Every finding on record at Logan Center

Based on record review and staff interviews, the facility failed to provide food in the correct consistency per physician orders and resident's individual needs for Resident # 168 resulting in a choking incident requiring emergency response and hospitalization. This created an immediate jeopardy situation. This failed practice had the potential to affect more than a limited number of residents. The facility had corrected this situation that began on 12/04/24 on 12/09/24. This issue is cited at past noncompliance. Resident identifiers: #168, #33, #51, #22, #25, #47, #39, #35, and #59. Facility Census: 63. Findings included: a) Resident #168 Review of a Facility Reported Incident (FRI) documentation revealed Resident #168 had a choking episode on 12/04/24. The resident was transferred to an acute care facility and admitted . The resident was hospitalized from [DATE] to 12/11/24. It was reported that the resident was served broccoli that was not chopped. According to the FRI, the resident indicated and gestured he was choking and staff immediately administered Heimlich technique and was able to clear his airway. A statement from a visitor stated, she assisted staff lower the patient to the floor and stated, Patient was choking on broccoli. I put my hands on his throat and felt something and pulled out a chunk of broccoli. The resident was ordered a Dysphagia Advanced texture diet by the physician. According to the facility's Diet and Nutrition Care Manual, Foods that are difficult to chew are chopped, ground, shredded, cooked, or altered to make them easier to chew and swallow. The corporate recipe for broccoli florets stated, Dys. Adv.: Prepare per recipe. Remove needed portions. Transfer to food processor, chop to pea-size pieces. Resident #168's tray card for 12/04/2024 stated Broccoli Florets, Chop. A written statement form [NAME] # 67 on 12/05/2024 stated, If we get suspended then everybody in dietary needs to be suspended bc we never was told to chop broccoli up. In the report the Dietary Manager said she had given him broccoli not chopped bc (because) its usually overcooked. On 06/09/2025 at 7:55 PM, when the surveyor asked who was ultimately responsible for ensuring correct diets are delivered, the Administrator stated, Staff doing the meal .cook and aide check each meal that goes out. Aide reads diet order as they plate it. The facility's Meal Distribution Plan stated, 4. The nursing staff will be responsible for verifying meal accuracy and timely delivery of meals to residents/patients. The facility's plan of correction included: An audit by the Director of Nursing (DON) conducted on 12/05/24 for all residents to ensure diet orders are correct and accurate. - completed. - DON/designees will conduct an observation round on 12/05/24 for all residents to ensure the correct diet is being served. - completed. - Re-education to all staff beginning on 12/04/24 to ensure diet orders are followed and the correct diet is being served with a post-test to validate understanding. - completed 12/09/24. - The Dietary Manager will monitor starting 12/05/24 to ensure diets are correctly served during meal service across all meals for 2 (two) weeks including weekends and holidays, the 5 (five) times a week for 4 (four) weeks, then 3 (three) times a week for 4 (four) weeks the randomly thereafter. Audit was completed 02/13/25, then continued randomly through last documented date during the survey (06/09/25). - Results of monitors will be reported by the DON/designee monthly to the Quality Improvement Committee. On 06/08/25 at 12:17 PM, during the dining observation, the food served to following resident's matched their tray cards: Residents # 33, # 51, #22, #2, #25, #47, #39, #35, and #59. On 06/10/25 at 11:30 AM, the kitchen tray line was observed for all halls. Good communication between all dietary staff members to ensure the correct meals were served was exhibited. The resident's diets were called out to the cook and two errors were caught before the tray was placed on the cart to be transported and served to the residents.

Based on observation, record review and staff interviews, the facility failed to ensure safe operating essential equipment for the facility's ice machine and Resident 21's bed. Resident identifier: #21. Facility census: 63. Findings: a) On 06/08/25 at approximately 3:48 p.m., an observation of the ice machine located in the dining area revealed the drainage line coming from the ice machine goes directly into the floor drain. On 06/08/25 at approximately 3:53 p.m., an interview with the facility's Maintenance Director and Regional Maintenance Director verified this finding. This finding was also acknowledged with the facility Administrator upon exit on 06/11/25 at approximately 1:00 p.m. b) Resident #21 On 06/09/25 at approximately 3:29 p.m., a record review of Resident #21 revealed a progress note dated 02/27/24 by Employee #21. The note revealed that the resident's bed had been dysfunctional for 3 days after witnessing Resident #21 fall on 02/27/24. On 06/09/25 at approximately 4:09 p.m., an interview with the facility Administrator verified that Resident #21's bed was malfunctioning and Employee #21 did not remove the malfunctioning bed out of service on 02/24/24. This finding was also acknowledged by the Administrator upon exit on 06/11/25 at approximately 1:00 p.m.

Based on record review and staff interview, the facility failed to develop a care plan in the area of fall prevention for Resident #42. Resident identifier: #42 Facility census: 63. Findings include: a) Resident #42 Resident #42 had a fall on 04/17/25. Resident #42 was assessed with bruising to forehead, ankle and knee. X-rays were ordered for the ankle and knee and neuro checks were ordered. Resident was sent to the local ER on [DATE] and was diagnosed with cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery. Resident #42's medical record revealed a fall risk evaluation was performed on 03/12/25 and a care plan review started on 03/7/25. Fall risks were identified as a focus area, goals were to have no falls with major injury and minor injury. However, the Interventions were Encourage resident to consume all fluids during meals. Observe for and report signs and symptoms of nausea/vomiting, and observe for changes in medical status, pain status, mental status and medication side effects. This finding was verified by Employee #45 on 06/09/25 at approximately 4:50 p.m. On 06/09/25 at approximately 4:38 p.m., a record review for Resident #42 revealed the resident's care plan dated 03/7/25 showed the resident was identified for falls risk as a focus area with goals were to have no falls with major injury and minor injury. The Interventions listed in the care plan were Encourage resident to consume all fluids during meals. Observe for and report signs and symptoms of nausea/vomiting, and observe for changes in medical status, pain status, mental status and medication side effects. On 06/09/25 at approximately 4;40 p.m., an interview with Employee # 45 verified this finding. This finding was also acknowledged by the Administrator on 06/11/25 at approximately 1:00 p.m.

Based on record review and staff interview, the facility failed to report alleged physical abuse to the proper state agencies within the required two (2) hour timeframe. This is true for one (1) of seven (7) residents reviewed under the care area of abuse. Resident identifier: #32. Facility Census: 63. Findings include: a) Resident #32 On 06/09/25 at 1:00 PM, a review of the facility policy entitled, Abuse Prohibition was completed. The review found in section 7.2 of the facility policy states, Report allegations involving abuse (physical, verbal, sexual, mental) not later than 2 hours after the allegation is made. On 06/09/25 at 11:21 AM, a facility-reported incident (FRI) dated 03/05/25 regarding an allegation of physical abuse on 03/04/25 was reviewed. The review found the alleged physical abuse was not reported to the proper state agencies within the required two (2) hour time frame. The alleged incident took place on 03/04/25 at 10:45 PM; and was not reported until 03/05/25 at 9:15 AM. The timeframe from the alleged event to the time of reporting was 10 and 1/2 hours. On 06/10/25 at 3:30 PM, an interview was held with the Administrator. The Administrator stated, both NAs are no longer employed here .for poor work performance and a hostile work environment. I did not substantiate the abuse due to the NA who reported the incident recanted her statement. The Administrator further stated, I am aware the allegation was not reported within the two (2) hour timeframe .I did education with the NA who did not report the alleged incident to the nurse in a timely fashion.

Based on record review and staff interview, the facility failed to be free from accidents/hazards by leaving Resident #21 in a broken bed. Resident identifier #21. Facility census 63. Findings include: a) On 06/09/25 at approximately 3:29 p.m., a record review for Resident #21 revealed a progress note dated 02/27/24 by Employee #21. The note reflected that the resident's bed had been dysfunctional for 3 days after witnessing Resident #21 fall on 02/27/24. On 06/09/25 at approximately 4:09 p.m., an interview with the facility Administrator verified that Resident # 21 bed was malfunctioning and employee #21 did not remove the malfunctioning bed out of service on 02/24/24. This finding was also acknowledged by the Administrator upon exit on 06/11/25 at approximately 1:00 p.m.

Based on resident interview, record review and staff interview the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice and the resident's choices, related to pain management. Resident #12 complained his medication was administered late frequently which caused him to suffer unnecessarily. This demonstrates actual physical harm for Resident #12. This was true for one (1) of three (3) reviewed for the care area of Pain. Resident identifier: Resident #12. Facility Census: 65. Findings included: a) Resident #12 During an interview on 9/25/23 at 12:09 PM, Resident #12 stated, I can't get my medications when needed. I am supposed to take my medicine before bedtime, but it is closer to midnight before I receive them. During an interview, on 09/25/23 at 2:31 PM, the Director of Nursing (DON) stated, (Resident #12's name) has been on comfort measures since admission on 05/16/23. During a record review on 09/25/23 at 3:00 PM, Resident #12's medical records found a diagnosis of Malignant Neoplasm of Unspecified Part of the Unspecified Bronchus or Lung and Secondary Malignant Neoplasm of Brain. During a record review, on 09/25/23 at 7:26 PM, of Resident #12's medical record found the following pain management orders: -08/01/23 Morphine Sulfate ER Oral Tablet Extended Release 30 MG. Give 1 tablet by mouth every 12 hours for pain. -05/12/23 Tylenol Tablet Give 500 mg by mouth every 4 hours as needed for Pain. During a review on 09/26/23 at 8:30 AM, of Resident #12's medication administration Audit report revealed Morphine Sulfate ER(extended relief) Oral Tablet 30 was administered more than (1) one hour after scheduled times of 9:00 AM and 9:00 PM on the following dates: -09/25/23 was administered at 10:53 AM -09/25/23 was administered at 10:20 PM -09/23/23 was administered at 10:21 AM -09/23/23 was administered at 10:40 PM -09/22/23 was administered at 12:17 AM -09/21/23 was administered at 10:28 PM -09/19/23 was administered at 11:52 AM -09/19/23 was administered at 10:16 PM -09/17/23 was administered at 10:23 AM -09/16/23 was administered at 10:32 AM -09/14/23 was administered at 10:14 PM -09/13/23 was administered at 10:15 PM -09/12/23 was administered at 10:56 AM -09/09/23 was administered at 10:55 AM -09/08/23 was administered at 11:40 PM -09/07/23 was administered at 10:32 AM -09/07/23 was administered at 10:45 PM -09/06/23 was administered at 10:09 PM -09/03/23 was administered at 11:15 PM -09/02/23 was administered at 11:48 PM -09/01/23 was administered at 10:25 AM -09/01/23 was administered at 11:12 PM During an interview, on 09/26/23 at 9:00 AM, Resident #12 stated, I am in a lot of pain. My legs and back are hurting. It ' s 9:00 now, I should have gotten my medication. I think they need to increase my pain medicine. I am in a lot of pain sometimes and then having to wait for medication, that makes it worse. On 09/26/23 at 9:35 AM, the DON was informed of Resident #12's pain and not receiving his pain medication timely. The DON confirmed medication should not be administered more than one (1) hour past the scheduled time. The DON acknowledged Resident #12's Morphine Sulfate 30 mg was more than one (1) hour late multiple times in the month of September. During an interview, on 09/26/23 at 9:39 AM, the Administrator acknowledged that Resident #12's medication was administered incorrectly.

Based on observations and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections with regards to Resident handwashing and to maintain a separation between the clean and soiled area of the laundry room to prevent contamination by airflow. This practice had the potential to affect more than an isolated number of residents. Facility census: 64. Findings included: a) Dining Room An observation during dining, on 08/07/23 at 12:44 PM, revealed the residents in the dining room, did not receive hand hygiene prior to or during the lunch meal tray pass. A second observation on 08/08/23 at 11:40 AM through 12:30 PM found no hand hygiene was offered prior to the noon meal. During an interview, on 08/08/23 at 12:18, with Nurse Aide (NA) #29 verified no hand hygiene was completed prior to the meal service. She stated that they usually use hand wipes for the residents. She stated that she would go get them now. b) Laundry An observation of the laundry area, on 08/08/23 at 9:35 AM, revealed the door between the soiled laundry area and the clean area did not have a separation to prevent air flow from the soiled to the clean side. The door separating the two areas was ajar, and air flow was noted into the clean side of the room from the soiled side where linens were being washed. There was no evidence of a ventilation fan running to pull the airflow away from the clean side of the room. An interview, with Laundry/Housekeeper #39, on 08/08/23 at 9:35 AM, verified the door was not sealed, due to being left ajar, which allowed air to flow from the soiled area of the laundry room into the clean area of the laundry room. Staff were observed to be folding clean clothes/linens from the dryer and clean clothing was present. Laundry/Housekeeper #39, stated further, during the interview, on 08/08/23 at 9:35 AM, that there was no ventilation fan running in the soiled area to pull the airflow away from the clean side of the laundry room. An interview, with the Administrator, on 08/08/23 at 11:08 AM, verified there was a problem with the door not closing and confirmed the door should close between the soiled and clean areas of the laundry room to prevent cross contamination.

Based on observation and staff interview, the facility failed to implement an ongoing activity program designed to meet the interests of and support the well-being of each resident specifically premeal activities not being provided. This was a random opportunity for discovery. Facility census: 64. Findings included: a) Dining observations An observation of Dining Room meal service on 08/07/23 from 11:42 AM to 12:15 PM, found 25 residents sitting with dining room waiting for their noon meal, six (6) residents appear to be sleeping . No Pre meal activities were provided. A second observation of the dining room on 08/08/23 from 11:35 AM to 12:30 PM, found 27 Resident's sitting around the room with no premeal activities being provided. During an interview on 08/08/23 at 1:27 PM with the Administrator confirmed staff should be present in the dining room providing premeal activities, such as soft music, television, or socialization.

Based on Quality Assurance Performance Improvement (QAPI) attendance sheets and staff interview, it was determined that the facility failed to ensure the required QAPI meetings were held, and all required QAPI committee members were in attendance. This deficient practice had the potential to affect more than an isolated number of residents in the facility. Facility census: 64. Findings included: Review of the QAPI attendance sheets found no evidence meetings were held the last two (2) quarters of 2022 (July, August, September-3rd quarter and October, November, and December 2022- 4th quarter) found no sign in sheets and/or minutes. Additionally, the Infection Preventionist (IP) failed to attend the QAPI meetings on 02/23/23 and 03/23/23. On 08/08/23 at 2:55 PM in an interview the administrator confirmed the QAPI meetings and minutes had disappeared, and there was no evidence of meetings held in 2022. She also confirmed the IP had not attended the meeting on the above-mentioned dates.

Based on observation, record review, staff interview and resident interview, the facility failed to provide dialysis services consistent with professional standards of care. This was true for one (1) of one (1) resident reviewed under the care area of dialysis. Resident identifier: #35. Facility census: 64. Findings included: a) Resident #35 1. Hemostats On 08/07/23 at 12:40 PM, a record review was completed for Resident #35. The review found a physician's order stating, keep hemostats to head of bed and chair at all times d/t (due to) dialysis port. (Typed as written.) The resident has a right upper chest port implanted for hemodialysis. The hemostats are kept close to the resident in case of any bleeding from the dialysis port. On 08/08/23 at 1:38 PM, an interview with Resident #35 was completed regarding the hemostats' location. Resident #35 stated, they keep them on the cart .they aren't normally in here. On 08/08/23 at 1:44 PM, Registered Nurse (RN) #9 stated, We keep them on the wall above his bed. Upon entering Resident #35's room, RN #9 stated, Where are they? I keep them right here while pointing at the wall. On 08/08/23 at 1:45 PM, RN #9 stated, They aren't here .I'll get some right now. 2. Dialysis Communication Book On 08/09/23 at 8:15 AM, the dialysis communication book was reviewed. The dialysis communication book was found to be incomplete on the following dates: --07/24/23 missing center nurse name and indication of new orders --07/19/23 missing date of facility nurse's signature --07/14/23 pre- and post-dialysis weights --07/03/23 pre- and post-dialysis weights --06/26/23 post dialysis weight --06/23/23 pre- and post-dialysis weights --05/24/23 pre- and post-dialysis weights --05/22/23 post dialysis weight --05/19/23 post dialysis weight --04/28/23 post dialysis weight --04/26/23 pre- and post-weights, receiving facility nurse's signature and date --04/24/23 pre- and post-dialysis weights and indication of new orders --04/21/23 pre- and post-dialysis weights, center nurse's signature --03/28/23 post dialysis weight --03/18/23 pre- and post-weights --02/28/23 post dialysis weight and indication of new orders --02/21/23 pre- and post-weights --02/14/23 post dialysis weight On 08/09/23 at 8:30 AM, the Administrator was notified regarding the missing hemostats and the incomplete dialysis communication book. The Administrator stated, I know how important these things are .this will be corrected.

Based on observation, and staff interview the facility failed to treat each resident with respect and dignity regarding meal service. This was a random opportunity for discovery. Facility census: 64. Findings included: a) Dining Room During an observation of meal services on 08/07/23 from 12:01 PM through tray pass revealed Resident's in the dining room seated together did not received their trays at the same time. A second dining observation of meal services on 08/08/23 from 12:01 PM through tray pass revealed Resident's in the dining room seated together did not received their trays at the same time. During an interview on 08/08/23 at 12:25PM the Dietary Account Manager #83 verified that the Residents seated together should be served at the same time.

Based on record review and staff interview, the facility failed to notify the Ombudsman of a resident's transfer to the hospital. This deficient practice had the potential to affect one (1) of two (2) residents reviewed for the care area of hospitalization . Resident identifier: #33. Facility census: 64. Findings included: a) Resident #33 Review of Resident #33's medical records showed in the last 120 days the resident was transferred to the hospital on 04/17/23 and 04/24/23. On 08/08/23 at 11:12 AM, the Administrator provided a report of discharges from the facility for the dates 03/16/23 to 06/11/23 and provided evidence the information was provided to the Ombudsman on 06/12/23. Resident #33's transfers to the hospital on 04/17/23 and 04/23/23 were not on the report. The Administrator confirmed the Ombudsman was not notified regarding Resident #33's transfers to the hospital on 04/17/23 and 04/23/23. No further information was provided through the completion of the survey.

Based on record review and staff interview, the facility failed to have a complete and accurate Minimum Data Set (MDS) in the care area of restraints and antipsychotic medication. Resident identifier: Resident # 24, and #50. Facility census 64. Findings included: a) Resident #24 A review of the medical record for Resident #24 discovered there was an order for a Merry [NAME] to be used, dated 06/26/23. A review of the MDS found nothing was marked for Restraints. During an interview on 08/08/23 at 2:29 PM, with Clinical Care Reimbursement (CCR) #1 agreed the use of a Merry walker was not on the MDS and should have been added. On 08/09/23 at 8:45 AM the Administrator made aware of the information above. b) Resident #50 Review of Resident #50's medical records showed the resident had been receiving the antipsychotic medication aripiprazole (Abilify) since returning to the facility from the hospital on 07/19/23. Resident #50's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 07/24/23 showed the resident had not received any antipsychotic medication in the seven (7) day look-back period. During an interview on 08/08/23 at 2:44 PM, Clinical Care Reimbursement Nurse #1 confirmed Resident #50's MDS with ARD 07/24/23 was incorrect and should have coded the resident received antipsychotic medication. No further information was provided through the completion of the survey.

Based on record review and staff interview, the facility failed to ensure a resident's comprehensive care plan was revised when there was a change in the resident's plan of care. This deficient practice had the potential to affect one (1) of one (1) residents reviewed for the care area of transmission-based precautions. Resident identifier: #33. Facility census: 64. Findings included: a) Resident #33 Upon observation on 08/07/23 at 11:30 AM, Resident #33 had a sign on the room of his door for Enhanced Barrier Precautions. Review of Resident #33's medical records showed the resident had a history of Methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) infections. Review of Resident #33's comprehensive care plan showed a focus related to the resident's history multi-drug resistance organism infections VRE and MRSA. However, an intervention for Enhanced Barrier Precautions was not included on the care plan. On 08/08/23 at 12:32 PM, the Assistant Director of Nursing confirmed Resident #33 was not care planned for Enhanced Barrier Precautions. No further information was provided through the completion of the survey.

Based on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. The facility failed to obtain laboratory testing in accordance with physician's orders for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #50. Facility census: 64. Findings included: a) Resident #50 Review of Resident #50's physician's orders showed an order written on 07/18/23 to obtain complete blood cell (CBC) laboratory testing every seven (7) days for four (4) weeks from 07/19/23 to 08/16/23. Review of Resident #50's laboratory results showed CBC results for 07/19/23 and 08/07/23. Further review of Resident #50's medical records showed an order written on 07/18/23 to obtain magnesium level laboratory testing every week, beginning 07/26/23. Review of Resident #50's laboratory results showed the resident's last magnesium level testing was on 07/19/23. During an interview on 08/09/23 at 8:00 AM, the Administrator confirmed Resident #50's CBC and magnesium testing were not obtained in accordance with the physician's orders. The Administrator was unable to provide additional CBC results or additional magnesium level testing. No further information was provided through the completion of the survey.

Based on review of the Centers for Disease Control (CDC) Adult Immunization Schedule, record review, and staff interview, the facility failed to ensure all eligible residents were offered and/or given the Pneumonia vaccine. This was true for one (1) of five (5) residents reviewed for immunizations. Resident identifier: #15. Facility census: 64. Findings included: CDC Adult Immunization Schedule review revealed the following: Previously received both PCV13 and PPSV23 but NO PPSV23 was received at age [AGE] years or older: 1 dose PCV20 at least 5 years after their last pneumococcal vaccine dose OR complete the recommended PPSV23 series as described here: Previously received both PCV13 and PPSV23, AND PPSV23 was received at age [AGE] years or older: Based on shared clinical decision-making, 1 dose of PCV20 at least 5 years after the last pneumococcal vaccine dose. a) Resident #15 During a medical record review found Resident #15 was (age) at the time of this survey. Resident #15's immunization record revealed the following information: Resident received two (2) doses of Pneumovax, the last one being given on 04/02/13, Prevnar (PCV)13 was last given on 07/19/16. On 08/08/23 at 3:47 PM, an interview with the Infection Preventionist (IP) stated that Resident #15 was eligible for the PCV 20, but she failed to offer. IP said the PCV 20 was just released. On 01/2023 the U.S. FDA recommended the use of PCV 20.

Based on facility documentation of reportable occurrences review, and staff interview, the facility failed to ensure that all alleged violations of abuse, were reported immediately, and failed to ensure the results of an investigation was reported within five (5) working days of the occurrence, to all officials (including to the State Survey Agency and Adult Protective Services (APS), where state law provides for jurisdiction in long-term care facilities) in accordance with State law, through established procedures. This deficient practice was found true for two (2) of four (4) residents reviewed. An allegation of abuse, the staff had knowledge of, was not reported in a timely manner involving Resident #58. The results, of a five (5) day investigation, were not reported in a timely manner involving Resident #36. Resident identifiers: Resident #58 and #36. Census: 66. Findings included: a) Policy Review Review of the policy and procedure, OPS300 for Abuse Prohibition, revision date of 10/24/22, showed, under Federal Definitions, verbal abuse was defined as any use of oral, written or gestured language, which included disparaging and derogatory terms to patients or families, or within their hearing distance, regardless of their age, ability to comprehend or disability. Under 6.1 of OPS300 for Abuse Prohibition Policy, revision date of 10/24/22, addressed all staff will identify events of suspected abuse, neglect, and report the incident to the supervisor immediately regardless of the shift worked. Under 6.1.1 of OPS300 for Abuse Prohibition Policy, revision date of 10/24/22, showed the supervisor will report the suspected abuse immediately to the Administrator or designee and other officials in accordance with state law. Under section 9.2 of OPS300 for Abuse Prohibition Policy, revision date of 10/24/22 all findings of a completed investigation would be reported to the State agency within 5 working days. b) Resident #58 A review of the Reportable Occurrence File, a statement from Nursing Assistant (NA #56) provided a written statement, during an investigation conducted on 03/20/23, which showed NA #56 had witnessed an occurrence of verbal abuse involving Resident #58. NA #56 provided a written statement, which showed on 03/18/23 at 08:30 PM, this nursing assistant was walking up 200 Hall where Licensed Practical Nurse (LPN #30) and the resident were being pretty loud. NA #56 went on to describe the situation, documenting NA #56 heard LPN #30 state if I had your miserable life (with hand gesture toward the resident), I would hate everyone too. At this time, it was documented Resident #58 requested the nurse to leave the room in which the nurse replied, I don't have to get out of your room I am in charge. It was recorded the resident had stated something would be thrown at the nurse in which it was written, if you throw it at me, I will throw it at your head. An additional written statement, provided by LPN #31, showed this LPN had witnessed the same remark being made to Resident #58, on the 03/18/23 date. LPN #31 documented she had heard the other nurse ask the resident Are you so miserable that you have to cuss at everyone who walks by your door? and added at this time, the resident told the nurse to get out of the room. Further review of the Reportable Occurrence File, noted a written note, dated 03/20/23, and signed by the Director of Nursing (DON), showing between the hours of 12 PM and 01:00 PM, the administrator had informed the DON, Resident #58 had requested to speak to the DON. The note showed Resident #58 telling the DON that LPN #30 had been in her room on Saturday and had hurt her feelings. The resident stated to the DON, LPN #30 had told her If I had to live this miserable life, I would hate everyone too. and told the DON, she did not want LPN #30 in the resident's room anymore. Based on review of reportable incident timelines, the facility reported the allegation of abuse on 03/20/23 at 13:16, when the facility staff had witnessed the occurrence on 03/18/23 at 08:30 PM, failing to meet the reporting time for abuse to be reported within two (2) hours. An interview, with the DON and Administrator, on 04/25/23 at 12:36 PM, revealed both the Administrator and DON confirmed all staff are mandatory reporters and the incident should have been reported immediately when staff witnessed the interaction and was not. Additionally, it was revealed the allegation of abuse was not reported to State Officials until brought to their attention by the resident on 03/20/23, two days after the incident had taken place. c) Resident #36 A review of the Reportable Occurrence File, revealed an allegation of abuse occurring on 11/21/23. Further review of the allegation showed when the allegation had been investigated, there was no evidence the results of the investigation had been sent to the State officials in accordance with State law. An interview, on 04/25/23 at 01:41 PM, with the Social Service Specialist, the Administrator and DON, revealed there was no evidence to show the facility sent the results of the five (5) day follow-up to APS or the State survey agency and confirmed the five (5) day follow- up should have been sent as part of the Abuse Prohibition policy.

Based on record review, review of facility documentation of reportable incidents, and staff interview, the facility failed to ensure evidence, in the response to allegations of abuse, that all alleged violations were thoroughly investigated for one (1) of three (3) resident's allegations of abuse reviewed. In addition, the facility failed to protect the resident after the allegation was identified to prevent further abuse from occurring. This deficient practice was identified for Resident #58, who was identified as having a witnessed verbal abuse; however, facility staff failed to protect the resident until a thorough investigation could be completed and failed to substantiate the allegation of abuse when there were witness statements confirming the allegation did occur. Resident identifier: Resident #58. Census: 66. Findings included: a) Policy review Review of the policy and procedure, OPS300 for Abuse Prohibition, revision date of 10/24/22, showed, under Federal Definitions, verbal abuse was defined as any use of oral, written or gestured language, which included disparaging and derogatory terms to patients or families, or within their hearing distance, regardless of their age, ability to comprehend or disability. Under 6.1 of OPS300 for Abuse Prohibition Policy, revision date of 10/24/22, addressed all staff will identify events of suspected abuse, neglect, and report the incident to the supervisor immediately regardless of the shift worked. Under 6.1.2 of OPS300 for Abuse Prohibition Policy, revision date of 10/24/22, noted the employee alleged to have committed the act of abuse will be immediately removed from duty, pending investigation. b) Resident #58 A review of the Reportable Occurrence File, a statement from Nursing Assistant (NA #56) provided a written statement, during an investigation conducted on 03/20/23, which showed NA #56 had witnessed an occurrence of verbal abuse involving Resident #58. NA #56 provided a written statement, which showed on 03/18/23 at 08:30 PM, this nursing assistant was walking up 200 Hall where Licensed Practical Nurse (LPN #30) and the resident were being pretty loud. NA #56 went on to describe the situation, documenting NA #56 heard LPN #30 state if I had your miserable life (with hand gesture toward the resident), I would hate everyone too. At this time, it was documented Resident #58 requested the nurse to leave the room in which the nurse replied, I don't have to get out of your room I am in charge. It was recorded the resident had stated something would be thrown at the nurse in which it was written, if you throw it at me, I will throw it at your head. An additional written statement, provided by LPN #31, showed this LPN had witnessed the same remark being made to Resident #58, on the 03/18/23 date. LPN #31 documented she had heard the other nurse ask the resident Are you so miserable that you have to cuss at everyone who walks by your door? and added at this time, the resident told the nurse to get out of the room. Further review of the Reportable Occurrence File, noted a written note, dated 03/20/23, and signed by the Director of Nursing (DON), showing between the hours of 12 PM and 01:00 PM, the administrator had informed the DON, Resident #58 had requested to speak to the DON. The note showed Resident #58 telling the DON that LPN #30 had been in her room on Saturday and had hurt her feelings. The resident stated to the DON, LPN #30 had told her If I had to live this miserable life, I would hate everyone too. and told the DON, she did not want LPN #30 in the resident's room anymore. Based on review of reportable incident timelines, the facility reported the allegation of abuse on 03/20/23 at 13:16, when the facility staff had witnessed the occurrence on 03/18/23 at 08:30 PM, failing to meet the reporting time for abuse to be reported within two (2) hours. An interview, with the DON and Administrator, on 04/25/23 at 12:36 PM, revealed the allegation of abuse, witnessed on 03/18/23, was not reported to State Officials until brought to their attention by the resident on 03/20/23, two days after the incident had taken place in which LPN #30 continued to work. The DON confirmed LPN #30 worked the following shift after the witnessed abuse occurred. Further review of the facility's investigation of the 03/18/23 abuse allegation, showed witness statements from four (4) staff members confirming the allegation of verbal abuse to Resident #58 by LPN #30 as follows: -NA #56's statement confirming the staff member heard LPN #30 state If I had to live the miserable live I would hate everyone too and If you want me out, get up and get me out Resident #58 requires extensive or total dependence for activities of daily living (ADLs). -LPN #17's statement verified Resident #58 had revealed to her LPN #30 was mean and had told her she was miserable -LPN #31's statement verified she had heard the other nurse ask the resident Are you so miserable that you have to cuss at everyone who walks by your door? and added at this time, the resident told the nurse to get out of the room. -NA #53's statement showed as this employee was picking up trays, Resident #58 told her LPN #30 was mean to her and would hate to be as miserable as her and verified when the resident told LPN #30 to leave the room, the LPN replied she was in charge and for the resident to get up and make her get out. Review of the Five (5) Day Follow-up Report, under outcome and results of the investigation for the 03/20/23 investigation, showed Based upon statements/interviews with staff, verbal abuse was not substantiated. An interview with the DON, on 04/25/23 at 12:22 PM, when questioned regarding the investigation not being substantiated, in spite of witness statements confirming the verbal abuse did occur, it was stated there had been no other issues with LPN #30 and some people just talk like that and need more education on resident conflict. An interview with the administrator, on 04/25/23 at 12:36 PM, stated any employee that witnessed or had knowledge of abuse were mandatory reporters and should have reported immediately to the supervisor or administration. Further, after review of the investigation, the administrator confirmed the investigation should have been substantiated and the facility failed to suspend LPN #30 immediately after the allegation was witnessed.

Based on review of facility documentation, and staff interview, the facility failed to ensure all nursing staff possessed the competencies and skills necessary to provide nursing and related services to meet the needs of the residents, to promote each resident's rights and mental and psychosocial well-being for one (1) of four (4) residents reviewed. This was true for Resident #58 during the review for an abuse allegation reporting and protection of a resident while an investigation was being conducted. During a witnessed case of verbal abuse, staff failed to provide care in accordance with training and facility policy and procedure for abuse prohibition. This was found to be true for one (1) of four (4) residents reviewed and had the potential to affect more than a limited number of residents. Resident identifier: Resident #58. Census: 66. Findings included: a) Policy review Review of the policy and procedure, OPS300 for Abuse Prohibition, revision date of 10/24/22, showed, under Federal Definitions, verbal abuse was defined as any use of oral, written or gestured language, which included disparaging and derogatory terms to patients or families, or within their hearing distance, regardless of their age, ability to comprehend or disability. Under 6.1 of OPS300 for Abuse Prohibition Policy, revision date of 10/24/22, addressed all staff will identify events of suspected abuse, neglect, and report the incident to the supervisor immediately regardless of the shift worked. Under 6.1.2 of OPS300 for Abuse Prohibition Policy, revision date of 10/24/22, noted the employee alleged to have committed the act of abuse will be immediately removed from duty, pending investigation. b) Resident #58 A review of the Reportable Occurrence File, a statement from Nursing Assistant (NA #56) provided a written statement, during an investigation conducted on 03/20/23, which showed NA #56 had witnessed an occurrence of verbal abuse involving Resident #58. NA #56 provided a written statement, which showed on 03/18/23 at 08:30 PM, this nursing assistant was walking up 200 Hall where Licensed Practical Nurse (LPN #30) and the resident were being pretty loud. NA #56 went on to describe the situation, documenting NA #56 heard LPN #30 state if I had your miserable life (with hand gesture toward the resident), I would hate everyone too. At this time, it was documented Resident #58 requested the nurse to leave the room in which the nurse replied, I don't have to get out of your room I am in charge. It was recorded the resident had stated something would be thrown at the nurse in which it was written, if you throw it at me, I will throw it at your head. An additional written statement, provided by LPN #31, showed this LPN had witnessed the same remark being made to Resident #58, on the 03/18/23 date. LPN #31 documented she had heard the other nurse ask the resident Are you so miserable that you have to cuss at everyone who walks by your door? and added at this time, the resident told the nurse to get out of the room. Further review of the Reportable Occurrence File, noted a written note, dated 03/20/23, and signed by the Director of Nursing (DON), showing between the hours of 12 PM and 01:00 PM, the administrator had informed the DON, Resident #58 had requested to speak to the DON. The note showed Resident #58 telling the DON that LPN #30 had been in her room on Saturday and had hurt her feelings. The resident stated to the DON, LPN #30 had told her If I had to live this miserable life, I would hate everyone too. and told the DON, she did not want LPN #30 in the resident's room anymore. Based on review of reportable incident timelines, the facility reported the allegation of abuse on 03/20/23 at 13:16, when the facility staff had witnessed the occurrence on 03/18/23 at 08:30 PM, failing to meet the reporting time for abuse to be reported within two (2) hours. An interview, with the DON and Administrator, on 04/25/23 at 12:36 PM, revealed the allegation of abuse, witnessed on 03/18/23, was not reported to State Officials until brought to their attention by the resident on 03/20/23, two days after the incident had taken place in which LPN #30 continued to work. The DON confirmed LPN #30 worked the following shift after the witnessed abuse occurred. Further review of the facility's investigation of the 03/18/23 abuse allegation, showed witness statements from four (4) staff members confirming the allegation of verbal abuse to Resident #58 by LPN #30 as follows: -NA #56's statement confirming the staff member heard LPN #30 state If I had to live the miserable live I would hate everyone too and If you want me out, get up and get me out Resident #58 requires extensive or total dependence for activities of daily living (ADLs). -LPN #17's statement verified Resident #58 had revealed to her LPN #30 was mean and had told her she was miserable -LPN #31's statement verified she had heard the other nurse ask the resident Are you so miserable that you have to cuss at everyone who walks by your door? and added at this time, the resident told the nurse to get out of the room. -NA #53's statement showed as this employee was picking up trays, Resident #58 told her LPN #30 was mean to her and would hate to be as miserable as her and verified when the resident told LPN #30 to leave the room, the LPN replied she was in charge and for the resident to get up and make her get out. Review of the Five (5) Day Follow-up Report, under outcome and results of the investigation for the 03/20/23 investigation, showed Based upon statements/interviews with staff, verbal abuse was not substantiated. An interview with the DON, on 04/25/23 at 12:22 PM, when questioned regarding the investigation not being substantiated, in spite of witness statements confirming the verbal abuse did occur, it was stated there had been no other issues with LPN #30 and some people just talk like that and need more education on resident conflict. An interview with the administrator, on 04/25/23 at 12:36 PM, stated any employee that witnessed or had knowledge of abuse were mandatory reporters and should have reported immediately to the supervisor or administration. Further, after review of the investigation, the administrator confirmed the investigation should have been substantiated and the facility failed to suspend LPN #30 immediately after the allegation was witnessed.

Based on medical record review and staff interview, the facility failed to ensure resident's Physician's Order for Scope of Treatment (POST) forms conveying end-of-life wishes were complete. This deficient practice was found for two (2) of 20 POST forms reviewed for the area of advanced directives during the Long-Term Care Survey Process. The POST forms for Resident #13 and #1 did not specify how long intravenous fluids were to be administered. Resident identifier: #13 and #1. Facility census: 66 Findings included: a) Resident #13 A medical record review of Resident #13's record on 04/04/22, revealed Section C of the POST completed on 06/05/20 did not specify how long intravenous fluids were to be administered. In an interview with the Social Service Director on 04/04/20 at 2:10 PM, they verified Section C did not specify how long intravenous fluids were to be administered. b) Resident #1 On 04/04/22 at 2:03 PM a record review for Resident #1 found the Physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This section was not completed in its entirety and did not specify a length of time for the use of IV fluids. This was confirmed with the Director of Nursing on 04/05/22 at 12:46 PM.

Based on record review, staff interview, Center for Disease Control and Prevention (CDC), Facility Policy, and observation,` the facility has failed to ensure and establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to store clean linens in a safe, clean and sanitary manner. Furthermore, the facility failed to appropriately place Residents #59 and #28, diagnosed with [REDACTED]. In addition, the facility failed to have PPE equipment readily available for staff. Resident #59 currently has a active [DIAGNOSES REDACTED]. There were not any signs on the door to alert staff or visitors of the type of precautions to use. Resident #28 was diagnosed with [REDACTED]. He also has multiple open non-healing wounds, Foley catheter, [MEDICAL CONDITION] bag, and a feeding tube. Staff did not use PPEs when providing care. These failed practices had the potential to affect more than a limited number residents at risk for serious harm and/or death resulting in a determination of an Immediate Jeopardy situation. --The facility was notified of the Immediate Jeopardy on 09/25/19 at 3:40 PM. --The facility submitted their plan of correction (P[NAME]) at 6:40 PM. --The State Agency requested changes at 6:48 PM on 09/25/19. --The facility submitted the second P[NAME] at 7:52 PM on 09/25/19. --The State Agency requested changes on 09/25/19 at 7:59 PM. --The facility submitted the third P[NAME] at 8:03 PM on 09/25/19 and their P[NAME] was accepted by the State Agency at 8:10 PM on 09/25/19. --Implementation of the abatement components of the P[NAME] was observed by the state agency at 9:10 AM on 09/26/19 and the immediacy of the situation was abated. An observation for abatement plan implementation on 09/26/19 at 9:00 AM, revealed that the following rooms had a sign on the door to see nurse before entering the room and an isolation cart by the door. room [ROOM NUMBER] Resident #59, room, 200 Resident #28, room [ROOM NUMBER] and 101 for questionable signs and symptoms of urinary infection. Staff was observed using PPE before entering the rooms. Record review for abatement plan implementation found a complete list of staff who have been re-educated about MDRO and Contact Precautions provided by the Infection Control Nurse (ICN) on 09/26/19 at 9:10 AM. After abatement of the immediate jeopardy at 9:10 AM on 09/26/19 the scope and severity of the deficiency was lowered to an E. This had the potential to affect more than a limited number of residents. Facility census 64. Findings included: a) Resident #59 1. CDC guidelines The CDC states the following concerning CRE and contact precautions (units of skilled nursing facilities, rehabilitation facilities), the use of Contact Precautions is more challenging and should be guided by the potential risk: --Contact Precautions (CP) that residents will serve as a source for additional transmission based on their functional and clinical status and the type of care activity that is being performed. For example, Contact Precautions should be considered for residents colonized or infected with CRE, particularly CP-CRE, who are ventilator-dependent (even if not in a ventilator unit), are incontinent of stool that is difficult to contain, have draining secretions or draining wounds that cannot be controlled. --Masks are not recommended for routine use to prevent transmission of MDROs from patients to HCWs. Use masks according to Standard Precautions when performing splash-generating procedures, caring for patients with open tracheostomies with potential for projectile secretions, and when there is evidence for transmission from heavily colonized sources (e.g., burn wounds). --Follow Standard Precautions in all healthcare acute care settings: Implement CP for all patients known to be colonized/infected with target MDROs. --In LTCFs, consider the individual patient's clinical situation and facility resources in deciding whether to implement CP. --Masks are not recommended for routine use to prevent transmission of MDROs from patients to HCWs. --Use masks according to Standard Precautions when performing splash-generating procedures, caring for patients with open tracheostomies with potential for projectile secretions, and when there is evidence for transmission from heavily colonized sources (e.g., burn wounds). --Patient placement in hospitals and LTCFs: When single-patient rooms are available, assign priority for these rooms to patients with known or suspected MDRO colonization or infection. Give highest priority to those patients who have conditions that may facilitate transmission, e.g., uncontained secretions or excretions. When single-patient rooms are not available, cohort patients with the same MDRO in the same room or patient-care area. --When co-horting patients with the same MDRO is not possible, place MDRO patients in rooms with patients who are at low risk for acquisition of MDROs and associated adverse outcomes from infection and are likely to have short lengths of stay. --For other residents with CRE (CP-CRE or non-CP-CRE) who are able to perform hand hygiene, contain their stool and secretions, and are less dependent on HCP for their activities of daily living, use of gowns and gloves should be based on the type of care provided. This consists of using gowns and/or gloves when there is potential for exposure to their fluids or secretions or there is a risk of the healthcare provider contaminating their clothes, etc. Examples of when gowns and/or gloves might be used include the following: bathing residents; assisting residents with toileting; changing residents' briefs; changing a wound dressing; and manipulating patient devices (e.g., urinary catheter). --Gowns and gloves might not be needed if there is minimal potential for cross-contamination from residents or their environment (e.g., setting a tray down in the room, entering the room without contacting the resident or their immediate environment). In addition, residents with CRE at lower risk for transmission (as described above) do not need to be restricted from common gatherings in the facility (e.g., meals, group activities). Further work is needed to define the risk of contamination of HCP hands and clothing with the range of activities performed in these settings. 2. Record Review and Observation Resident #59 currently has a active [DIAGNOSES REDACTED]. He has a Foley catheter and is receiving an antibiotic currently for the urinary tract infection [MEDICAL CONDITION]. He is not on contact precautions for this MDRO to prevent transmission of communicable diseases and infections. 3. Staff Interview On 09/25/19 at 3:00 PM, an interview with Administrator and DoN, stated, It is contained in his catheter and he does not need to be on precautions. They were asked how the staff knew when a resident was in contact precautions. DON stated, the nurses will tell the aides they need to take extra precautions because of the infection and the staff passed the information about the residents in report at change of shift from nurse to nurse and nurse aide to nurse aide. On 09/25/19 at 3:12 PM, the Nurse Aide (NA)#43 (who normally assigned to Resident #59) stated, that she needed to wear a gown when providing care to the resident because he had a super bug right now. When asked where she would get a gown, she stated they are usually right here in a cart, but I don't see them right now. The NA did not indicate any other areas that she could get a gown other than the cart. On 09/25/19 at 3:15 PM, DON was asked where the NA would get a gown from, she stated, we have some back here referring to a room on the 200 hall and the central supply room. When asked where the cart the NA referred to was, she said, these are them. She pointed to carts which were stored in the Central supply room that was in the back of the room with boxes stacked in front of them and the carts were stacked on top of each other. Not accessible for the staff to use. During an interview on 09/25/19 at 3:20 PM, Administrator and Director of Nursing (DoN) were asked about not placing residents in contact precautions for MDROs. The DoN stated, that she did not believe that they have use contact precautions for these residents because it is contained in a catheter. b) Resident #28 1. Record Review and Observation Resident #28 was diagnosed with [REDACTED]. He has multiple open wounds on his coccyx, gluteal folds, and his right foot, feeding tube, Foley catheter, [MEDICAL CONDITION] bag. 2. Staff interview On 09/25/19 at 12:30 PM, Infection Control Nurse (ICN), was asked if Resident #28 was placed in Contact Precautions in (MONTH) when the Urinary culture was positive for ESBL. She stated, No because it is contained in his catheter. She further stated, that the facility had 30 to 35 people in the facility who had MRDOs', and she said, I think that is a lot. She went on to say, The aides know they need to wear gowns when caring for him. She was asked if she monitored the staff to make sure that the staff are wearing gowns while providing care. She said, that she had not, but she is sure they are. According to the facility's Infection Control Monthly Line Listing sheet, Resident #28 has a history of the following: ESBL,[MEDICAL CONDITION], VRE, Acinetobacter baumannii, KPC and open areas. Resident #28 currently shares room with Resident #20 who has no history of having any MRDO's. On 09/25/19 at 8:41 AM, Licensed Practical Nurse (LPN) #17 stated, that Resident # 28 was going to the wound clinic, but in (MONTH) the clinic said, that there was nothing else they could do for him. She cleaned the bedside table, washed her hands, she removed supplies from the treatment cart with the reusable items were placed on the table still inside of the bags with the resident's name on the bag. She proceeded into the room without using any PPE's and provided wound care. An interview with NA #40, (who was assigned to care for Resident #28) on 09/25/19 at 3:15 PM, found she was not aware of him having any infection in which she needed to take extra precautions for. She confirmed she had worked with him in (MONTH) of 2019 and does not recall ever being told that he had a MRDO infection. She went on to say she was not aware if she needed to take extra precautions while providing him care. She stated, everybody has a little bit of something, so we just need to be careful. She confirmed, she did not wear a gown when providing care to this resident and could not recall wearing a gown in (MONTH) when he was actively being treated for [REDACTED]. Even though he has a [DIAGNOSES REDACTED]. During an interview on 09/25/19 at 3:20 PM, Administrator and Director of Nursing (DoN) were asked about not placing residents in contact precautions for MDROs. The DoN stated, that she did not believe that they have use contact precautions for these residents because it is contained in a catheter. She was asked about the opened and draining wounds on Resident #28 and if the staff should be using PPE's while providing care. She stated, that they do when it is indicated. She was informed that the Wound Treatment Nurse and the NA's were observed not using PPE's today. The DoN went on to say, that the nurse aides would not know what MDROs' were, because she does not even know about all of them herself. The catheters do contain the urine, but while emptying and providing care for the resident the urine is no longer contained and there is risk for the staffs clothing, shoes, and etc. coming in contact with the resident's infectious urine and then could be spread throughout the facility. The same for the wounds while they are covered and the drainage is contained, when the wounds are being cleaned and dressing changes the infectious drainage is no longer contained. c) Review of the facility infection control monthly line listing During a review of the infection control monthly line listings through (MONTH) 2019, it was revealed that the following residents were known to have MDROs: 1. 300 Hall: --On 09/16/19 Resident #59 was positive for CRE in his urine, and was facility acquired, and the type of precaution was Standard (S). --On 07/03/19 Resident #266 was positive for CRE in the urine, facility acquired and was placed in standard precautions. --On 06/25/19 Resident #55 was positive for ESBL in the urine, facility acquired, and placed in standard precautions. --On 05/20/19 Resident #46 was positive for VRE in the urine, community acquired, and placed in standard precautions. --On 05/16/19 Resident #22 was positive for ESBL in the urine, facility acquired, and placed in standard precautions. --On 05/09/19 Resident #267 was positive for VRE in the urine, facility acquired, placed in standard precautions. --On 04/29/19 Resident #267 was positive for ESBL in a wound, facility acquired. placed in standard precautions. --On 04/22/19 Resident #266 was positive [MEDICAL CONDITION] in a wound, facility acquired, and placed in standard precautions. --On 04/09/19 Resident #22 was positive for ESBL in the urine, facility acquired. and placed in standard precautions 2. 200 hall: --On 08/13/19 Resident #8 was positive for ESBL in the urine, and was facility acquired, the type of precaution was S. --On 08/04/19 Resident #50 was positive for ESBL and KPC in the urine, and was facility acquired, and placed in standard precautions, --On 08/19/19 Resident #29 was positive for ESBL and KPC in the urine, facility acquired, and placed in standard precautions. --On 07/30/19 Resident #34 was positive [MEDICAL CONDITION] in an abscess, community acquired. and placed in standard precautions. --On 07/19/19 Resident #32 was positive for ESBL in the urine, facility acquired, and placed in standard precaution. --On 07/03/19 Resident #50 was positive for ESBL in the urine, facility acquired, and place in standard precaution. --On 06/03/19 Resident #65 was positive for CRE in the urine, facility acquired, and placed in standard precautions. --On 05/29/19 Resident #65 was positive for CRE in the urine, facility acquired, and placed in standard precautions. --On 05/18/19 Resident #32 was positive for ESBL in the urine, facility acquired, and placed in standard precautions. --On 05/09/19 Resident #27 was positive for ESBL in the urine, facility acquired, and placed in standard precautions. --On 04/16/19 Resident #65 was positive for VRE in the urine, facility acquired, and placed in standard precautions. --On 04/13/19 Resident #16 was positive for ESBL in the urine, facility acquired, and placed in standard precautions. 3. 100 Hall: --On 07/03/19 Resident #28 was positive for ESBL in the urine, facility acquired, placed in standard precautions. d) Administrator Interview During an interview on 09/25/19 at 3:45 PM, Administrator said, that they knew that the infection control was not being done correctly at this time. But they have been waiting on the cooperate office to release the new policies and protocols. . d) Laundry Room Linen Storage The facility failed to store clean linens in a clean and sanitary manner within an area in the laundry room that maintained appropriate infection control standards. On 09/24/19 at 3:24 p.m. during tour of laundry room with Housekeeping Supervisor (HS) #69 observation was made that revealed two (2) clean resident privacy curtains, one (1) pair of resident window curtains, and several clean mop heads hanging in soiled intake laundry room section of laundry. Two (2) bags of dirty linens (kitchen rags and housekeeping rags) were laying in the room on top of a small non-industrial washing machine within the room. HS #69 stated this room was used for sorting Resident linens and washing of housing the kitchen rags and housekeeping rags in the small washing machine. HS #69 agreed the clean linens and mop heads should not be stored in that area of the laundry rooms. During an interview on 09/24/19 at 4:10 p.m. the Administrator stated HS #69 had already informed her of the issue and the clean linens and mop heads are in the process of being laundered and moved into an appropriate clean storage area.

Based on resident interview, record review and staff interview, the facility failed to ensure a resident who is incontinent of urine and bowel was assessed and provided appropriate treatment and services to achieve as much normalcy to bladder/bowel functioning as possible and prevent urinary tract infections. Resident #51 experienced harm due to not receiving the appropriate treatment and services to restore as much bladder/bowel function as possible and prevent urinary tract infections. Resident #51 knew when she needed to go to the bathroom. Resident #51 was unable to take herself to the toilet. She required the use of a sit to stand lift for transfers. Resident #51 had to sit in a wet brief at times and had developed urinary tract infections and a rash on her bottom. Resident #51 would wear a brief to keep clothing dry. The facility had developed a toileting plan but the plan was not implemented. This was true for one 1 of 1 residents reviewed for the care area of bladder and bowel incontinence. Resident identifier: #51. Facility census: 65. Findings included: a) Resident #51 On 09/12/18 at 8:13 AM, the resident said she was only incontinent of urine because no one takes her to the bathroom, timely. I know when I need to go. The resident said she wore a brief to keep her clothing dry. The resident said she drew the line when it came to having a bowel movement in her brief. The resident said she had numerous urinary tract infections (UTI's) because she sat in a wet brief and she had a rash on her bottom. The resident said she was wet and the nursing assistant (NA) was coming to clean her up to get ready for therapy. She said she was last toileted by a night shift NA who came in her room around 4:00 PM She said she did not ask for help when she had to go about a half hour ago because staff were busy passing out trays. The resident said she usually used the bedside commode, which was present in her room. She said she was unable to take herself to the bathroom and staff used a lift to help her get to the bedside commode. She described the lift as a sit to stand lift. Review of the most recent annual minimum data set (MDS), an annual, with an assessment reference assessment (ARD) of 08/18/18 found the resident was coded as being frequently incontinent of urine. (7 or more episodes of urinary incontinence but at least one episode of continent voiding.) Bowel incontinence is coded as occasionally incontinent (one episode of bowel incontinence for the past 7 days.) The MDS noted the resident had no hearing or visual problems. She was able to make herself understood and able to understand others. Her brief interview for mental status (BIMS) noted the resident's score was a 15. A score of 15 indicated the resident was cognitively intact and a score of 15 was the highest score obtainable. The resident had no behavior or mood problems and did not resist care in the past 7 days. Review of the current [DIAGNOSES REDACTED]. She had no dementia or psychological issues. Toileting was coded as total dependence and required 2 staff members. The MDS noted the resident had moisture associated skin damage (MSDS) (i.e. incontinence-associated [MEDICAL CONDITION], perspiration, drainage.) The MDS noted the resident was on a current toileting program or trial toileting program for both bowel and bladder incontinence. The care area assessment (CAA) completed with the annual MDS with an ARD of 08/18/18 did not reference any modifiable factors contributing to transitory urinary incontinence such as [MEDICAL CONDITION], atrophic vaginitis, psychological or psychiatric problems, caffeine use, pain, UTI, medications, constipation, excessive fluid intake, or environmental factors. Other factors on the CAA that contribute to incontinence were urinary urgency and need for assistance in toileting and [MEDICAL CONDITION] bladder. Types of incontinence were listed as mixed stress incontinence with urgency and functional (can't get to toilet in time due to physical disability, external obstacles or problems thinking or communication.) Review of the current care plan for bladder/bowel incontinence found the following problem: (Name of resident) is frequently incontinent of her bladder. She relates incontinence of her bladder due to stress, urgency, and impaired mobility. Occasionally incontinent of bowels, she relates her incontinence of her bowels due to urgency and impaired mobility, history of constipation. History of urinary tract infections (UTI's) and problems with hemorrhoids. Refuses to go to the bathroom at times according to direct care staff. The care plan did not reference any [DIAGNOSES REDACTED]. The goal associated with the problem was: She will participate with prompt voiding/prompt bowel training as she is able to do so and will be no more than occasionally incontinent of her bladder and usually continent of her bowels by the next 3 months. Care Plan Interventions included: Prompt voiding/prompt bowel training every 2 hours before and after meals, at bedtime and as needed. Praise all efforts and accomplishments made. A urinary incontinence evaluation was completed on 08/17/18. The assessment noted the incontinence was not new. There was no new medical or surgical condition associated with the onset of urinary incontinence and there is no exacerbation of a pre-existing medical condition associated with the onset of urinary incontinence. The resident has urgency incontinency and stress symptom, (i.e. wet when coughs, sneezes, bends or laughs. ) She has no retention/overflow symptoms. Restrictions include mobility and diuretics. The actions included on the assessment included If no clinical symptoms or transient/reversible causes identified or unable to be reversed urinary incontinence is persistent. Initiate 3 day continence management diary and complete urinary incontinence nursing interventions. Review of a document supplement recording found an order for [REDACTED]. Review of the supplement documentation for August, (YEAR) found the orders were not initialed as being completed on the 11AM-7PM and 7AM-3PM shifts on 08/25/18 and the 11AM-7PM shift on 08/29/18 and 08/30/18. At 12:50 PM on 09/17/18, the resident's regular day shift nursing assistant (NA) #25 was interviewed with the director of nursing present. NA #25 said the resident was not on a toileting program. The resident just puts the call light on when she needs changed. The NA was asked twice if the resident was on a toileting program or if she had to do anything specific related to toileting. Her response was repeated and the NA again said the resident was not on a toileting program. After the interview, the DoN said the resident was on a toileting program and this task was on the NA's bedside Kardex report which the DON provided. The Kardex directed prompt voiding/prompt bowel training every 2 hours before and after meals, at bedtime and as needed. The DoN said the NA should have known that. Review of a physician's progress note, dated 06/21/18 found the physician noted, Seeing patient on a routine visit. Has been on Bactrim for E. Coli (Escherichia coli) and UTI almost finished. Symptoms resolve but patient remains incontinent and holds urine before asking for assistance . Further record review found the resident was started on [MEDICATION NAME] 500 milligrams for 10 days and Microbid 100 milligrams two times a day for 10 days on 09/16/18 for a [DIAGNOSES REDACTED]. On 06/11/18, the resident received Bactrim twice a day for 10 days for a UTI. On 04/30/18, the resident received [MEDICATION NAME] daily for 10 days for a UTI. The record review revealed the resident had 3 UTI's in the past 5 months. At approximately 10:00 AM on 09/19/18, a copy of a 3 day continence management dairy was discussed with the DON. The diary directed staff to code the residents bowel and bladder habits every 2 hours for 3 days. The dairy noted 60 occasions to rate the resident as being continent of bowel, incontinent of bowel, continent of urine (toileted) , dry (not toileted), and incontinent of urine. On 15 occasions the resident was dry (not toileted.) On 1 occasion she was toileted and continent of bowel. On 44 occasions she was incontinent of urine. The diary was completed from 08/17/18 through 08/21/18. The DoN said, It is what it is, when asked if the diary was completed correctly. The DoN confirmed the resident had not been to see a urologist related to the frequent UTI's. No evidence was presented to verify the facility explored the possible reasons for the reoccurring UIT's. The NA was not toileting the resident every 2 hours, before and after meals and at bedtime per the toileting plan.

Based on record review and staff interview, the facility failed to ensure adequate assistance when utilizing the mechanical lift resulting in injury to one (1) of four (4) sampled residents. Two (2) nursing assistants (NAs) performed a mechanical lift despite the care plan intervention requiring three (3) staff members to assist with lift transfers. The resident fell during the transfer resulting in a hip fracture and forehead laceration. Resident Identifier: #20. Facility Census: 61. Findings include: a) Resident #20 On 12/10/12 at 2:49 p.m., review of the incident/accident reports revealed a fall involving Resident #20. The resident was being transferred at 2:30 p.m. on 10/17/12 using the mechanical lift when one (1) side of the sling "popped off." The resident sustained [REDACTED]. Review of the care plan, at 3:10 p.m. on 12/10/12, found it provided special instruction for transfers of this resident. Transfers required "mechanical lift and assist of 3." The intervention was initiated prior to the fall on 08/09/12. The Kardex also indicated the assistance of three (3) was required for transfers. Further instruction was found on the wall sticker directly outside the resident's door. "TA3" was noted on the sticker further indicating the need for a three (3) person assist for transfers. All notifications/instructions found coincided. Individual performance improvement plans were reviewed on 12/10/12 at 3:50 p.m. for the two (2) NAs involved with the incident. The reports noted violation of safety rules contributed to unsafe conditions. Failure to ensure safety precautions during a lift was the referenced policy violation. The patient fall investigation form regarding the incident was reviewed on 12/11/12 at 1:30 p.m. The form acknowledged transfer of the resident back to bed using the mechanical lift when one (1) end of the sling came loose resulting in the fall. No names were listed as witnesses, though two (2) NAs were involved. A staff in-service was also checked not applicable, although the facility's protocol was not followed by nursing assistants who transferred the resident with two (2) assist, instead of the required three (3) person assist. An interview with the director of nursing (DON - Employee #27) occurred on 12/10/12 at 4:09 p.m. The DON agreed the NAs did not follow the care plan for a three (3) person assist when using the mechanical lift with the resident. She stated this was the reason for writing the two (2) performance improvement plans. The DON indicated the NAs had to receive/demonstrate the safe resident handling program information, which included verifying the number of staff required for each resident during mechanical lift use, before being permitted to use the mechanical lift with residents again. .

Based on medical record review and staff interview, the facility failed to adequately implement the care plan for one (1) of four (4) sample residents. Only two (2) nursing assistants (NAs) were utilized during use of a mechanical lift when a three (3) person assist was designated on the plan of care. Resident Identifier: #20. Facility Census: 61. Findings include: a) Resident #20 On 12/10/12 at 2:49 p.m., the incident/accident reports were reviewed. The reports indicated the resident had fallen on 10/17/12 at 2:30 p.m. The fall resulted from one (1) side of the mechanical lift sling becoming detached causing the resident to fall onto the floor. The resident sustained [REDACTED]. Upon review of the care plan, at 3:10 p.m. on 12/10/12, it was found the resident required the use of a mechanical lift with the assistance of three (3) staff. At 3:50 p.m. on 12/10/12, the director of nursing (DON - Employee #27) supplied the performance improvement plans for the nursing assistants (NAs) who had transferred the resident. Only two (2) NAs were identified on the improvement plans. An interview with the DON, Employee #27, occurred on 12/10/12 at 4:09 p.m. The DON agreed the NAs did not follow the care plan for a three (3) person assist when using the mechanical lift with this resident. She informed this was the reason for writing the two (2) performance improvement plans. The DON indicated the NAs had to receive/demonstrate the safe resident handling program tasks, which included verifying the number of staff required for each resident during mechanical lift use, before assisting residents with additional lifts following this incident. .

Part I -- Based on observation, staff interview, staff-assisted checks of facility water temperatures, interview with the life safety code (LSC) surveyor, review of the Guidance to Surveyors found in the State Operations Manual published by the Centers for Medicare & Medicaid Services (CMS), and record review, the facility failed to provide a resident environment as free of accident hazards as possible, by failing to assure water temperatures at hand sinks in resident rooms remained in a safe temperature range to prevent injuries. Water temperatures were measured, using the facility's thermometer in the presence of the maintenance supervisor (Employee #69), to be as high as 128 degrees Fahrenheit (F) at the hand sinks in various residents rooms. According to Table 1 in the Guidance to Surveyors for this requirement found in Appendix PP of the CMS State Operations Manual, a third degree burn can occur after exposure of only one (1) minute to a water temperature of 127 degrees F, and after exposure of only fifteen (15) seconds to a water temperature of 133 degrees F. The excessively hot water temperatures found in the sinks in various residents' room placed more than an isolated number of residents in immediate jeopardy of harm or death due to the potential for scalding / burn injuries, especially for independently mobile residents with cognitive impairment and/or decreased sensitivity to pain and/or extreme temperatures. In the administrator's absence, the director of nursing (DON) was informed of the immediate jeopardy determination at 1:00 p.m. on 08/04/10. The DON was informed, at 2:55 p.m. 08/04/10, that the circumstances leading to the immediate jeopardy were found to have been removed, when the facility was able to able to sustain a maximum hot water temperature of less than 110 degrees F, as verified by surveyor observation and testing. After removal of the immediate jeopardy, no deficient practice remained with respect to excessively hot water temperatures in the resident environment. Facility census: 65. Findings include: a) On 08/04/10 at 10:30 a.m., the LSC surveyor informed the maintenance supervisor (Employee #69) of finding water temperatures at the hand sinks in various residents' rooms of 127 degrees F. At that time, the DON instructed the maintenance supervisor to turn down the temperature of the water heaters. At approximately 11:00 a.m., Employee #69 assisted the surveyor with checking water temperatures in each sink in the resident rooms utilizing facility equipment. A check of the hand sinks located in each resident room found the excessively hot water temperatures registered as follows: Room #210 - 128 degrees F Room #308 - 127 degrees F Room #307 - 128 degrees F Room #305 - 128 degrees F Room #304 - 127 degrees F Room #303 - 127 degrees F Room #301 - 128 degrees F Room #109 - 127 degrees F Room #107 - 127 degrees F Room #103 - 127 degrees F Room #102 - 128 degrees F Room #101 - 127 degrees F Room #100 - 127 degrees F Water temperatures at the hand sinks in the remaining rooms each registered above 120 degrees F but below 128 degrees F. According to the maintenance supervisor, one (1) of the facility's three (3) hot water heaters had a faulty mixing valve and pump. He indicated he normally checked the hot water temperatures in resident rooms each week. He went on to state that, during his last check on 07/30/10, the temperatures were within the acceptable range. The maintenance supervisor provided the documentation regarding water temperatures in resident rooms. The logs showed temperatures were checked in resident rooms weekly and that the temperatures never registered above 112 degrees F during the July. - - According to information in the Guidance to Surveyors for this requirement found in Appendix PP of the CMS State Operations Manual: Table 1. Time and Temperature Relationships to Serious Burns Water Temp - Time Required for a 3rd Degree Burn to Occur 155 degrees F - 1 sec 148 degree F - 2 sec 133 degrees F - 15 sec 127 degrees F 1 min 124 degrees F 3 min 120 degrees F 5 min 100 degrees F - Safe Temperature for Bathing (See Note) Note: Burns can occur even at water temperatures below those identified in the table, depending on an individual's condition and the length of exposure. - - The DON (Employee #21) submitted a plan to turned down the temperatures of the water heaters at the time the maintenance supervisor informed her of the 127 degrees F temperature readings. This intervention took place at 11:00 a.m. on 08/04/10. - - At approximately 12:45 p.m. on 08/04/10, the maintenance supervisor reported the temperatures in resident sinks were decreasing to a range of 104 degrees F to 108 degrees F on the 300 hall. - - At approximately 1:00 p.m. on 08/04/10 the maintenance supervisor accompanied the surveyor around the facility, where the hot water temperatures in all resident rooms were checked using the facility's equipment. At that time, rooms on 100, 200 and 300 halls were registering above the acceptable 110 degrees F range. The water temperature still registered at 128 degrees F in Rooms #102, #302, #305, and #210. The State survey agency's program manager was subsequently informed of the excessive hot water temperatures in these resident areas. The determination that these findings placed the residents in immediate jeopardy, due to the high risk for sustaining third degree burnings after only brief periods of exposure to hot water, was conveyed to the DON at 1:00 p.m. on 08/04/10. - - At approximately 2:00 p.m. on 08/04/10, the maintenance supervisor accompanied the surveyor for another check of the hot water temperature in the sinks in every resident rooms. At this time, hot water temperatures at the hand sinks were below 110 degrees F. The DON was informed at that time that the residents were no longer in immediate jeopardy of injury or death from excessive hot water temperatures. -- Part II -- Based on observation and record review, the facility failed to identify the need for and provide adequate supervision and/or assistive devices to prevent recurrent self-injury (skin tears due from her own fingernails). Resident identifier: #43. Facility census: 65. Findings include: a) Resident #43 Record review found the resident was assessed as requiring extensive assistance to being totally dependent for activities of daily living. She also had partial loss of voluntary movement Observation of the resident, on 08/04/10 and throughout the survey, found she moved about very little independently. She would demonstrate some spastic type movements when moved about by staff. During review of the resident's medical record, it was noted she had orders for treatment of [REDACTED]. Documentation also noted the resident had fragile skin. The resident's care plan included goals for: "The resident will not experience any injury d/t (due to) husband repositioning her. ..." Another goal was for her not to "... experience any problems related to husband feeding her or repositioning her or providing care. ..." There was also a goal for grooming which included an intervention for: "Staff to provide daily care: ... provide oral care, hair care, nail / skin care... " There was no evidence these similar injuries had been identified and addressed by the facility to prevent recurrence. .