it harder to arrange room changes. We were all off this weekend and I had the signs being copied to place on the doors. We had bins outside some rooms. This was sporadic. I stopped everything after I received the shift report and started testing all the residents from scratch since we have agency staff working in the unit. We were not aware we needed to wear gowns and gloves on the unit. The Infection Preventionist informed us we needed to wear proper PPE after you had been on the unit. [Staff E, CNA's name] was the staff who didn't have the N95 mask on while on the unit. We all found out we needed to wear gowns in the halls and only N95 mask afterwards. The Infection Preventionist came into the unit and provided the correct signs for all the rooms. We were using the contact signs because that was what we had at that time. I had sent a text message to [Staff F, LPN's name] at 9:22 AM stating some rooms had signs and some did not. She replied that we needed to have signage on resident doors for contact/droplet precautions and since I was off during the weekend that is why I decided to do my own report since I did not know when those signs went on the doors. I am the primary nurse on the unit and do my own thing due to the agency staff that work the unit. During an interview on 5/8/2023 at 1:01 PM, Staff C, CNA, stated, We get report on the unit at 6:45 AM. Residents were starting to come up positive for COVID. [Staff A, LPN's name] decided to recheck to make sure [to determine if additional residents were positive]. We were not aware we needed to wear a gown and gloves while working on the unit. I know as you go into the room you wear a face shield, N95 mask, gloves, and gown. This unit is different. COVID positive residents are outside of the rooms. We had contact precaution signs on the doors. Contact precautions is pretty much used for everything. [Staff A, LPN's name] never mentioned that the signs provided were not the correct ones. During an interview on 5/8/2023 at 1:21 PM, Staff E, CNA, stated, I was wearing a surgical mask because that was what we were supposed to do until they told us to wear N95 masks later on 5/8/2023. [Staff A, LPN's name] told us to put up the contact precaution signs on the COVID positive resident doors. Nobody told us that we needed to include droplet precautions. I worked Friday and rooms for [Residents #70, #42, #37 and #94's names] all had contact precaution signs on the door. I was wearing only a surgical mask while in contact with two COVID positive residents that were sitting in the living room area. The residents were not wearing masks. It is hard for them to keep the masks on. I did not know we had to wear gowns while in the common area. During an interview on 5/8/2023 at 1:31 PM, Staff B, Director of Central Supply, stated, On Friday night, three residents tested positive for COVID and I posted the signs I had available. Monday, [Staff A, LPN's name] said to make copies. It was the same two signs. One said, 'stop see the nurse' and the other one 'contact precautions.' I went and got the copies. That is when you saw us posting the signs on the doors. Later that day, I saw the Infection Preventionist hanging the other signs which basically say the same things as the other ones. When [Staff A, LPN's name] asked me to make copies and hang the signs, she never mentioned they were not appropriate [signs]. I placed the signs on Friday before I left, so at least the people entering would at least stop at the door [resident's door]. I think we use the same protocol for all, the same precautions. I did not have a gown when entering the Memory Care Unit. I was not going in the rooms. I was just hanging signs on the resident rooms. I did hear some more residents tested positive but I'm not familiar with their faces. I was not aware the residents that were COVID positive were in the common areas in the Memory Care Unit. For contact precautions, I would say we use a blue mask [surgical mask], gown, and gloves. If it is droplet, we are expected to wear a face shield, N95, and gown. When I exited the Memory Care Unit, I went around the facility and made sure all PPE bins were fully stocked. During an interview on 5/8/2023 at 1:45 PM, the Director of Nursing (DON) stated, As far as monitoring infection control, I do it with the Infection Preventionist. We collaborate on how we are going to move forward. Residents who test negative for COVID should be removed from COVID positive rooms. Signage should be on the door as well as personal protective equipment. I do not know what happened with [Resident #92's name]. I reached out to the nurse that worked that weekend and she has not reached out back. I round daily regarding education on PPE. I am in the middle of my infection control training. Staff should wear appropriate PPE when in contact with positive residents. I went to the memory care unit on 5/4/2023 and again on 5/5/2023 and I was wearing an N95 and face shield. I was not wearing a gown since I was only at the nursing station and hallway. The staff were informing me of a COVID positive resident, and I then informed my boss and the Infection Control Preventionist. Staff was instructed to notify the physician, family, and follow orders. They were also instructed to isolate residents as much as they can. I would say I oversee infection prevention when the Infection Preventionist is not available. During a telephonic interview on 5/9/2023 at 2:33 PM, Staff F, LPN/Infection Prevention Trainee, stated, I would keep communication via phone with Infection Preventionist, Administrator and DON for guidance as to my role I wasn't sure. When I spoke to [Staff A, LPN's name], I told them to follow normal protocol which include signs, carts with PPE, and wearing proper PPE. There was a lot of texting back and forth, a lot of the guidance came from the Infection Control Preventionist. Staff needed to make sure that signs stated droplet and contact if I am not mistaken. Via text, I was notified that Sunday [5/7/2023], 10 residents tested positive for COVID. I did not give any guidance. It was pretty much the DON and Administrator who were going back and forth providing guidance. When the Infection Preventionist is not available, the DON and the Regional Clinical Consultant were responsible. During a telephonic interview on 5/9/2023 at 2:55 PM, the Medical Director stated, I was not aware of the COVID-19 outbreak status in the facility. I have been the Medical Director since January. No one contacted me in the last two weeks concerning the COVID-19 outbreak status at the facility. My expectation was for residents who have a roommate and test positive for COVID, the positive resident should be put in a room with others who are positive. The roommate would generally be placed or transferred with patients with a negative test result. I would have expected the resident who tested negative to be removed from the room of the one who tested positive. During an interview on 5/11/2023 at 12:15 PM, Staff E, CNA, stated, I do not take lunch in the breakroom. I go outside using the back door. We are allowed to use the employee breakroom for lunch if we want. When my shift is over, I exit the unit and walk through the facility to clock out. During an interview on 5/11/2023 at 12:16 PM, Staff G, CNA, stated, I work all over the facility. Last time I worked in the Memory Care Unit was last Thursday or Friday [5/4/2023 or 5/5/2023]. I worked with [Staff E, CNA's name] and we were only wearing surgical face masks while taking care of the residents in the Memory Care Unit. Residents were already coming up positive and I didn't know I was supposed to wear an N95. During an interview on 5/11/2023 at 12:20 PM, Staff H, LPN, stated, I only work in the Memory Care Unit and worked last Sunday [5/7/2023]. I wore an N95 mask. I did not leave the unit on Sunday for lunch or break. I exit the unit and walk through the facility to clock out. During an interview on 5/11/2023 at 12:50 PM, Staff I, CNA, stated, I do not remember what rooms I was assigned to. I think I worked in the back hall of the 200 Hall. On Monday, I was wearing a surgical mask when I came in, then we were told to wear an N95 mask when you guys showed up. Review of the COVID-19 Line List documented as of 5/11/2023 revealed the facility had a total of 28 COVID-19 positive residents. During an interview conducted on 5/12/2023 at 8:49 AM, the Administrator stated, Biggest thing was on 5/1/2023 when residents started testing positive for COVID. I sat down with my Director of Nursing (DON) and Infection Preventionist (IP) and referred back to our policies and procedures. I had the DON and IP come up with a clinical procedure and isolation and personal protective equipment to go into place. We had an Ad Hoc meeting on 5/1/2023, got the isolation signs and continued to test. We reviewed residents and patient care and began putting a plan in place. I took the clinical piece and had my DON and IP work together. The Medical Director was aware of the policies we have in place, but he was not involved in the meeting held on 5/1/2023. The DON provided coverage while the Infection Preventionist was out. My Infection Preventionist tested positive on 5/2/2023. The DON was responsible for overseeing infection control in the facility. With COVID positive [residents], we need to have droplet and contact precautions. The signs [visual alerts] should have been posted. I became aware the COVID Unit [Memory Care Unit] was not on isolation on 5/8/2023. COVID positives are not allowed to cohort with non-positive residents. They are not allowed to remain in the same room. When this was brought to my attention, we separated them on 5/8/2023 [Residents #92 and #50]. It was my understanding that staff were wearing the appropriate personal protective equipment and appropriate signage was posted. The DON was here on Friday [5/5/2023] and she was here on [5/6/2023] on Saturday. The signage was provided to her and put in place. The DON notified me on 5/7/2023 of the COVID positives and it was my understanding that we had made the Memory Care Unit a red unit [COVID Unit]. During an interview on 5/12/2023 at 8:50 AM, the Regional [NAME] President stated, As long as the staff is properly donning and doffing their PPE and handwashing before they exit the unit, they are able to go through the facility to clock out. During an interview on 5/12/2023 at 8:57 AM, the Regional Director of Clinical Services stated, I personally provided the correct signs on 5/4/2023. I know the two signs on Serenity [Memory Care Unit] signs were not on the doors on Monday morning [5/8/2023]. The CDC wants correct singular signs of contact and droplet precaution signs versus a combined sign. I knew the individual rooms in the Serenity Unit did not have signs posted. I was not aware of the incident in the C-wing [200 Hall where Residents #92 and #50 reside]. I was not aware of the room in the C-wing [200 Hall, having the wrong sign]. On 5/4/2023, signage was identified as a concern and I personally placed a color sign on the A-wing [100 Hall] and provided two signs to the DON to place on the Serenity doors. The plan we had in place was not working. I provided correct signs, and the facility was not using them. On Monday morning [5/8/2023] when I showed up, I realized that signs had not been posted. On 5/4/2023, a cover message was sent out to all staff stating to wear eye protection and N95 mask for the A-wing and Serenity Unit [100 Hall and Memory Care Unit]. A request was made for documentation of all staff having received and read the cover message. No documentation was provided. During an interview on 5/12/2023 at 10:30 AM, the Regional Director of Clinical Services stated, The incorrect signage [in the Memory Care Unit] on 5/4/2023 was corrected immediately and didn't warrant follow up. It was a singular incident. No performance plan was needed. We would not evaluate at a later date. The signage was incorrect on the entrance of Serenity on that day [5/4/2023]. I did not enter the Serenity Unit; less people is better. The signage on the outside was what was observed. I was not notified that the facility had positives in the building over the weekend. If I had that information as a Clinical Leader, I would have come into the facility. Especially with a cluster as big as seven. I would have come in, the Director of Nursing and/or the Infection Preventionist facilitated the room changes, notifications, and process. I would not say it was a systemic break, it was the action of employees regardless of the education provided. The system was in place but not followed. The process broke. There was a hole, definitely a gap. I did not put in a root cause analysis. I had included it in my notes and dealt with it appropriately. The expectation is that PPE and handwashing are followed. They are allowed to come into facility to exit [to clock out]. I was not aware that staff was not using the appropriate PPE, but I can prove that 128 staff members received the message sent regarding the PPE to wear. I am not able to say if the Director of Nursing went into the Memory Care Unit to verify staff were following instructions on PPE. The audits [5/1/2023 and 5/3/2023] do not have to do with the current issue. Currently, we suspended the Director of Nursing for failure to follow clinical direction and follow the clinical policy in relation to infection control. A request was made for documentation of all staff having received and read the cover message. No documentation was provided. Review of Resident #26's progress note dated 5/4/2023 documented, Resident COVID tested with positive result. Resident placed on transmission-based precautions. Review of Resident #94's progress note dated 5/4/2023 documented, Resident noted with head congestion. States he does not feel well. Temp. [temperature] 99.6. Covid test positive. Residents are [Sic.] placed in transmission-based precautions. Review of Resident #42's admission record documented diagnosis to include chronic respiratory failure with hypercapnia, and chronic obstructive pulmonary disease. Review of Resident #42's progress note dated 5/4/2023 documented, Resident with positive covid test. Noted with temp 99.5. No cough or congestion noted. Notified [Physician Assistant's name] PA, resident placed on transmission-based precautions. Review of Resident #72's admission record documented diagnosis to include chronic obstructive pulmonary disease. Review of Resident #72's progress note dated 5/4/2023 documented, Resident with positive covid test. Afebrile, no cough or congestion noted. Notified [Physician Assistant's name] PA, resident placed on transmission-based precautions. Review of the progress note dated 5/5/2023 for Resident #92, who resided on the 200 Hall in a semi-private room with Resident #50, documented, Pt [patient] experiencing SOB [shortness of breath], shallow respirations, tachypnea. 114/60 [blood pressure] 92P [pulse] 98.4T [temperature] 24R [respirations] 95% RA [oxygen saturation on room air]. Lungs have crackles in bilateral lower lobes. Blood glucose 156. Covid + [positive] rapid test. PCP [Primary Care Physician] contacted, new orders for Paxlovid BID x 5 days [twice a day times 5 days, an antiviral pill that reduces the amount of the virus that cause COVID-19 in the body and prevents symptoms from getting worse], Son notified of covid+ status and informed that he recently has gotten over covid and would like to know if a mask needs to be worn while visiting his mother. Son educated on proper PPE. Review of the clinical record for Resident #50 documented the resident tested positive for COVID-19 on 5/8/2023. Review of Resident #61's progress notes dated 5/7/2023 documented, Resident tested for covid due to other residents' positive status. Resident tested positive. Review of the medical record for Resident #61 did not provide on order to place the resident on transmission-based precautions dated 5/7/2023. Review of Resident #45's progress note dated 5/8/2023 documented, Resident tested this morning for COVID positive. [Doctor's name] PA [Physician Assistant's name] was notified, waiting for response. Asked to advise for any orders. Waiting for response from [Physician Assistant's name] PA. Review of the Line Listing dated 5/7/2023 documented Resident #58 tested positive. Review of the medical record for Resident #58 did not provide documentation of the resident having tested positive for COVID-19. Review of Resident #99's progress note dated 5/7/2023 documented, Resident tested for covid d/t [due to] other residents' positive status. Residents tested positive. Review of Resident #13's progress note dated 5/7/2023 documented, Resident noted with mild symptoms, runny nose. tested for covid, positive result. Review of Resident #85's progress note dated 5/8/2023 documented, Resident was tested this morning with results of COVID positive. Called [Physician Assistant's name] PA with [Doctor's name] asking to advise for any new orders. Waiting for response. Review of Resident #69's progress note dated 5/7/2023 documented, Resident tested for covid due to positive status of other residents. Resident with positive result. Review of Resident #60's progress note dated 5/7/2023 documented, Resident with mild cold symptoms. tested for covid, results positive. Review of Resident #53's admission record documented diagnosis to include COPD (chronic obstructive pulmonary disease). Review of Resident #53's progress note dated 5/9/2023 documented, Spoke with son, [Resident #53 son's name] of mother testing positive for COVID. Review of Resident #88's progress note dated 5/8/2023 documented, Attempted to contact family message left with family of mother positive results when tested this afternoon for COVID. Review of Resident #59's progress noted dated 5/8/2023 documented, Resident COVID positive. Review of Resident #76's progress note dated 5/10/2023 documented, Resident status updated to COVID positive, resident is currently on airborne isolation r/t [related to] to positive test. Review of the policy and procedure titled Abuse- Prevention last reviewed on 4/27/2023 read, Policy. It is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation. Procedure. 2. Assure that residents are free from neglect by having the structures and processes to provide needed care and serv [TRUNCATED]

Based on observation, interview, and record review, the facility failed to protect the residents' rights to be free from neglect by failing to follow/implement facility policy and procedures and Centers for Disease Control and Prevention (CDC) guidelines related to transmission-based precautions for the prevention of the possible spread of infection to staff, visitors, and residents. The facility neglected to ensure appropriate visual alerts were posted outside of the memory care unit and on the 200 Hall related to identified COVID-19 (Coronavirus Disease 2019) outbreak. The facility neglected to maintain contact/droplet precautions by not having the staff donning appropriate Personal Protective Equipment (PPE) to include N95 respirators, gowns, gloves, and eye protection when in close and prolonged contact with COVID-19 positive residents on the memory care unit. On 5/11/2023, the facility had a total of 28 COVID-19 positive residents out of a census of 109 residents. This failure has the likelihood for serious harm, serious impairment or death for people [AGE] years of age or older, people who have a severe underlying medical condition, and people who live in nursing homes are at higher risk for developing serious complications from COVID-19 illness. Individuals who are infected might develop serious diseases with difficulty breathing. Some individuals might require intensive care for the treatment of multi organ failure, respiratory failure, and septic shock. COVID-19 infection can lead to death. Findings include: During an observation on 5/8/2023 at 8:45 AM, the facility's main entrance did not have visual alerts posted to inform visitors and staff of an infection outbreak. There were surgical masks in a box on the receptionist desks. There was no other PPE observed in the lobby for visitors and staff to don (putting on) prior to entering the facility. During an observation on 5/8/2023 beginning at 9:45 AM of the Memory Care Unit entrance double doors, there were no visuals alerts posted to inform visitors and staff of an identified infection outbreak. There was no signage of the need to don PPE before entering the unit and there was no personal protective equipment at the entry to indicate the need for donning PPE prior to entering. After entering the unit, there were two rooms observed to have bins containing PPE consisting of gowns, gloves, N95 respirators, and face shields for Residents #45, #60, #42, and #72's rooms. There were no visual postings on the doors for Residents #45, #60, #42, and #72 to inform visitors or staff of the need to see the nurse prior to entering the room or the need to don PPE prior to entering the rooms. Staff A, Licensed Practical Nurse (LPN), was observed wearing an N95 respirator, and another staff member was observed wearing a surgical mask. Neither staff member was wearing a gown, gloves, or eye protection. Three residents were observed in the dining room and five residents were observed in the common living area of the Memory Care Unit. During an observation on 5/8/2023 at 9:45 AM, Staff A, LPN, exited the nursing station and administered medications to a resident sitting in the dining room of the Memory Care Unit. Staff A, LPN was wearing an N95 respirator, and was not wearing a gown, gloves or eye protection. During an observation on 5/8/2023 at 9:46 AM, Staff E, Certified Nursing Assistant (CNA), was observed exiting a resident's room toward the end of the hallway and entered the living area where the five residents were sitting. Staff E was observed to be wearing a surgical mask, and was not wearing a gown, gloves, or eye protection. During an observation on 5/8/2023 at 9:46 AM, Staff C, CNA, was wearing an N95 respirator in the dining room area. A resident stood up and Staff C assisted the resident back to a sitting position in a chair. Observations were made of the remaining rooms on the unit that did not have a storage bin in front of the rooms. During an observation on 5/8/2023 at 10:10 AM, Staff B, Director of Central Supply, and Staff C, CNA, were wearing N95 respirators, and Staff E, CNA, was wearing a surgical mask. Staff B, Staff C, and Staff E were not wearing gowns, gloves, or eye protection. Staff B, Staff C, and Staff E were placing Contact Precautions signs on multiple room doors of the Memory Care Unit. During an interview on 5/8/2023 at 10:10 AM on the Memory Care Unit, Staff A, LPN, stated, [Resident #94's name] is COVID positive. That is why the room door has a contact precaution sign posted. This is the sign we use for COVID positive. During an observation on 5/8/2023 at 10:11 AM, Residents #26, #70, #58, #157, #71, #69, #45, #60, #42, #72, #53, #99, #76, #61, #52, #85, #13, #88, #94, and #37's room doors had signage which read, Contact Precautions. Review of the COVID-19 Line List documented as of 5/4/2023 revealed the facility had a total of 7 COVID-19 positive residents. Four (4) of the 7 positive residents resided on the Memory Care Unit. Review of the COVID-19 Line List documented as of 5/7/2023 revealed the facility had a total of 16 COVID-19 positive residents. Twelve (12) of the 16 positive residents resided on the Memory Care Unit. Review of the COVID-19 Line List documented as of 5/8/2023 revealed the facility had a total of 21 COVID-19 positive residents. Fourteen (14) of the 21 positive residents resided on the Memory Care Unit. During an observation on 5/8/2023 at 9:53 AM of Residents #92 and #50's rooms, which were located on the 200 Hall, there was a visual posting that read, Contact Precaution. During an interview on 5/8/2023 at 9:55 AM, Staff D, Registered Nurse (RN), stated, Both of the residents in the room had tested positive last Thursday [Resident #92 tested positive on 5/5/2023 and Resident #50 tested positive on 5/8/2023]. We use masks, gowns, gloves, and face shields. Both residents are in isolation and cannot come out until they are negative. During an interview on 5/8/2023 at 10:27 AM, the Infection Preventionist stated, [Resident #50's name] is negative as of right now. [Resident #92's name] tested COVID positive on Saturday [5/6/2023]. [Resident 92's name] son came into the building to visit, and he tested COVID positive. Both [Resident #50's name and Resident #92's name] are sharing a room since they are both isolated due to the exposure. I recommended that they share a room due to the level of their exposure. We will test [Resident #50's name] today and again tomorrow. The Memory Care Unit census is 20 residents, and 12 residents are positive as of 5/8/2023. These residents are severely cognitively impaired, and the approach was to isolate the entire wing. We have residents who wander into other residents' rooms. They are exit seekers and at risk for elopement and we cannot move them anywhere else safely. Memory care should have Personal Protective Equipment (PPE) outside of the double doors to Serenity [Memory Care Unit name]. I cannot say that is in place now. I tested positive on 5/2/2023 and I am not sure where it came from. My symptoms started late Monday afternoon. I did the 5-day quarantine and returned today [5/8/23]. The Serenity Unit has only contact precaution signs and not droplet precautions [signs]. I came back to work using the CDC criteria and came back due to 'crisis staffing criteria' as I was needed to come back in to work. The Memory Care Unit staff started testing positive on 5/4/2023. We had a staff member who tested positive on 5/1/2023 [The Activity Director]. Her last day working in the facility was 4/28/2023. She worked on all three units. Our community rate was low enough that we were not wearing masks. We started wearing masks on 5/1/2023. We have three staff members out due to COVID. We are testing staff twice a week on Tuesday and Thursday. We last tested residents on 5/4/2023. We will be testing residents again tomorrow. During an observation on 5/8/2023 at 10:45 AM, the Memory Care Unit entrance double doors had no visual posting to alert visitors and staff before entering the unit with instructions about current infection prevention and control recommendations for the unit. No personal protective equipment was observed outside of the doors. During an observation on 5/8/2023 at 10:45 AM, in the Memory Care Unit, Staff A, LPN, was assisting residents and was wearing an N95 respirator, and was not wearing a gown, gloves, or eye protection. During an observation on 5/8/2023 at 10:46 AM, Staff C, CNA, was supervising a resident in the dining area. Staff C was wearing an N95 respirator and was not wearing a gown, gloves, or eye protection. During an observation on 5/8/2023 at 10:46 AM, Staff E, CNA, was supervising a resident in the dining area. Staff C was wearing a surgical mask, not an N95 respirator, and was not wearing a gown, gloves, or eye protection. During an interview on 5/8/2023 at 10:46 AM in the Memory Care Unit, the Infection Preventionist stated, All rooms in the locked memory care unit were incorrectly labeled with contact precaution signs and the signs should say droplet and contact precautions. Signs should be posted on residents' doors as soon as the test results come in. During an observation on 5/8/2023 at 12:03 PM, Staff E, CNA, was passing out lunch trays to the residents in the Memory Care Unit. Staff E was wearing a surgical mask, not an N95 respirator, and was not wearing a gown, gloves, or eye protection. Coming in close contact, she placed each food tray on the table in front of each resident. During an interview on 5/8/2023 at 12:15 PM, Staff A, LPN, stated, I was not here over the weekend. What I did when I came back to work was to do my own report and test all the residents again to make sure what their COVID status was at this time. I had the staff take all the signs down. That is why when you entered the unit, some rooms did not have signs posted on the doors. The Infection Preventionist was out due to COVID and [Staff F, LPN's name] took over. The girls [Certified Nursing Assistants assigned to the Memory Care Unit] were helping me put the signs back on the doors after the COVID test results came back. Normally if a resident tested positive for COVID, we will move the resident out of the room to a single room or if two residents are positive, we will double them up in the same room. This is the memory care unit, and we need to be careful that the residents do not get out of the unit making it harder to arrange room changes. We were all off this weekend and I had the signs being copied to place on the doors. We had bins outside some rooms. This was sporadic. I stopped everything after I received the shift report and started testing all the residents from scratch since we have agency staff working in the unit. We were not aware we needed to wear gowns and gloves on the unit. The Infection Preventionist informed us we needed to wear proper PPE after you had been on the unit. [Staff E, CNA's name] was the staff who didn't have the N95 mask on while on the unit. We all found out we needed to wear gowns in the halls and only N95 mask afterwards. The Infection Preventionist came into the unit and provided the correct signs for all the rooms. We were using the contact signs because that was what we had at that time. I had sent a text message to [Staff F, LPN's name] at 9:22 AM stating some rooms had signs and some did not. She replied that we needed to have signage on resident doors for contact/droplet precautions and since I was off during the weekend that is why I decided to do my own report since I did not know when those signs went on the doors. I am the primary nurse on the unit and do my own thing due to the agency staff that work the unit. During an interview on 5/8/2023 at 1:01 PM, Staff C, CNA, stated, I was off during the weekend and just came back to work today. We get report on the unit at 6:45 AM. Residents were starting to come up positive for COVID. [Staff A, LPN's name] decided to recheck to make sure [to determine if additional residents were positive]. We were not aware we needed to wear a gown and gloves while working on the unit. I know as you go into the room you wear a face shield, N95 mask, gloves, and gown. This unit is different. COVID positive residents are outside of the rooms. We had contact precaution signs on the doors. Contact precautions is pretty much used for everything. [Staff A, LPN's name] never mentioned that the signs provided were not the correct ones. During an interview on 5/8/2023 at 1:21 PM, Staff E, CNA, stated, I was wearing a surgical mask because that was what we were supposed to do until they told us to wear N95 masks later on 5/8/2023. [Staff A, LPN's name] told us to put up the contact precaution signs on the COVID positive resident doors. Nobody told us that we needed to include droplet precautions. I worked Friday and rooms for [Residents #70, #42, #37 and #94's names] all had contact precaution signs on the door. I was wearing only a surgical mask while in contact with two COVID positive residents that were sitting in the living room area. The residents were not wearing masks. It is hard for them to keep the masks on. I did not know we had to wear gowns while in the common area. During an interview on 5/8/2023 at 1:31 PM, Staff B, Director of Central Supply, stated, On Friday night, three residents tested positive for COVID and I posted the signs I had available. Monday, [Staff A, LPN's name] said to make copies. It was the same two signs. One said, 'stop see the nurse' and the other one 'contact precautions.' I went and got the copies. That is when you saw us posting the signs on the doors. Later that day, I saw the Infection Preventionist hanging the other signs which basically say the same things as the other ones. When [Staff A, LPN's name] asked me to make copies and hang the signs, she never mentioned they were not appropriate [signs]. I placed the signs on Friday before I left, so at least the people entering would at least stop at the door [resident's door]. I think we use the same protocol for all, the same precautions. I did not have a gown when entering the Memory Care Unit. I was not going in the rooms. I was just hanging signs on the resident rooms. I did hear some more residents tested positive but I'm not familiar with their faces. I was not aware the residents that were COVID positive were in the common areas in the Memory Care Unit. For contact precautions, I would say we use a blue mask [surgical mask], gown, and gloves. If it is droplet, we are expected to wear a face shield, N95, and gown. When I exited the Memory Care Unit, I went around the facility and made sure all PPE bins were fully stocked. During an interview on 5/8/2023 at 1:45 PM, the Director of Nursing (DON) stated, As far as monitoring infection control, I do it with the Infection Preventionist. We collaborate on how we are going to move forward. Residents who test negative for COVID should be removed from COVID positive rooms. Signage should be on the door as well as personal protective equipment. I do not know what happened with [Resident #92's name]. I reached out to the nurse that worked that weekend and she has not reached out back. I round daily regarding education on PPE. I am in the middle of my infection control training. Staff should wear appropriate PPE when in contact with positive residents. I went to the memory care unit on 5/4/2023 and again on 5/5/2023 and I was wearing an N95 and face shield. I was not wearing a gown since I was only at the nursing station and hallway. The staff were informing me of a COVID positive resident, and I then informed my boss and the Infection Control Preventionist. Staff was instructed to notify the physician, family, and follow orders. They were also instructed to isolate residents as much as they can. I would say I oversee infection prevention when the Infection Preventionist is not available. During a telephonic interview on 5/9/2023 at 2:33 PM, Staff F, LPN/Infection Prevention Trainee, stated, I would keep communication via phone with Infection Preventionist, Administrator and DON for guidance as to my role I wasn't sure. I tested positive on the 3rd [May] showing symptoms. When I spoke to [Staff A, LPN's name], I told them to follow normal protocol which include signs, carts with PPE, and wearing proper PPE. There was a lot of texting back and forth, a lot of the guidance came from the Infection Control Preventionist. Staff needed to make sure that signs stated droplet and contact if I am not mistaken. Via text, I was notified that Sunday [5/7/2023], 10 residents tested positive for COVID. I did not give any guidance. It was pretty much the DON and Administrator who were going back and forth providing guidance. Last time I was in the building was Wednesday [5/3/2023] until 4 PM. When the Infection Preventionist is not available, the DON and the Regional Clinical Consultant were responsible. During a telephonic interview on 5/9/2023 at 2:55 PM, the Medical Director stated, I was not aware of the COVID-19 outbreak status in the facility. I have been the Medical Director since January. No one contacted me in the last two weeks concerning the COVID-19 outbreak status at the facility. My expectation was for residents who have a roommate and test positive for COVID, the positive resident should be put in a room with others who are positive. The roommate would generally be placed or transferred with patients with a negative test result. I would have expected the resident who tested negative to be removed from the room of the one who tested positive. During an interview on 5/11/2023 at 12:15 PM, Staff E, CNA, stated, I do not take lunch in the breakroom. I go outside using the back door. We are allowed to use the employee breakroom for lunch if we want. When my shift is over, I exit the unit and walk through the facility to clock out. During an interview on 5/11/2023 at 12:16 PM, Staff G, CNA, stated, I work all over the facility. Last time I worked in the Memory Care Unit was last Thursday or Friday [5/4/2023 or 5/5/2023]. I worked with [Staff E, CNA's name] and we were only wearing surgical face masks while taking care of the residents in the Memory Care Unit. Residents were already coming up positive and I didn't know I was supposed to wear an N95. During an interview on 5/11/2023 at 12:20 PM, Staff H, LPN, stated, I only work in the Memory Care Unit and worked last Sunday [5/7/2023]. I wore an N95 mask. I did not leave the unit on Sunday for lunch or break. I exit the unit and walk through the facility to clock out. During an interview on 5/11/2023 at 12:50 PM, Staff I, CNA, stated, I do not remember what rooms I was assigned to. I think I worked in the back hall of the 200 Hall. On Monday, I was wearing a surgical mask when I came in, then we were told to wear an N95 mask when you guys showed up. Review of the COVID-19 Line List documented as of 5/11/2023 revealed the facility had a total of 28 COVID-19 positive residents. During an interview conducted on 5/12/2023 at 8:49 AM, the Administrator stated, Biggest thing was on 5/1/2023 when residents started testing positive for COVID. I sat down with my Director of Nursing (DON) and Infection Preventionist (IP) and referred back to our policies and procedures. I had the DON and IP come up with a clinical procedure and isolation and personal protective equipment to go into place. We had an Ad Hoc meeting on 5/1/2023, got the isolation signs and continued to test. We reviewed residents and patient care and began putting a plan in place. I took the clinical piece and had my DON and IP work together. The Medical Director was aware of the policies we have in place, but he was not involved in the meeting held on 5/1/2023. The DON provided coverage while the Infection Preventionist was out. My Infection Preventionist tested positive on 5/2/2023. The DON was responsible for overseeing infection control in the facility. With COVID positive [residents], we need to have droplet and contact precautions. The signs [visual alerts] should have been posted. I became aware the COVID Unit [Memory Care Unit] was not on isolation on 5/8/2023. COVID positives are not allowed to cohort with non-positive residents. They are not allowed to remain in the same room. When this was brought to my attention, we separated them on 5/8/2023 [Residents #92 and #50]. It was my understanding that staff were wearing the appropriate personal protective equipment and appropriate signage was posted. The DON was here on Friday [5/5/2023] and she was here on [5/6/2023] on Saturday. The signage was provided to her and put in place. The DON notified me on 5/7/2023 of the COVID positives and it was my understanding that we had made the Memory Care Unit a red unit [COVID Unit]. During an interview on 5/12/2023 at 8:50 AM, the Regional [NAME] President stated, As long as the staff is properly donning and doffing [taking off] their PPE and handwashing before they exit the unit, they are able to go through the facility to clock out. During an interview on 5/12/2023 at 8:57 AM, the Regional Director of Clinical Services stated, I personally provided the correct signs on 5/4/2023. I know the two signs on Serenity [Memory Care Unit] signs were not on the doors on Monday morning [5/8/2023]. The CDC wants correct singular signs of contact and droplet precaution signs versus a combined sign. I knew the individual rooms in the Serenity Unit did not have signs posted. I was not aware of the incident in the C-wing [200 Hall where Residents #92 and #50 reside]. I was not aware of the room in the C-wing [200 Hall, having the wrong sign]. On 5/4/2023, signage was identified as a concern and I personally placed a color sign on the A-wing [100 Hall] and provided two signs to the DON to place on the Serenity doors. The plan we had in place was not working. I provided correct signs, and the facility was not using them. On Monday morning [5/8/2023] when I showed up, I realized that signs had not been posted. On 5/4/2023, a cover message was sent out to all staff stating to wear eye protection and N95 mask for the A-wing and Serenity Unit [100 Hall and Memory Care Unit]. A request was made for documentation of all staff having received and read the cover message. No documentation was provided. During an interview on 5/12/2023 at 10:30 AM, the Regional Director of Clinical Services stated, The incorrect signage [in the Memory Care Unit] on 5/4/2023 was corrected immediately and didn't warrant follow up. It was a singular incident. No performance plan was needed. We would not evaluate at a later date. The signage was incorrect on the entrance of Serenity on that day [5/4/2023]. I did not enter the Serenity Unit; less people is better. The signage on the outside was what was observed. I was not notified that the facility had positives in the building over the weekend. If I had that information as a Clinical Leader, I would have come into the facility. Especially with a cluster as big as seven. I would have come in, the Director of Nursing and/or the Infection Preventionist facilitated the room changes, notifications, and process. I would not say it was a systemic break, it was the action of employees regardless of the education provided. The system was in place but not followed. The process broke. There was a hole, definitely a gap. I did not put in a root cause analysis. I had included it in my notes and dealt with it appropriately. The expectation is that PPE and handwashing are followed. They are allowed to come into facility to exit [to clock out]. I was not aware that staff was not using the appropriate PPE, but I can prove that 128 staff members received the message sent regarding the PPE to wear. I am not able to say if the Director of Nursing went into the Memory Care Unit to verify staff were following instructions on PPE. The audits [5/1/2023 and 5/3/2023] do not have to do with the current issue. Currently, we suspended the Director of Nursing for failure to follow clinical direction and follow the clinical policy in relation to infection control. A request was made for documentation of all staff having received and read the cover message. No documentation was provided. Review of Resident #26's admission record documented the resident was [AGE] years old with diagnoses to include congestive heart failure, chronic kidney disease, stage III and age-related cognitive decline. Review of Resident #26's progress note dated 5/4/2023 documented, Resident COVID tested with positive result. Resident placed on transmission-based precautions. Review of Resident #94's admission record documented the resident was [AGE] years old with diagnoses to include urinary tract infection, hypertensive, chronic kidney disease, neoplasm of uncertain behavior of prostate, chronic kidney disease, and cognitive communication deficit. Review of Resident #94's progress note dated 5/4/2023 documented, Resident noted with head congestion. States he does not feel well. Temp. [temperature] 99.6. Covid test positive. Residents are [Sic.] placed in transmission-based precautions. Review of Resident #42's admission record documented the resident was [AGE] years old with diagnosis to include chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease, and dementia. Review of Resident #42's progress note dated 5/4/2023 documented, Resident with positive covid test. Noted with temp 99.5. No cough or congestion noted. Notified [Physician Assistant's name] PA, resident placed on transmission-based precautions. Review of Resident #72's admission record documented the resident was [AGE] years old with diagnosis to include chronic obstructive pulmonary disease, type II diabetes mellitus, viral hepatitis C, and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of Resident #72's progress note dated 5/4/2023 documented, Resident with positive covid test. Afebrile, no cough or congestion noted. Notified [Physician Assistant's name] PA, resident placed on transmission-based precautions. Review of Resident #92's admission record documented the resident was [AGE] years old with diagnoses to include hypertension, depression, osteoarthritis, repeated falls, dementia, and dysphagia. Review of the progress note dated 5/5/2023 for Resident #92, who resided on the 200 Hall in a semi-private room with Resident #50, documented, Pt [patient] experiencing SOB [shortness of breath], shallow respirations, tachypnea. 114/60 [blood pressure] 92P [pulse] 98.4T [temperature] 24R [respirations] 95% RA [oxygen saturation on room air]. Lungs have crackles in bilateral lower lobes. Blood glucose 156. Covid + [positive] rapid test. PCP [Primary Care Physician] contacted, new orders for Paxlovid BID x 5 days [twice a day times 5 days, an antiviral pill that reduces the amount of the virus that cause COVID-19 in the body and prevents symptoms from getting worse], Son notified of covid+ status and informed that he recently has gotten over covid and would like to know if a mask needs to be worn while visiting his mother. Son educated on proper PPE. Review of the admission record for Resident #50 documented the resident was [AGE] years old, with diagnosis to include chronic kidney disease, stage 3, type II diabetes mellitus, and cognitive communication deficit and resided on the 200 Hall in a semi-private room with Resident #92. Review of Resident #61's admission record documented the resident was [AGE] years old with diagnosis to include atrial fibrillation, altered mental status, chronic obstructive pulmonary disease, and dementia. Review of Resident #61's progress notes dated 5/7/2023 documented, Resident tested for covid due to other residents' positive status. Resident tested positive. Review of the medical record for Resident #61 did not provide on order to place the resident on transmission-based precautions dated 5/7/2023. Review of Resident #45's admission record documented the resident was [AGE] years old with diagnosis to include hypertensive chronic kidney disease, Alzheimer's Disease with early onset, squamous cell carcinoma of skin of left upper limb, type 2 diabetes, and unspecified dementia. Review of Resident #45's progress note dated 5/8/2023 documented, Resident tested this morning for COVID positive. [Doctor's name] PA [Physician Assistant's name] was notified, waiting for response. Asked to advise for any orders. Waiting for response from [Physician Assistant's name] PA. Review of Resident #58's admission record documented the resident was [AGE] years old with diagnosis to include dementia, hypertensive chronic kidney disease stage IV, and personal history of tuberculosis. Review of the Line Listing dated 5/7/2023 documented Resident #58 tested positive. Review of the medical record for Resident #58 did not provide documentation of the resident having tested positive for COVID-19. Review of Resident #99's admission record documented the resident was [AGE] years old with diagnosis to include dementia and mood affective disorder. Review of Resident #99's progress note dated 5/7/2023 documented, Resident tested for covid d/t [due to] other residents' positive status. Residents tested positive. Review of Resident #13's admission record documented the resident was [AGE] years old with diagnosis to include chronic kidney disease, heart failure, dementia, and type II diabetes mellitus. Review of Resident #13's progress note dated 5/7/2023 documented, Resident noted with mild symptoms, runny nose. tested for covid, positive result. Review of Resident #85's admission record documented the resident was [AGE] years old with diagnosis to include hypertensive heart disease, dementia, and cognitive communication deficit. Review of Resident #85's progress note dated 5/8/2023 documented, Resident was tested this morning with results of COVID positive. Called [Physician Assistant's name] PA with [Doctor's name] asking to advise for any new orders. Waiting for response. Review of Resident #69's admission record revealed the resident was [AGE] years old with diagnosis to include paranoid schizophrenia, dementia, bipolar disorder, and anxiety. Review of Resident #69's progress note dated 5/7/2023 documented, Resident tested for covid due to positive status of other residents. Resident with positive result. Review of Resident #60's admission record documented the resident was [AGE] years old with diagnosis to include dementia, pseudo bulbar, and cognitive communication. Review of Resident #60's progress note dated 5/7/2023 documented, Resident with mild cold symptoms. tested for covid, results positive. Review of Resident #53's admission record documented the resident was [AGE] years old with diagnosis to include dementia, COPD (chronic obstructive pulmonary disease), Alzheimer's Disease, and palliative care. Review of Resident #53's progress note dated 5/9/2023 documented, Spoke with son, [Resident #53 son's name] of mother testing positive for COVID. Review of Resident #88's admission record documented the resident was [AGE] years old with diagnosis to include Alzheimer's Disease and schizoaffective. Review of Resident #88's progress note dated 5/8/2023 documented, Attempted to contact family message left with family of mother positive results when tested this afternoon for COVID. Review of Resident #59's admission record documented the resident was [AGE] years old with diagnosis to include cognitive communication deficit, allergic rhinitis, and other idiopathic peripheral autonomic neuropathy. Review of Resident #59's progress noted dated 5/8/2023 documented, Resident COVID positive. Review of Resident #76's admission record documented the resident was [AGE] years old with diagnosis to include unspecified dementia, chronic kidney disease, other disorders of lung, and elevation od levels of liver transaminase levels. Review of Resident #76's progress note dated 5/10/2023 documented, Resident status updated to COVID positive, resident is currently on airborne isolation r/t [related to] to positive test.

Based on observation, interview, and record review, the facility failed to ensure that residents received respiratory care services consistent with professional standards of practice for 2 of 12 residents receiving continuous oxygen services, Residents #15 and #43 (Photographic evidence obtained). Findings include: 1. During an observation on 5/8/2023 at 9:27 AM, Resident#43 was lying in bed, being administered oxygen via nasal cannula. The oxygen concentrator was set at 2 liters per minute. During an observation on 5/9/2023 at 7:03 AM, Resident #43 was lying in bed, being administered oxygen via nasal cannula. The oxygen concentrator was observed set at 2 liters per minute. Review of the physician's order dated 2/21/2022 for Resident #43 read, Oxygen at 3 liters/minute continuously per nasal cannula. Document every shift for From home use [Sic.]. Related to Chronic Obstructive Pulmonary Disease, Unspecified Chronic Bronchitis, Dependence on Supplemental Oxygen. Review of the Medication Administration Record (MAR) for Resident #43 documented the resident was administered 3 liters of oxygen on 5/8/2023 and 5/9/2023. During an interview on 5/10/2023 at 7:52 AM, Staff D, Registered Nurse (RN), stated, [Resident #43's name] has an order for 3 liters continuous. The oxygen concentrator setting is not right. 2. During an observation on 5/8/2023 at 10:10 AM, Resident #15 was lying in bed, being administered oxygen via nasal cannula. The oxygen concentrator was set at 2.5 liters per minute. During an observation on 5/9/2023 at 7:10 AM, Resident #15 was lying in bed, being administered oxygen via nasal cannula. The oxygen concentrator was set at 2 liters per minute. Review of the physician's order dated 4/17/2023 for Resident #15 read, Oxygen at 4 liters per minute prn [as needed] per nasal cannula; apply humidification. Every Shift for COPD related to Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation. Review of the Treatment Administration Record (TAR) for Resident #15 documented the resident was administered 4 liters of oxygen on 5/8/2023 and 5/9/2023. During an interview on 5/10/2023 at 7:48 AM, Staff D, RN, stated, The order says that [Resident #15's name] needs 4 liters of continuous oxygen. The oxygen concentrator setting is not right. During an interview on 5/10/2023 at 9:02 AM, the Director of Nursing stated, My expectations are that the nurses are to follow physician orders when administering oxygen. Review of the policy and procedure titled Oxygen Administration/Safety/Storage/Maintenance with a review date of 4/27/2023 read, Oxygen will be administered in accordance with physician orders and current standards of practice.

Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and included the expiration date when applicable, in two medication rooms and two medication carts. Findings: On [DATE] at 9:45 PM, the surveyor observed C Wing Medication Room with Staff D, Licensed Practical Nurse (LPN), and found four [MEDICATION(S)] prefilled syringes in the medication refrigerator, with the expiration dates of [DATE], [DATE], [DATE], and [DATE] on the packaging (Photographic evidence obtained). During an interview on [DATE] at approximately 9:45 AM, Staff D, LPN, stated, Yes, they are all expired. On [DATE] at 9:55 AM, the surveyor observed the Medication Cart 2 on C Wing with Staff G, LPN, and found one opened vial of [MEDICATION(S)] insulin that was not dated (Photographic evidence obtained). During an interview on [DATE] at approximately 9:55 AM, Staff G, LPN, picked up and examined the vial and stated, The weekend nurse probably opened it. It is not dated. It should be dated. On [DATE] at 10:10 AM, the surveyor observed the Medication Cart 3 on C Wing with Staff E, Registered Nurse (RN), and found one opened bottle of [MEDICATION(S)] 0.005% eye drop that was not dated (Photographic evidence obtained). During an interview on [DATE] at approximately 10:10 AM, Staff E, RN, stated, I don't see that it was dated. On [DATE] at 10:20 AM, the surveyor observed the Medication Room on A Wing with Staff F, RN, and found nine [MEDICATION(S)] prefilled syringes in the medication refrigerator, with the expiration dates of [DATE], [DATE] on two syringes, [DATE], [DATE], [DATE] and [DATE] on three syringes (Photographic evidence obtained). During an interview on [DATE] at approximately 10:20 AM, Staff F, RN, stated, They are all expired. Review of the facility policy and procedure titled, 3.8 Accessing a Multi-Dose Vial last revised on [DATE], read, Considerations: 2. If multiple-dose vials must be used (e.g., insulin, [MEDICATION(S)]) each vial is dedicated to a single patient. Guidance: 6. Multi-dose vials will be labeled after opening with: 6.2. Date and time. 7. Multi-dose vials are to be discarded if: 7.2. Open and undated. Review of the facility policy and procedure titled 8.2 Disposal/Destruction of Expired or Discontinued Medication last revised on [DATE], read, Procedure: 1. Facility staff should destroy and dispose of medication in accordance with Facility policy and Applicable Law, and applicable environmental regulations. 4. Facility should place all discontinued or out-dated medications in a designated, secure location which is solely for discontinued medication or marked to identify the medications are discontinued and subject to destruction.

Based on interview and record review, the facility failed to ensure residents received care and services to maintain or improve their ability to carry out the activities of daily living (ambulation) for 1 of 5 residents reviewed for restorative and rehabilitation services, Resident #38, in a total sample of 32 residents. Findings: During an interview on 12/13/2021 at 9:24 AM, Resident #38 stated that she used to be able to walk, she was supposed to be walking with a walker 3 times a week, but she was not walking with a walker 3 times a week. Review of the Order Listing Report read, Resident Name: [Resident #38's Name]. Order Summary: Restorative ROM [Range of Motion] and ambulation program every day shift every Mon [Monday], Wed [Wednesday], Fri [Friday]. Review of Resident #38's restorative program record for December 2021 revealed the restorative goal of ambulation with front wheeled walker. The record showed no entry for participation of the resident in the restorative ambulation program from 12/1/2021 through 12/13/2021. During an interview on 12/14/2021 at 9:41 AM, Staff A, Restorative Certified Nursing Assistant, stated Resident #38 had not walked three times a week with a front wheeled walker during December 2020 as outlined on the Restorative Order Listing Report. Staff A stated that there was no back up staff to supplement the restorative program and other assignments had taken her away from the restorative program.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents reviewed, Resident #31, in a total sample of 32 residents. Findings: Review of the progress note dated 11/21/2021 for Resident #31 revealed at 5:30 AM, Resident #31 was observed lying on the floor with the left side of his body under the bed with his head facing the foot of the bed. Resident #31 was yelling in pain, and his right leg was abducted with his right foot plantar flexed under his body. Emergency services was called for suspected injury. Resident #31 returned to the facility at 10:30 AM with a diagnosis of fractured coccyx. Review of Resident #31's Emergency Department Discharge Instructions dated 11/21/2021 revealed Resident #31 had discharge diagnoses of dementia, fall from bed and fractured coccyx. Review of Resident #31's care plan initiated on 3/19/2021 revealed fall injury prevention interventions that included landing mats at bedside due to recent fall. During an observation on 12/13/2021 beginning at 9:29 AM, Resident #31 was lying in his bed. No landing mats were in place on the floor at beside as a fall injury prevention intervention. During an observation on 12/14/2021 beginning at 8:51 AM, Resident #31 was lying in his bed. No landing mats were in place on the floor at beside as a fall injury prevention intervention. During an interview on 12/14/2021 at 9:09 AM, Staff B, Registered Nurse, stated that she didn't know why landing mats were removed from the floor of Resident #31's beside. During an interview on 12/14/2021 at 9:23 AM, Staff C, Certified Nursing Assistant (CNA), stated that he had worked with Resident #31 for almost a year. Staff C stated he was not sure if there were landing mats on the floor of Resident #31's beside.

Based on observation, interview, and record review, the facility failed to ensure the self-administered medications were stored safely and securely and failed to ensure the facility had a process to demonstrate that the residents had taken the self-administered medications, for 2 of 3 residents, Residents #1 and #3. Findings: 1. On 11/8/2021 at 9:58 AM, during an observation of Resident #1, there was a bottle of Blood Flow 7, a bottle of Heal N Sooth, both with an expiration date of March 2023, and a [MEDICATION(S)] Inhaler on top of the bedside table. There was no lockbox in the resident's room. During an interview on 11/8/2021 at 9:58 AM, Resident #1 stated, I keep the medications on top of the bedside table. They were never locked. I had confused people from the other unit that came in and out of my room, so I keep my door closed. I want to take my own medications as both medications are for my [CONDITION(S)], and I take three tablets of them every day. During an interview on 11/8/2021 at 10:34 AM, Staff C, Registered Nurse (RN), stated she was the primary nurse for Resident #1. When asked if she had any resident on self-administration, Staff C replied, [Resident #1's name]. When asked what are the medications that Resident #1 self-administers, Staff C replied, She takes some vitamin medications from Amazon. During an interview on 11/8/2021 at 1:46 PM, Resident #1 stated she purchased her own lockbox to store her debit cards only. When asked if she had a record at her bedside to document the medications she is taking, the resident replied, I never recorded anything. No one told me so. Review of Resident #1's records revealed the resident was admitted on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Minimum Date Set (MDS) with Assessment Reference Date (ARD) of 9/25/2021 revealed a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive response). Review of the active physician orders dated 11/8/2021 did not reveal any order for Resident #1 to self-administer the medications. There was no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's care plan reads, Focus: [Resident #1's name] has a physician's order for unsupervised self-administration of the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . Date Initiated: 08/25/2021 . Interventions: - Discuss medications with each supervised administration. Demonstrate correct administration as required. Review each med as necessary with the client . - Lockbox provided to resident . - Observe resident's self-administration (FREQ) . - Provide written documentation on each medication for the resident to keep as reference at the bedside. During an interview with Staff C, RN, on 11/8/2021 at 2:06 PM, when asked if she checked the documentation at residents' bedside each shift per facility policy, Staff C stated, No. When asked if Resident #1 had any documentation at bedside where they record the medication that they self-administered, Staff C replied, You know, [Resident #1's name] is a difficult resident. 2. On 11/8/2021 at 11:16 AM, during an observation of Resident #3, there was one Eye Drop Moisturizer 15 ml. (milliliter) with an expiration date of 8/2022, and one Ocular Lubricant 15 ml., with an expiration date of 11/2022 on her bedside table. The eyedrops were in their original box with a prescription label. There was no lockbox in the resident's room. During an interview on 11/8/2021 at 11:17 AM, Resident #3 stated, I want to take my own eye drops and has been using the eye drops several times a day because of my dry eyes. Review of the active physician orders dated 11/8/2021 did not reveal any order for Resident #3 to self-administer the medications. Review of a physician order dated 10/11/2021 for Resident #3 revealed an order to discontinue Ocular Ophthalmic Solution, 1 drop both eyes twice daily for 30 days. Review of Resident #3's MDS with an ARD of 8/28/2021 revealed a BIMS score of 15. Review of Resident #3's care plan reads, Focus: [Resident #3's name] has a physician's order for unsupervised self-administration of the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . Date Initiated: 10/14/2021 . Interventions: - Discuss medications with each supervised administration. Demonstrate correct administration as required. Review each med as necessary with the client . - Observe resident's self-administration (FREQ) . - Provide written documentation on each medication for the resident to keep as reference at the bedside. During an interview with Resident #3 on 11/8/2021 at 1:49 PM, when asked if the nurses had observed her self-administer her eye drops, Resident #3 replied, Not sure. When asked if she had a record or form at bedside to document every time she self-administered the eye drops, she replied, No, I never had any of that. When asked if she was aware of the stop date of the eye drops twice a day for 30 days, Resident # 3 replied, No. I take them several times a day when my eyes are dry. Review of the Policy and Procedure titled, Self-Administration of Medication with a review date of 4/15/2019, reads, Policy: Each resident who desires to self-administer medication is permitted to do so if the facilities [sic.] interdisciplinary team has determined the practice would be safe for the resident and other residents in the facility. Procedure: 1. If the resident desires to self-administer medication, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This assessment will be repeated as the resident's condition warrants. 2. The interdisciplinary team determines the resident's ability to self-administer medications by means of a skills assessment as follows (utilize form LCCA-541): a. The facility may utilize the resident's existing medication package; have the resident complete all steps except for the actual removal of the medication from the package. b. The resident is instructed in: use of the package; medication name, type, and reason for use; reading of the label; and scheduling of medication doses. c. The resident is requested to read the label on each package and indicate at what times the medication should be taken and any other instructions for use. d. The resident is asked to demonstrate the removal of the medication from the package and in the case of non-solid dosage forms, e.g., inhaler, to verbalize the steps involved in administration. e. The resident is asked to complete a Bedside Record indicating the administration of the medication. 3. A 72-hour trial will be conducted for each resident who wishes to self-administer medications. 4. If the resident demonstrates the ability to safely self-administer medications, a further assessment of the safety of bedside medication storage is conducted. 5. Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the rooms of, or room with, residents who self-administer. The following conditions will be met for bedside storage to occur: a. The manner of storage prevents access by other residents. Lockable drawers or cabinets are required if unlocked storage is ineffective. b. The medications provided to the resident for bedside storage are kept in the containers dispensed by the provider pharmacy. c. The resident will document on the Bedside Medication Record each time a medication is taken. The documentation is reviewed on each nursing shift, and the administration of the medication by the resident is noted on the MAR [Medication Administration Record] kept at the nurses' station. Notation of each dose self-administered is made by placing a check mark in the appropriate space and noting in the nursing comments the initials of the nurse who reviewed the Bedside Documentation Record. Only one signature per shift is required by the nurse documenting the self-administration of the medication. 6. All nurses and CNA's [sic.] are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage and to give unauthorized medications to the charge nurse for return to the family or responsibly party. Families or responsible parties are reminded of this procedure and related policies at the time of the initial assessment and as needed thereafter. 7. Medications stored at the bedside are reordered in the same manner as other medications. The nursing staff is responsible for proper rotation of bedside stick and removal of expired medications. 8. When the interdisciplinary team determines that bedside or in-room storage of medications would be a safety risk to other residents, the medications of residents permitted to self-administer are to be stored in the central medication cart or in the medication room.

Based on observation, policy and procedure review, and interview the facility failed to ensure hand hygiene was enforced to prevent the possible spread of infection for 2 of 5 staff nurses during medication administration observation. Finding: An observation on 3/4/20 at 11:25 AM of Staff F, Licensed Practical Nurse (LPN) showed there was a bottle of hand sanitizer on the medication cart. Resident #39 approached Staff F and asked for her arthritis medication, Tylenol. Staff F was observed to administer the medication to Resident #39. The LPN had been observed touching items on the medication chart prior to the administration. The LPN did not use hand sanitizer or wash her hands prior to the medication administration. Staff F was observed to take the medication cup and water cup from Resident #39. The water cup was handled by the rim with Staff F's bare hand coming in contact with where Resident #39 had drank out of the water cup. Staff F disposed of the cups and did not use hand sanitizer or wash her hands. Staff F proceeded to room [ROOM NUMBER], there was a new resident admitted to the room, and assisted the newly admitted resident to the bathroom placing her bare hands on the residents' bare shoulder and back. Staff F exited room [ROOM NUMBER] and proceeded to go the nurse's station. The LPN was observed not to use hand sanitizer or wash her hands after exiting the room. There was a hand sanitizer dispenser observed by the Resident's room door. During an interview on 3/4/20 at 11:42 AM with Staff F, when questioned if she had completed hand hygiene before or after the medication administration, Staff F stated, No I did not do hand hygiene. When asked if the LPN completed hand hygiene before entering room [ROOM NUMBER] Staff F stated, No, I did not. When asked if the LPN performed hand hygiene prior to assisting the resident to the bathroom and after assisting the resident to the bathroom she stated, No I did not. When asked if the LPN performed hand hygiene after exiting the resident's room, Staff F stated, No, I did not. During an interview conducted on 3/4/20 at 12:00 PM with the Infection Control Nurse the observation of Staff F, LPN was reviewed. The Infection Control Nurse stated the nurse should have stopped to sanitize her hands. Record review of Policy and Procedure titled, Hand Hygiene Chapter 6: General Resident Care, Guide to Infection Prevention And Control reviewed 7/25/19: Purpose: to decrease the risk of transmission of infection by appropriate hand hygiene. Policy: Handwashing/hand hygiene is generally considered the most important single procedure for preventing nosocomial infection. During an observation of the medication administration on 3/4/2020 at 6:00 AM with Staff G, Registered Nurse (RN) for Resident #67 it showed Staff G, RN prepared medications and entered the Resident's room, administered the medications and left the room without performing hand hygiene. The RN went back to the medication cart and prepared medications for Resident #98 without performing hand hygiene prior to the preparation. The RN entered Resident #98's room administered the medications and left the room without performing hand hygiene. During an observation of the medication administration on 3/4/2020 at 8:55 AM for Resident #82 with Staff B, LPN (Licensed Practical Nurse) showed Staff B placed the medications, Calcium 600 mg, Vitamin D 3, and [MEDICATION NAME] in the palm of her hand to put them into a small plastic bag to crush them. Staff B pulled apart [MEDICATION NAME], two capsules, with ungloved hands, into a medicine cup, she entered the Resident's room and administered the medication without performing hand hygiene. During an interview on March 4, 2020 at 6:02 AM Staff G, LPN stated, I did not wash or use hand sanitizer when I entered or exited the residents' rooms or between residents while preparing the medications. I should have washed them. During an interview on March 4, 2020 at 9:08 AM Staff H, RN stated, All staff are educated on hand hygiene and it is an expectation that during medication administration we always wash our hands or use hand sanitizer. During an interview on March 4, 2020 at 9:15 AM Staff B, LPN stated, I should not have put the medications in my hand or opened the capsules without gloves. I should have used hand sanitizer when I entered the room before I administered the medications to the Residents. During an interview on March 4, 2020 at 9:25 AM the Director of Nursing stated, It is my expectation that all staff follow the medication administration policies and procedures for safe medication administration.

Based on observation, interview, and policy and procedure review the facility failed to ensure that all drugs and biologicals used in the facility were stored and labeled in accordance with current professional standards, including proper refrigeration, and failed to remove expired medications from active medications for 4 of 4 medication carts observed out of 6 medication carts. Findings: During an observation of medication administration with Staff B, LPN (Licensed Practical Nurse) on March 4, 2020 at 8:55 AM for Resident #82 it showed the LPN placed the resident's medications in her hand and then transferred them to a medication cup. The LPN then poured the liquid medication into another cup, entered the resident's room, stated the medications to be administered, placed the medication cup on the resident's overbed table, and left the resident's room with the medications on the bedside table. The LPN did not return to the room. Assistance was requested by this surveyor and Staff H, RN (Registered Nurse) responded to the room. The medications were still present at the bedside on the bedside table. The following medications were observed at the bedside by Staff H, RN, Aspirin 81 mg (milligrams), [MEDICATION NAME] 80 mg and [MEDICATION NAME]-[MEDICATION NAME] syrup (a cough suppressant)10-100/5 ml (milliliters), for a total of 10 ml. During an interview with Staff H, RN on March 4, 2020 at 9:08 AM she stated, We are not to leave any medications at the residents' bedsides, when staff administer medications they should stay at the bedside until the resident takes all the medications. It is against our policy to do this. During an interview on March 4, 2020 at 9:15 AM with Staff B, LPN she stated, I should not have put the medications in my hand or opened the capsules without gloves. I should have used hand sanitizer when I entered the room before I administered medications to residents. I should not have left the medicines at the bedside without watching to make sure the resident took them. He does not have an order to self- administer medications or have medications at his bedside. I thought it was okay because he is awake and alert. I always do that. During an interview with the Director of Nursing on March 4, 2020 at 9:25 AM, she stated, It is my expectation that all staff follow the medication administration policies and procedures for safe medication administration. Staff should never leave medications unattended at the bedside. During an observation on March 2, 2020 at 9:40 AM of the medication cart on the 200 hallway with Staff A, Registered Nurse (RN) there was one (1) bottle of Latanoprost 0.005% eye drops with an open date of January 8, 2020, and an expiration date of February 18, 2020, one (1) bottle of [MEDICATION NAME] 1% eye drops with an open date of December 23. 2019, one (1) bottle of [MEDICATION NAME] 1% eye drops with an open date of January 4, 2020, one (1) bottle of [MEDICATION NAME] 1% eye drops with an open date of January 16, 2020, one (1) bottle of [MEDICATION NAME] 1% eye drops with no open date or expiration date, one (1) bottle of Dorzolamide-[MEDICATION NAME] eye drops with an open date of November 27, 2019, one (1) bottle of Bimatoprost 0.03% eye drops with an open date of November 27, 2019, and one (1) bottle of Dorzolamide-[MEDICATION NAME] eye drops with an open date of January 5, 2020. There was one (1) unopened bottle of Latanoprost 0.005% eye drops with a refrigerate until opened sticker on the medication that was dispensed from the pharmacy on February 4, 2020 observed in the medication cart. During an observation on March 2, 2020 at 10:15 AM of a medication cart on the 200 wing with Staff B, Licensed Practical Nurse (LPN) there was one (1) opened bottle of Latanoprost 0.005% eye drops, one (1) bottle of Moxifloxacin 0.5% eye drops and one (1) bottle of [MEDICATION NAME] eye drops with no dates documented when the bottles were opened or expiration dates. There were two (2) bottles of Sunmark eye drops with no documentation of the open dates or expiration dates. One (1) bottle of [MEDICATION NAME] 0.2% eye drops with no documented open date or expiration date. There was one (1) unopened bottle of Latanoprost 0.005% eye drops with a refrigerate until opened sticker on the medication that was dispensed from the pharmacy on January 5, 2020. During an observation on March 2, 2020 at 10:35 AM of a medication cart on the 100 wing with Staff C, LPN there was one (1) opened bottle of Latanoprost 0.005% eye drops with no documented open date or expiration date, there was one (1) opened bottle of [MEDICATION NAME] 2% with no documented open date or expiration date, and one (1) opened tube of [MEDICATION NAME] 0.5 % eye ointment with no documented open date or expiration date. During an observation on March 2, 2020 at 11:01 AM with Staff D, LPN of a medication cart on the 100 wing, there was one (1) opened bottle of Latanoprost 0.005% eye drops with no documented open date or expiration date and one (1) unopened bottle of Latanoprost 0.005% eye drops with a refrigerate until opened sticker on the medication that was dispensed from the pharmacy on February 5, 2020. During an interview on March 2, 2020 at 9:50 AM with Staff A, Registered Nurse she stated, I don't know how long eye drops are good for once they are opened, I guess the expiration date that is on the bottle. We should label all medications when we open them. The unopened latanoprost eye drops should be in the refrigerator, I'm not sure why they are in the medication cart. During an interview on March 2. 2020 at 10:25 AM with Staff B, Licensed Practical Nurse, she stated, I know that all medications should be labeled when they are opened. I can't tell you why the Latanoprost eye drops aren't in the refrigerator, they should be until they get opened. During an interview on March 2, 2020 at 10:50 AM with Staff C, LPN she stated, All medications should be labeled when they are opened. I'm not really sure why they don't have that and all medications that are labeled refrigerate until opened should remain in the refrigerator until they are opened. During an interview on March 2.2020 at 11:15 with Staff D, LPN, he stated, The unopened bottle of eye drops should have been put in the refrigerator, I'm not sure why it is on the cart. All medications should be labeled with the date they were opened and an expiration date if they need one. I'm not sure why these eye drops don't have the day they were opened. During an interview with the DON on March 3, 2020 at 10:00 AM she stated, I expect that all staff will follow the policy and procedures for labeling medications with the date opened and expiration dates. The nurses should be checking the medication carts daily and removing any expired medications. Review of Policy and Procedure #5.3, titled Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles with an effective date of December 01, 2007, revision date April 5, 2019 was reviewed and read: 4. Facility should ensure that medications and biologicals that (1) have an expiration date on the label, (2) have been retained longer than recommended by the manufacturer/supplier guidelines or (3) have been contaminated or deteriorated are stored separate from other medications until destroyed or returned to pharmacy or supplier. 5. Once any medication or biological package is opened, Facility should follow manufacturers/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. 11. Facility should ensure that the medications and biologicals are stored at their appropriate temperatures according to the United States Pharmacopeia guidelines for temperature ranges. Facility staff should monitor the temperatures of vaccines twice a day. 11.1 Room Temperature: 59 degrees to 77 degrees Fahrenheit. 11.2 Refrigeration: 36 degrees to 46 degrees Fahrenheit. 17. Facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with Pharmacy return/destruction guidelines and applicable law. 18. Facility personnel should inspect nursing station storage area for proper storage compliance on a regularly scheduled basis. Review of Policy #6.0 titled, General Dose Preparation and Medication Administration with an effective date December 1, 2007 revision date January 1, 2013 was reviewed and read: 3.9 Facility staff should not leave medications or chemicals unattended. 3.11 Facility staff should enter the date opened on the label of the medications with shortened expiration dates (e.g., insulins, irrigation solutions etc.). 3.11.1 Facility staff may record the expiration date based on date opened on the label of the medications with shortened expiration dates. 4. Prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: 4.1 Facility staff should: 4.1.3 Check the expiration date on the medication. 5. During medication administration, facility staff should take all measures required by facility policy and applicable law, including but not limited to the following: 5.9 Observe the resident's consumption of the medications.

Based on interview and record review, the facility failed to ensure the accurate completion of the Quarterly Comprehensive Assessment related to falls for 1 of 4 residents review for falls, Resident #57, in a total sample of 41 residents. Findings: A review of the Minimum Data Set (MDS) Quarterly Comprehensive assessment dated [DATE] for Resident #57 revealed the resident is rarely/never understood and has had one fall since the prior assessment. A review of the clinical record for Resident #57 revealed a nursing progress note dated 1/25/2020 that read: 21:11 (9:11 PM) Behavior note: Patient was found on mat on floor next to bed. Bed was in low position, no injuries noted. Patient shows no signs/symptoms of distress. Patient was assisted back to bed. A review of the clinical record for Resident #57 revealed no Fall Assessment following fall on 1/25/2020. An interview was conducted with the Staff E, Licensed Practical Nurse (LPN), MDS (Minimum Data Set) Assistant on 3/4/20 at 9:19 AM. She stated there were no falls reported in risk management. She stated she did not read the progress note on 1/25/2020 about the fall. The assessment dated [DATE] did not reflect the fall on 1/25/20