Every finding on record at Madison Carriage Cove Short Stay Rehabilitation

Based on the FDA Food Code, policy review, observation, and interview, the facility failed to ensure food was appropriately stored, distributed, and labeled. This deficient practice had the potential to affect all residents who received meals prepared in the facility's kitchen. This placed residents at risk for potential contamination and use of spoiled foods, and adverse health outcomes including food-borne illnesses. Findings include:The FDA Food Code 2022, 3-501.17 documented, Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.The facility's Food Safety Requirements policy dated 12/8/25, documented Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon deliver/receipt and ensure timely and proper storage. iv. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use by date, or frozen (where applicable)/discarded; v. and Keeping foods covered or in tight containers.On 1/20/26 from 7:45 AM - 8:05 AM, with the FSM present, an initial tour and observation of the kitchen was conducted with the following results:Walk-in freezer:- an open box containing frozen French bread dough, not covered, sealed, or dated.- an open bag containing frozen chicken breast, not sealed, or dated.- a loaf of sliced bread in a bag laying on the floor between the wall and the shelving.The FSM picked up the loaf of bread from the floor and stated it must have fallen off the shelf and the French bread and chicken breast should have been sealed and dated.Walk-in refrigerator:- container of heavy cream with a best by date of 1/18/26.The FSM discarded the heavy cream and stated it was recently ordered and did not notice the best by date of 1/18/26.

Based on policy review, observation, and staff interview, it was determined the facility failed to ensure infection control prevention practices were maintained when 1) residents consumed meals prepared in the facility kitchen, and 2) residents received insulin injections to manage their diabetes. These failures put residents at risk for adverse outcomes including potential infections or food-borne illness due to cross contamination. Findings include:The facility's Handwashing Guidelines-Dietary Employees, dated 12/8/25, documented Dietary employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment, utensils, and unwrapped single service and single use articles and in the following situations:a. Every time an employee enters the kitchen; at the beginning of the shift; after returning from break; after using the toilet.b. After hands have touched anything unsanitary, i.e., garbage, soiled utensils/equipment, dirty dishes, etc.c. After hands have touched bare human body parts other than clean hands (such as face, nose, hair etc.).d. After coughing, sneezing, or blowing your nose, using tobacco, eating or drinking.e. After handling chemicals and before beginning to work with food.f. While preparing food, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks.g. When switching between working with raw food and working with ready to eat food.h. Before donning gloves for working with food.i. After caring for or handling service animals or aquatic animals.j. After engaging in any activity that may contaminate the hands.The facility's Food Safety Requirements policy, dated 12/8/25, documented Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects .e. Hairnets should be worn when cooking, preparing, or assembling food, such as stirring pots or assembling the ingredients of a salad .The FDA Food Code, 2022 documents Food Employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unpwrapped single-service and single-use articles and.(F) during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. Resident #2 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE], with multiple diagnoses which included diabetes and anxiety. Resident #2's physician orders documented Basaglar KwikPen Subcutaneous Solution Pen-injection 100 Unit/ML (Insulin Glargine) inject 15 units subcutaneously.and Insulin Lispro Injection Solution 100 Unit/ML (Insulin Lispro) as per sliding scale. On 1/27/26 at 8:31 AM, observed LPN #1 place a syringe containing Glargine insulin on Resident #2's bed next to him as she cleaned the injection site. LPN #1 then picked up the syringe off the bed and administered the insulin to Resident #2. On 1/27/26 at 8:38 AM, LPN #1 stated she should not have placed the insulin syringe on Resident #2's bed. On 1/28/26 at 3:28 PM, the IP stated LPN #1 should have placed her resident medications on a protective cover on top of Resident #2's bedside table, not in his bed. On 1/28/26, the following was observed in the kitchen between 11:55 AM and 12:45 PM during meal service: - The Kitchen Supervisor was observed leaving the tray line and going into the walk-in refrigerator and returning to the tray line to continue prepping plates without performing hand hygiene. - The Kitchen Supervisor was observed leaving the tray line and going into the dry-storage and returning to the tray line to continue prepping plates without performing hand hygiene. - Dietary Aide #1 was observed pureeing resident food items without performing hand hygiene. - Dietary Aide #2 was observed prepping plates from the tray line and placing them on the food cart. She was observed leaving the kitchen to deliver food trays to the residents and not performing hand hygiene when returning to the kitchen to prep more plates. - The FSM and Dietary Aide #2 had their hair pulled back into a ponytail and a baseball type hat on. The ponytails were hanging out of the back of the hat without being restrained by a hairnet. On 1/28/26 at approximately 1:15 PM, the Kitchen Supervisor stated he was probably not seen washing his hands as much as he should have because one of the hand washing sinks was out of order. On 1/28/26, at approximately 1:20 PM, during an interview with the FSM, she stated she thought they did not have to wear hairnets if they wore a hat. She also stated the procedure for hand hygiene in the kitchen was to wash hands when visibly dirty and when changing tasks.

Based on observations, policy review and staff interviews it was determined the facility failed to ensure medications were properly stored, not expired, and disposal of unused medications. This was true for the facility. This failure created the potential for residents to receive expired medications with decreased efficacy or cross contamination from topical products. Findings include: The facility's policy, Destruction of Unused Drugs dated 12/29/25, documented.unused, unwanted and non-returnable medications should be removed from their storage area and secured until destroyed.The following was observed during the medication cart audits. On 1/28/26 at 8:52 AM, the South Hall medication cart was audited with LPN #2 present. Observed the following: - one bottle of Gas Relief with a manufacturer expiration date of 7/25 printed on the bottle On 1/28/26 at 8:53 AM, LPN #2 stated, the bottle of Gas Relief should have been discarded and had not been. On 1/28/26 at 2:01 PM, the North Hall medication storage room was audited with LPN #1 present. Observed the following in the available supplies for resident use: - One tube of barrier cream with a prescription label affixed to the product for resident who had been discharged from the facility on 10/3/25. - One tube of barrier cream with a prescription label affixed to the product for resident who had been discharged from the facility on 11/18/25. On 1/28/26 at 4:38 PM, the DON stated the expired and unused medications should have been removed from the medication cart and storage room and had not been.

Based on observation, record review and interview, the facility failed to ensure residents were free of medication preparation and administration errors for 1 of 1 resident (Resident #2) observed for medication preparation and administration of insulin. This failed practice placed the resident at risk for not receiving their prescribed medication dosage and other adverse outcomes. Findings include: Resident #2 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE], with multiple diagnoses which included diabetes and anxiety. Resident #2's physician orders documented Basaglar KwikPen Subcutaneous Solution Pen-injection 100 Unit/ML (Insulin Glargine) inject 15 units subcutaneously.and Insulin Lispro Injection Solution 100 Unit/ML (Insulin Lispro) as per sliding scale.On 1/27/26 at 8:27 AM, observed LPN #1 remove Glargine insulin pen from the medication cart and dial the insulin pen to 15 Units as ordered. LPN #1 did not prime the insulin pen with 2 Units before dialing the ordered dose. On 1/27/26 at 8:32 AM, LPN #1 administered the Glargine insulin to Resident #2. On 1/27/26 at 8:37 AM, LPN #1 stated she did not prime the insulin pen today and sometimes will prime the pen prior to administering insulin. On 1/28/26 at 4:18 PM, the DON stated insulin pens should be primed with 2 units prior to administering the ordered insulin dosage.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure a Pre-admission Screening and Resident Review (PASARR) Level 1, was completed prior to admitting 1 of 3 residents (Resident #32) whose medical records were reviewed for PASARR Level 1 screenings. This failure created the potential for harm if residents required but did not receive specialized services for mental health while residing in the facility. Findings include:The facility's Resident Assessment - Coordination with PASARR Program policy dated 12/24/25, documented:- 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. - a. PASARR Level I - initial pre-screening that is completed prior to admission.Resident #32 was admitted to the facility on [DATE], with multiple diagnoses including kidney failure and cancer.On 1/28/26 at 8:47 AM, Resident #32's medical record documented her PASRR I dated 12/16/25 had not been received by the facility until 12/16/25, four days after she was admitted to the facility on [DATE].On 1/28/26 at 9:21 AM, the ADON stated she had not requested or received the PASRR I prior to Resident #32 being admitted on [DATE] but remembered it was missing on 12/16/25 and asked the hospital for the PASRR I on 12/16/25.

Based on observation, CPAP manufacturers warning guidelines, record review, and interviews, it was determined the facility failed to provide respiratory services consistent with manufacturers warning guidelines and professional standards of practice. This was true for 1 of 2 residents (Resident #8) whose respiratory equipment was observed. This failure created the potential for residents' respiratory equipment to malfunction and possibly increase the risk of fire. Findings include: [NAME] CPAP contained the following manufacturers warning guidelines:- Oxygen supports combustion. Oxygen should not be used while smoking or in the presence of an open flame.- When using oxygen with this system, turn the device on before turning on the (supplemental) oxygen. Turn the oxygen off before turning the device off. This will prevent oxygen accumulation in the device.- Explanation of the Warning: When the device is not in operation and the oxygen flow is left on, oxygen delivered into the tubing may accumulate within the device's enclosure. Oxygen accumulated in the device enclosure will create a risk of fire.- When using oxygen with this system, a [NAME] Respironics Pressure Valve must be placed in-line with the patient circuit between the device and the oxygen source. The pressure valve helps prevent the backflow of oxygen from the patient circuit into the device when the unit is off. Failure to use the pressure valve could result in a fire hazard.Resident #8 was initially admitted to the facility on [DATE], and readmitted to the facility on [DATE], with multiple diagnoses including left femur fracture and chronic respiratory failure with hypoxia (a long-term, potentially fatal condition where damaged lungs cannot properly transfer oxygen to the blood, often causing low oxygen levels).On 1/27/26 at 11:26 AM, observed Resident #8's CPAP was turned off however the oxygen was still turned on at 2 lpm and being bled into the CPAP device. On 1/27/26 at 4:40 PM, observed with the Administrator, Resident #8's supplemental oxygen was being bled into his CPAP which was not turned on. Resident #8's CPAP did not have a [NAME] Respironics Pressure Valve (which does not allow oxygen backflow into the CPAP device) installed.On 1/27/26 at 4:45 PM, the Administrator stated the oxygen in Resident #8's room should have been shut off when his CPAP was turned off and was not.

Based on observation and staff interview, it was determined the facility failed to ensure daily nurse staffing sheets were maintained for a minimum of 18 months. This failed practice had the potential to affect all residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's staffing levels. Findings include:On 1/27/26 at 2:00 PM, the DON stated she only had daily staffing sheets from when she started her employment with this facility in August 2025.On 1/27/26 at 2:05 PM, the Administrator stated he was not sure what happened to the daily staffing sheets from January 2025 through July 2025.

Based on record review and staff interview, it was determined the facility failed to ensure controlled medications were tracked and kept secure from potential theft and/or diversion. This was true for 1 of 2 medication carts reviewed. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medication in the facility. Findings include: On 1/27/26 at 7:50 AM, during the North Hall medication cart audit, observed the narcotic accountability sheets, dated 1/1/26 to 1/27/26, with 1 licensed nurse signature not documented on 1/21/26. On 1/27/26 at 8:12 AM, LPN #1 stated two nurses should have signed the narcotic accountability sheet when they accepted the medication cart or released the medication cart. On 1/28/26 at 4:38 PM, the DON stated two nurses should have signed the narcotic accountability sheet when they accepted the medication cart or released the medication cart.

Based on policy review, I&A review, record review, and staff interview, it was determined the facility failed to ensure adequate supervision and implement interventions to prevent falls. This was true for 1 of 1 resident, (Resident #24) whose records were reviewed for falls. This resulted in harm to Resident #24. Findings include: The State Operation Manual, Appendix PP, dated 8/8/24, defined Avoidable Accident as an accident occurred because the facility failed to: Identify environmental hazards and/or assess individual resident risk of an accident, including the need for supervision and/or assistive devices. The facility's Accidents and Supervision policy revised 12/20/24, defines supervision/adequate supervision as an intervention and means of mitigating risk of an accident. Resident #24 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including surgical aftercare following surgery on the digestive system and septicemia (bacteria that enters the bloodstream and spreads throughout the body). On 10/29/24, Resident #24 returned from the hospital with a wound vacuum (a medical device that uses negative pressure to remove fluid, debris, and bacteria from infected or non-healing wounds) and a foley catheter (a device that drains urine from your urinary bladder into a collection bag outside of your body). On 11/16/24 at 8:40 AM, RN #2 found Resident #24 lying on the floor at his bedside with his walker on the opposite side. RN #2 documented the following. - the wound vacuum was attached to the walker and the wound vacuum tubing was laying over his bed, pulling his walker into the bed. - the foley catheter was hanging from right side of bed frame. - Resident #24 appeared to have tripped on the foley catheter tubing or wound vacuum tubing. - Resident #24 stated he was trying to get out of bed when he tripped on something. Resident #24 was transferred to the hospital where he was diagnosed with a right hip fracture, subdural hematoma, and UTI. The IDT Review Note dated 11/18/24, documented Resident #24 was getting out of his bed on the left side when he fell . Therapy confirmed it is typical for Resident #24 to exit his bed from the left side. Resident #24's care plan was not updated with new fall interventions. On 11/28/24, Resident #24 rolled out of bed onto the floor and sustained an abrasion to his right elbow. Resident #24's care plan was not updated with new fall interventions. On 12/1/24 at 8:20 AM, RN #3 found Resident #24 on the floor in his room. RN #3 documented the following. - Resident #24 was disoriented, confused and incontinent of urine when she approached him. - Resident #24's wheelchair was on the other side of the room and his walker was at the foot of his bed. - Resident #24 received a skin tear and scattered bruising on his right upper arm. - Resident #24 stated he stood up when getting out of bed and his hip gave out on him. Resident #24 was transferred to the hospital where he was diagnosed with a traumatic subarachnoid hemorrhage (brain bleed) and UTI. On 1/23/24 at 11:28 AM, the DON stated new fall interventions were not implemented after Resident #24's falls on 11/16/24 and 11/28/24. The DON stated they should have updated Resident #24's care plan after each fall.

Based on observation, interview, policy review, and review of the Idaho Food Code, the facility failed to appropriately store, label, and serve foods. This deficient practice had the potential to affect all residents who received meals from the facility kitchen served in the dining room and resident rooms. This placed residents at risk for potential contamination and use of spoiled foods, and adverse health outcomes, including food-borne illnesses. Findings include: Review of the Idaho Food Code, revised February 2021, stated ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. The facility's Food Safety Requirements policy dated [DATE], documented under Policy Explanation and Compliance Guidelines 1. b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms. 3. C. iv. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded. On [DATE] at 7:00 AM, observed in kitchen area with the CFM the following. In the walk-in refrigerator observed. - containers of tomato juice and lemon aide were not labeled or dated. - meat (ham) stored in a zip lock bag, lying on top of an open bag of lettuce. - unlabeled and non-dated opened bag of shredded cheese. - an opened brick of cheese not dated. - an non-dated sandwich in a bag. - an unlabeled and non-dated bag of lunch meat. - an unlabeled and non-dated bag of spinach that was opened to room air. - an undated tray of sliced tomato, onion, pickles on plates wrapped in plastic. The CFM stated those were from a few days ago. In the walk-in freezer observed. - a large bag of cubed carrots open to the air, not sealed correctly and not dated when opened. In the dry food storage area observed. - expired onion powder. - expired garlic powder. On [DATE] at 7:25 AM, the CFM stated the opened non-dated food items should have been dated and correctly sealed and the bag of meat should not have been stored on top of an opened bag of lettuce. The sandwich and lunch meat bags should have been labeled and dated. On [DATE] at 2:10 PM, during a second trip into kitchen the following issues were noted. In the walk-in refrigerator observed. - a bag of lettuce opened to air and not sealed correctly. On [DATE] at 2:12 PM, the CFM stated that the bag of lettuce should have been sealed correctly. On [DATE] at 2:15 PM, observed in the grill area of the kitchen. - a liquid butter alternative container stored above the grill area, was not dated with opened date. - a squirt bottle that had contained liquid butter alternative for use on the grill was not labeled of contents and was not dated. On [DATE] at 2:20 PM, the CFM stated both liquid butter alternative containers should have been dated when opened and labeled of contents.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure resident comprehensive care plans were completed and reviewed with residents and update care plans when changes occur to resident's care. This was true for 3 of 13 residents (#7, #13, and #24) whose care plans were reviewed. This placed residents at risk of adverse outcomes if care and services were not provided as residents needs changed. Findings include: The facility's Care Planning-Resident Participation policy dated 12/13/24, documented the facility will discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences, and allow them to see the care plan, initially, at routine intervals, and after significant changes. The facility will obtain a signature from the resident and/or resident representative after discussion or viewing of the care plan. The State Operations Manual, Appendix PP documents a resident's care plan must be reviewed after each assessment and revised based on changing goals, preferences, and needs of the resident and in response to current interventions. 1. Resident #7 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including osteomyelitis (a bone infection) of vertebra, sacral and sacrococcygeal region, chronic post-traumatic stress disorder, and nutritional deficiency. On 1/23/25, Resident #7's medical record had no documentation the comprehensive care plan had been reviewed with her or her representative within 21 days of admission to the facility. On 1/23/25 at 10:35 AM, the CCO stated the comprehensive care plan should have been completed within 21 days of admission and reviewed with Resident #7. 2. Resident #13 was admitted on [DATE], with multiple diagnoses including metabolic encephalopathy (when the brain does not function properly due to an imbalance in electrolytes, metabolites, or other substances in the body), pneumonia, and UTI. Resident #13's care plan dated 9/24/24, documented the following: - May administer PRN bolus hydromorphone (an opioid pain medication) 0.0500M/bupivacaine (a local anesthetic) 0.0500 mg every 3 hours up to 4 doses within 24 hours. Resident #13's physician order dated 10/30/24, documented the following: - May administer PRN bolus hydromorphone 0.0750 mg/bupivacaine 0.0750 mg every 3 hours up to 4 doses within 24 hours. Resident 13's care plan was not revised to increase the hydromorphone to 0.0750 mg/bupivacaine 0.0750. 3. Resident #24 was initially admitted to the facility on [DATE], with multiple diagnoses including surgical aftercare following surgery on the digestive system and septicemia (bacteria that enters the bloodstream and spreads throughout the body). On 11/16/24, Resident #24 fell in his room and sustained a right hip fracture and subdural hematoma. Resident #24's care plan was not updated with new fall interventions realted to this fall. On 11/28/24, Resident #24 received an abrasion on his right arm after rolling out of his bed. Resident #24's care plan was not updated with new fall interventions realted to this fall. On 12/1/24, Resident #24 fell in his room and sustained a traumatic subarachnoid hemorrhage (brain bleed). On 1/23/24 at 11:28 AM, the DON stated new fall interventions were not implemented after Resident #24's falls on 11/16/24 and 11/28/24. The DON stated they should have updated Resident #24's care plan with new interventions after each fall. 51121

Based on policy review, observation, record review, and staff interview, it was determined the facility failed to ensure residents were assessed to determine if they were safe to self-administer medications. This was true for 1 of 1 residents (Resident #13) reviewed for self-administration of medications. This failure created the potential for adverse effects if residents self-administered medications inappropriately. Findings include: The facility's Resident Self Administration of Medication policy, dated 12/16/24, documented the interdisciplinary team would assess and determine if self-administration of medication is clinically appropriate for a resident. The results of the assessment would be recorded on the Medication Self-Administration Safety Evaluation. Resident #13 was admitted on [DATE], with multiple diagnoses including metabolic encephalopathy (when the brain does not function properly due to an imbalance in electrolytes, metabolites, or other substances in the body), pneumonia, and UTI. Resident #13's care plan intervention dated 9/24/24, documented the following: - For complaint of pain not alleviated with use of Tylenol encourage/remind resident to use pain pump bolus. May administer PRN bolus hydromorphone 0.0500M/bupivacaine 0.0500 mg every 3 hours up to 4 doses within 24 hours. Turn on communicator device, place device over pain pump, open app and tap deliver bolus button. Device will confirm dose administered. Staff may assist resident with bolus if needed. Resident #13's physician order dated 10/30/24, documented the following: - For complaint of pain not alleviated with other interventions encourage/remind resident to use pain pump bolus. May administer PRN bolus hydromorphone (a opioid pain medication) 0.0750 mg/bupivacaine (a local anesthetic) 0.0750 mg every 3 hours up to 4 doses within 24 hours. Turn on communicator device, place device over pain pump, open app and tap deliver bolus button. Device will confirm dose administered. Staff may assist resident with bolus dosing if needed. On 1/23/25 at 2:02 PM, the CCO stated Resident #13 did not have an assessment to self-administer medication and she should have.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure residents and their representatives received assistance to exercise their right to formulate an advanced directive. This was true for 3 of 4 residents (#7, #185, and #186) whose records were reviewed for advanced directives. This deficient practice created the potential for harm or adverse outcomes if residents' wishes were not followed or documented. Findings include: The facility Residents' Rights Regarding Treatment and Advance Directives dated 12/24/24, documented it is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive. Should the resident have an advance directive, copies will be requested and placed in the medical record as provided by resident/representative as well as communicated to the staff. 1. Resident #7 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including osteomyelitis (a bone infection) of vertebra, sacral and sacrococcygeal region, chronic post-traumatic stress disorder, and nutritional deficiency. Resident #7's medical record had various active conflicting resuscitation status documents as listed below. - POST document dated 2/6/24, documented Resident #7 was listed as a full code. - Resident #7's living will and DPOA Health Care dated 2/6/24, documented Resident #7 was listed as a full code. - facility code status document dated 1/2/25, documented Resident #7 was listed as DNR. - facility social services document dated 1/3/25, documented Resident #7 was listed as a full code. - nursing worksheet dated 1/21/25, documented Resident #7 was listed as DNR. On 1/23/25 at 10:30 AM, the facility chief clinical officer stated Resident #7's DNR status documents are confusing and need to be clarified. 2. Resident #185 was admitted to the facility on [DATE], with multiple diagnoses including fracture of the right femur and diabetes. Resident #185's medical record did not contain documentation of the following; - an advance directives. - of the facility offering to assist the resident to formulate an advance directive. - the resident declined to formulate an advanced directive. Resident #185's IDT care plan conference document dated 1/17/25, documented under code status, he was a DNR. The rest of Resident #185's advance directives questions were left blank on the IDT care plan conference. 3. Resident #186 was admitted to the facility on [DATE], with multiple diagnoses including major depressive disorder and parkinsonism (general term for a group of neurological disorders that affect movement characterized by slowness, stiffness, tremors, and instability). Resident #186's medical record did not contain documentation of the following; - an advance directives. - of the facility offering to assist the resident to formulate an advance directive. - the resident declined to formulate an advanced directive. The advance directive questions section of Resident #186's IDT care plan conference document dated 1/21/25, was left blank and the document was not signed. On 1/23/25 at 10:30 AM, the CCO stated the advance directives should have been completed for Residents #185 and #186.

Based on policy and record review, and staff interview it was determined the facility failed to ensure pertinent health information was provided to the receiving hospital for 1 of 1 resident (Resident #14) reviewed for transfers. This deficient practice had the potential to result in adverse outcomes if the residents were not treated in a timely manner due to a lack of information provided upon transfer. Findings include: The facility's Transfer and Discharge (including AMA) policy dated 12/2/24, documented for a transfer to another provider, for any reason, the following information must be provided to the receiving provider: a. Contact information of the practitioner who was responsible for the care of the resident. b. Resident representative information, including contact information. c. Advance directive information. d. All other information necessary to meet the resident ' s needs, which includes, but may not be limited to: - Resident status, including baseline and current mental, behavioral, and functional status, reason for transfer, recent vital signs. - Diagnoses and allergies. - Medications (including when last received). - Most recent relevant labs, other diagnostic tests, and recent immunizations. - All special instructions and/or precautions for ongoing care, as appropriate such as: - Treatments and devices (oxygen, implants, IVs, tubes/catheters). - Transmission-based precautions such as contact, droplet, or airborne. - Special risks such as risk for falls, elopement, bleeding, or pressure injury and/or aspiration precautions. - The resident ' s comprehensive care plan goals. e. All other information necessary to meet the resident ' s needs, which includes, but may not be limited to: - Resident status, including baseline and current mental, behavioral, and functional status, reason for transfer, recent vital signs. - Diagnoses and allergies. - Medications (including when last received). - Most recent relevant labs, other diagnostic tests, and recent immunizations. - Additional information, if any, outlined in the transfer agreement with the acute care provider. Resident #14 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including respiratory failure and hypercapnia (carbon dioxide retention). A Transfer to Hospital Summary Note dated 7/26/24 at 11:25 PM, documented MD #2 gave the okay to send Resident #14 to the hospital due to her change in condition. Resident #14's medical record did not include documentation that pertinent medical information was provided to the receiving hospital. A Transfer to Hospital Summary Note dated 9/1/24 at 9:20 PM, documented Resident #14 was sent to the hospital due to weakness and lethargy. Resident #14's medical record did not include documentation that pertinent medical information was provided to the receiving hospital. On 1/22/25 at 12:02 PM, the ADON stated Resident #14's medical records did not contain documentation of what was sent with her when she was transferred to the hospital and it should have been documented.

Based on policy and record review, and staff interview, it was determined the facility failed to ensure a bed hold notice was provided to residents or their representatives upon transfer to the hospital. This was true for 2 of 2 residents (#14 and #24) reviewed for transfers. This deficient practice created the potential for harm if residents were not informed of their right to return to their former bed/room at the facility within a specified time. Findings include: The facility's Bed Hold Prior to Transfer policy dated 12/2/24, documented the facility would provide written information to the resident and/or the resident representative regarding bed hold policies prior to transferring a resident to the hospital. 1. Resident #14 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including respiratory failure and hypercapnia (carbon dioxide retention). A Transfer to Hospital Summary Note dated 7/26/24 at 11:25 PM, documented MD #2 gave the okay to send Resident #14 to the hospital due to her change in condition. Resident #14's medical record did not document a Bed Hold had been provided to her or her representative. A Transfer to Hospital Summary Note dated 9/1/24 at 9:20 PM, documented Resident #14 was sent to the hospital due to weakness and lethargy. Resident #14's medical record did not document a Bed Hold had been provided to her or her representative. 2. Resident #24 was initially admitted to the facility on [DATE], with multiple diagnoses including surgical aftercare following surgery on the digestive system, septicemia (bacteria that enters the bloodstream and spreads throughout the body), and respiratory failure. On 10/24/24, Resident #24 was transferred to the hospital for dehiscence (separation or opening) of his abdominal incision. On 11/16/24, Resident #24 was transferred to the hospital following a fall in his room resulting in a right hip fracture and subdural hematoma. On 12/1/24, Resident #24 was transferred to the hospital following a fall in his room resulting in a brain bleed. There was no documentation in the medical record a bed hold was offered to Resident #24 for his transfers to the hospital on 10/24/24, 11/16/24, or 12/1/24. On 1/22/25 at 12:02 PM, the ADON stated they did not have documentation that Resident #14 or her representative received a bed hold, and they should have. On 1/22/25 at 12:05 PM, the ADON stated they did not have documentation Resident #24 or his representative received a bed hold for his hospital transfers on 10/24/24, 11/16/24, or 12/1/24. 50983

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure medications available for residents were labeled, dated, and stored appropriately; this was true for 1 of 2 medication storage rooms inspected, and 1 of 2 medication carts audited for labeling and storage of medication. This failure created the potential for residents to miss doses of medication, to receive expired medications with decreased efficacy, and created the potential for misappropriation of resident's medications. Findings include: The CDC guidelines for Preventing Unsafe Injection Practices, dated 3/26/24, documented once a multi-dose vial is opened (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer states another date for that opened vial. The beyond-use-date should never exceed the manufacturer's original expiration date. The facility's Medication Storage policy dated 12/16/24, documented the following: - the facility was to ensure all medications housed on the premises are stored in medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. - During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. - Schedule II controlled medications are to be stored within a separately locked permanently affixed compartment when other medications are stored in the same area, such as in a refrigerator. 1. On 1/21/25 at 2:12 PM, the facility's south side medication cart was inspected with RN #1 present, the following were found: - 2 small white pills and 1 oval white pill lying on the bottom of the second drawer. RN #1 stated she was not sure what the pills were and they should not have been there. On 1/22/25 at 12:05 PM, the ADON stated the medication carts are cleaned on Sunday and the pills should not have been loose in the cart. 2. On 1/21/25 at 2:16 PM, the facility's south side medication room was inspected with RN #1 present, the following were found: - a Tubersol solution (a clear colorless solution used for detection of tuberculosis infection) vial with no opened date, was observed in the resident medication refrigerator. RN #1 confirmed there was no open date on the bottle of Tubersol solution or the box the solution was in. On 1/22/25 at 12:03 PM, the ADON stated the Tubersol solution should have been dated when it was opened. 3. On 1/23/25 at 8:09 AM, observed in the south side medication storage room, the medication storage refrigerator had the emergency narcotic kit in the refrigerator sitting on a shelf, not permanently affixed. On 1/23/25 at 8:11 AM, the ADON stated the emergency narcotic kit had hospice narcotics in it. She also stated she did not know the narcotic box needed to be permanently affixed. On 1/23/25 at 11:15 AM, observed the south medication cart was unlocked with no nurse present. On 1/23/25 at 11:17 AM, RN #2 stated he was just down the hall but, the cart should have been locked. On 1/23/25 at 11:30 AM, the DON stated nursing staff must lock med carts when they are not present.

Based on observation and staff interview, it was determined the facility failed to ensure infection control prevention practices were maintained to provide a safe and sanitary environment. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection. Findings include: The facility's Meal Supervision and Assistance policy dated 12/20/24, documented staff will offer to assist residents with hand hygiene prior to meal service. The facility's Standard Precautions Infection Control policy revision date 1/30/23, documented hand hygiene was to be completed after touching blood, body fluids, secretions, excretions, contaminated items, before and after removing PPE, between resident contacts, before and after meals, and after using the restroom. The facility's Handling Soiled Linen policy revision date 12/12/24, documented linen should not be allowed to touch the uniform or floor and should be handled as little as possible, with minimum agitation to avoid contamination of air, surfaces, and persons. The facility's Enhanced Barrier Precautions policy dated 12/12/24, documented an order for enhanced barrier precautions will be obtained for residents with any of the following: Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices. The following was observed for infection control: a) On 1/21/25 at 7:40 AM, observed the DA #2 serve breakfast to rooms [ROOM NUMBERS]. She did not assist residents with cleaning hands or encourage the residents to clean their hands. On 1/21/25 at 7:43 AM, the DA #2 stated she did not offer hand hygiene or encourage them to wash their hands and she should have. On 1/21/25 at 8:06 AM, observed the DA #2 serve breakfast to room [ROOM NUMBER], 223, and 234. She did not assist residents with cleaning hands or encourage the residents to clean their hands. On 1/21/25 at 8:10 AM, the DA #2 stated she did not offer hand hygiene or encourage them to wash their hands and she should have. b) Resident #29 was admit to the facility on [DATE], with multiple diagnoses including hemiplegia (partial paralysis on one side of the body) and kidney failure. On 1/23/25 at 8:31 AM, CNA #1 and CNA #2 were observed providing catheter care to Resident #29. CNA #1 cleaned Resident #29's peri area and cleaned her catheter. After CNA #1 finished providing catheter care she changed her gloves. CNA #1 did not perform hand hygiene before applying a new pair of gloves. CNA #2 assisted with placement of new brief and then removed her gloves and applied new gloves. CNA #2 did not perform hand hygiene before applying new gloves. CNA #1 removed the bed pad out from underneath Resident #29 and placed it on the floor. Observed in Resident #29's bed a large amount of black substance on the bed linens, underneath her. The CNAs did not remove the black substance or change the bed linens. The clean bed pad was placed over the black substance. CNA #1 applied barrier cream to Resident #29's peri area and inner thighs and then applied the barrier cream to abdominal pannus without changing her gloves. On 1/23/25 at 8:43 AM, CNA #1 stated she should have performed hand hygiene between each glove change, she should have put the linens in a bag and not on the floor, and she should have changed Resident #29's bed linens. She also stated she should have changed her gloves after applying the barrier cream to Resident #29's peri area and before touching her abdominal pannus. c) Resident #29's care plan dated 12/17/24, directed staff to use of EBP when inside of her room for high-contact resident care activities. High contact resident care activities include dressing, bathing, transferring, changing linens, changing briefs, assisting with toileting, and device care. On 1/23/25 at 11:26 AM, observed CNA #1, CNA #2, and the OT use a Hoyer lift to transfer resident #29 without PPE gowns on. On 1/23/25 at 11:30 AM, CNA #1 stated they only wear a PPE gown when providing incontinent care and they should have worn a PPE gown for transferring. On 1/23/25 at 11:34 AM, the ADON stated the staff should have had PPE gowns on when transferring Resident #29. 51121

Based on interview, document review, review of the Centers for Disease Control and Prevention (CDC) guidance, and review of facility policy, the facility failed to maintain an infection prevention and control program (IPCP) that included a functional Antibiotic Stewardship Program that followed the McGeer Criteria for antibiotics for 1 of 13 residents (Resident #185) whose medical records were reviewed. This had the potential to affect residents being prescribed antibiotics that were potentially unnecessary. Findings include: The Centers for Disease Control and Prevention (CDC) Core Elements of Antibiotic Stewardship for Nursing Homes guidelines dated 3/18/24, documented facility perform reviews on resident medical records for new antibiotic starts to determine whether the clinical assessment, prescription documentation and antibiotic selection were in accordance with facility antibiotic use policies and practices. When conducted over time, monitoring process measures can assess whether antibiotic prescribing policies are being followed by staff and clinicians. The facility's Antibiotic Stewardship Program policy dated 12/19/23, documented under Policy Explanation and Compliance Guidelines. - 4.a.iv. The McGeer Criteria may be used to determine whether to treat an infection with antibiotics. - 4.a.v. All prescriptions for antibiotics shall specify the dose, duration, and indications for use. Resident #185 was admitted to the facility on [DATE], with multiple diagnoses including fracture of the right femur and diabetes. Resident #185's medical record documented erythromycin eye ointment was ordered on 1/3/25, however there was no duration or end date for use. On 1/23/25 at 10:09 AM, the IP stated she was normally notified via PCC (electronic medical records) dashboard when an antibiotic is started and she checks the orders at that time. The IP stated she had not seen the erythromycin antibiotic ordered for Resident #185 so the lack of duration date was not caught and it should have been.

Based on policy review, record review, and staff interview, it was determined the facility failed to develop, review with the resident, and implement a baseline care plan. This was true for 1 of 13 residents (Resident #7) whose care plans were reviewed. These failures placed residents at risk of negative outcomes if services were not provided or provided incorrectly due to lack of information in their baseline care plans. Findings include: The facility's Care Planning-Resident Participation policy dated 12/13/24, documented the facility will discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences, and allow them to see the care plan, initially, at routine intervals, and after significant changes. The facility will obtain a signature from the resident and/or resident representative after discussion or viewing of the care plan. Resident #7 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including osteomyelitis (bone infection) of vertebra, sacral and sacrococcygeal region, chronic post-traumatic stress disorder, and nutritional deficiency. Resident #7's medical record had no documentation that the baseline care plan had been reviewed with and copy given to Resident #7 or her representative. On 1/22/25 at 2:45 PM, the CCO stated the baseline care plan should have been completed within 48 hours of admission, reviewed with, and a copy given to Resident #7 but was not.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for 1 of 3 residents (Resident #188) reviewed for insulin administration. This failed practice created the potential for harm should residents experience adverse outcomes from low blood sugar when the hypoglycemic (low blood sugar) protocol was not followed. Findings include: The facility's policy, Hypoglycemia Management, dated 1/2/24, documented, If the blood glucose [sugar] reading is 70 mg/dL or below, the nurse will utilize the hypoglycemic protocol as per the practitioner's orders, with the follow up blood glucoses as indicated, and notify the practitioner of the results as ordered. Resident #188 was admitted to the facility on [DATE], with multiple diagnoses including acute respiratory failure with hypoxia (a condition where there is not enough oxygen in the tissues of the body) and type 2 diabetes mellitus. A physician order, dated 4/17/24, directed staff to perform blood glucose tests before administering insulin before each meals and at bedtime. A physician order, dated 4/26/24, included a hypoglycemic order for Resident #188 which stated, for blood glucose less than 70 mg/dL, treat with 4-8 oz juice or 1 tube oral glucose gel. Recheck BG [blood glucose] in 15 minutes after treatment. If BG remains less than 70 mg/dL, repeat treatment until BG is 70 mg/dL or greater. Resident #188's MAR documented the following low blood glucose readings before breakfast: - On 4/24/24, she had an BG reading of 58 mg/dL. - On 4/26/24 she had an BG reading of 52 mg/dL. - On 4/27/24 she had an BG reading of 67 mg/dL. The MAR did not include documentation of follow-up blood glucose checks by the nurses or notification of Resident #188's physician, as required by the hypoglycemic protocol. On 5/2/24 at 3:33 PM, the DON and CRN were interviewed together and Resident #188's record was reviewed in their presence. The DON and CRN confirmed Resident #188's physician was not notified, and that professional standards of practice in the hypoglycemic protocol were not followed for Resident #188 on 4/24/24, 4/26/24, and 4/27/24.

Based on observation, review of facility infection surveillance documents, review of nurse schedules, staff interview, and policy review, it was determined the facility failed to ensure infection control prevention practices were implemented and maintained to prevent and contain COVID-19 infections. The facility's failure to implement and maintain infection control measures to prevent transmission of COVID-19 placed all negative staff in the facility, and all 24 residents on the COVID-19 negative units in the facility, in immediate jeopardy of serious harm, impairment, or death related to COVID-19 infection. Findings include: 1. The facility did not have designated staff to work the COVID-19 positive unit each shift and ensure staff who tested positive worked on the COVID-19 positive unit only after meeting criteria to return to work. Examples include: a. The CDC website, accessed on 10/14/20, included a section titled Responding to Coronavirus in Nursing Homes, which documented facilities were to assign dedicated healthcare professionals (HCP) to work only on the COVID-19 positive unit. The website also included Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, which documented dedicated means that HCP are assigned to care only for COVID-19 positive patients during their shift. The facility included two halls, the North hall and the South hall. The North hall had a plastic barrier that covered floor to ceiling and wall to wall separating rooms 216-223 from the other rooms in the North hall. This area was identified as the COVID-19 positive unit. Residents #1, #2, and #3 tested positive for COVID-19 and resided in this unit. The facility's Daily Nursing Staff Assignment, dated 9/28/20 - 10/8/20, included nurse staffing assignments for the North and South halls, which were 12-hour shifts. The schedule documented one licensed nurse was assigned to the North hall for the night shifts, for both the COVID-19 negative and COVID-19 positive residents. The schedule documented one licensed nurse was assigned to the North hall for the day shifts on 9/28/20 - 9/30/20, 10/3/20 -10/4/20, and 10/6/20-10/8/20, to serve both the COVID-19 negative and COVID-19 positive residents. On 10/8/20 at 10:05 AM, RN #1 stated she was assigned to the North hall, to care for both the COVID-19 negative and COVID-19 positive residents. RN #1 stated Residents #1, #2, and #3 were in the COVID-19 positive unit at the end of the North hall on the other side of the plastic barrier. RN #1 stated she crossed the plastic barrier to administer medications and completed assessments for the 3 residents on the COVID-19 positive unit and then crossed back through the plastic barrier to the COVID-19 negative unit to administer medications and completed assessments for the 12 residents that were negative for COVID-19. RN #1 stated she mainly stayed on the COVID-19 negative unit. On 10/8/20 at 11:43 AM, RN #1 was observed crossing the plastic barrier from the COVID-19 negative unit into the COVID-19 positive unit with medications for Resident #1. On 10/8/20 at 12:03 PM, RN #1 was observed crossing the plastic barrier from the COVID-19 positive unit into the COVID-19 negative unit. On 10/8/20 at 12:09 PM, RN #1 was observed administering medications to Resident #6, who resided on the COVID-19 negative unit. On 10/8/20 at 5:15 PM, the DON stated there were shifts where the nurses' scheduled to work the North hall from 9/28/20 to present were crossing the plastic barrier and working both the COVID-19 positive unit and negative unit for both the day shifts and night shifts. On 10/8/20 at 5:45 PM, LPN #1 stated she was scheduled to work 12 hours on the night shift. LPN #1 stated she had worked the North hall when the COVID-19 positive unit was initiated. LPN #1 stated she had crossed the barrier from the negative unit into the COVID-19 positive unit to pass medications, complete nurse assessments, and provided cares for the residents residing on the COVID-19 positive unit. b. On 10/8/20 at 9:25 AM, the DON stated staffing at the facility had not been at a crisis level. On 10/8/20 at 12:35 PM, the ICP stated the facility was following CDC guidance for mitigating staff shortages and to determine when positive staff could return to work. At 12:50 PM, the ICP provided the survey team with two CDC documents. The first CDC document was titled Strategies to Mitigate Healthcare Personnel Staffing Shortages, updated 7/17/20. The second CDC document was titled Criteria for Return to Work for Healthcare Personnel with [DIAGNOSES REDACTED]-CoV-2 (COVID-19) Infection (Interim Guidance), updated 8/10/20. The document titled Strategies to Mitigate Healthcare Personnel Staffing Shortages stated, If HCP (Health Care Personnel) are tested and found to be infected with [DIAGNOSES REDACTED]-CoV-2, they should be excluded from work until they meet all Return to Work Criteria. The document titled Criteria for Return to Work for Healthcare Personnel with [DIAGNOSES REDACTED]-CoV-2 (COVID-19) Infection (Interim Guidance) stated HCP could return to work when at least 10 days had passed since symptoms first appeared, and at least 24 hours had passed since their last fever without the use of fever-reducing medications, and symptoms (e.g., cough, shortness of breath) had improved. The facility's Novel Coronavirus Prevention and Response policy, dated 9/2/20, stated interventions to prevent the spread of respiratory germs within the facility included monitoring staff for fever and respiratory symptoms. The policy stated Restrict (staff) from work and follow current guidance about testing and returning to work (e.g., local health department, CDC). The facility did not follow the guidance from the CDC or their policy. i. On 10/8/20 at 10:05 AM, RN #1 stated she tested positive for COVID-19 on 9/28/20, and had symptoms of a fever, cough, sore throat, nausea, occasional diarrhea, and fatigue. RN #1 stated she was assigned to and worked the COVID-19 positive unit on 10/1/20, 10/2/20, and 10/5/20. RN #1 returned to work three days after testing positive for COVID-19 and while she had active symptoms. RN #1 stated today, 10/8/20, she was assigned to work both the COVID-19 negative and COVID-19 positive units on the North hall and was crossing the plastic barrier to administer medications to both the COVID-19 negative and COVID-19 positive units. On 10/8/20 at 10:47 AM, RN #1 stated she had nausea and occasional diarrhea on 10/7/20, but none yet so far today. RN #1 stated she did not have her taste and smell and was fatigued. RN #1 stated she answered the questions on the staff screening log and someone else took her temperature. RN #1 was observed with a flushed face and she stated her N95 mask and face shield made her warm. The facility's staff screening log, dated 10/8/20, documented RN #1 had marked, yes for cough, congestion, shortness of breath, or sore throat. RN #1 marked, no for nausea, diarrhea, or lack of taste or smell. The screening log documented RN #1's temperature was 97.7 Fahrenheit. On 10/8/20 at 11:28 AM, RN #1 stated she filled out the screening log and was not assessed by a nurse or the ICP regarding the questions she answered yes too. RN #1 stated she was told by the DON on 10/7/20 that she could return to work because her symptoms had decreased. ii. COVID-19 test results and staff timecards documented staff returned to work prior to the 10-day criteria, as follows: - The BOM tested positive on 9/14/20 and worked on 9/23/20 (9 days). - CNA #1 tested positive on 9/25/20 and worked on 9/30/20 (5 days). - RN #1 tested positive on 9/29/20 and worked on 10/1/20, 10/2/20, and 10/5/20 (2 days). - CNA #2 tested positive on 9/29/20 and worked on 10/3/20 and 10/4/20 (4 days). - CNA #3 tested positive on 9/29/20 and worked on 10/3/20 and 10/4/20 (4 days). On 10/8/20 at 5:22 PM, the DON stated the CDC was the facility's primary source of information related to positive staff returning to work. The facility failed to ensure they had designated staff assigned to the COVID-19 positive unit each shift, and staff who tested positive met criteria for return to work and did not provide cares for residents who were on the COVID-19 negative unit. These deficient practices placed staff and residents who had tested negative of COVID-19, at imminent risk of COVID-19 infection and subsequent serious harm, impairment, or death related to the infection. On 10/8/20 at 7:18 PM, the Administrator, DON, and ICP were informed verbally of a determination of Immediate Jeopardy. The written notification was provided to the facility via email on 10/9/20 at 11:49 AM. On 10/9/20 at 12:42 PM, the facility provided a plan to remove the immediacy. The facility alleged the plan to remove the immediacy was implemented 10/8/20 at 10:00 PM. The plan was accepted on 10/9/20 at 1:45 PM. The facility's IJ removal plan included: -Designated staff had been placed into the COVID-19 positive unit and will not cross over to the barrier during their shift. -Staff who tested positive and are having active COVID-19 symptoms will not be assigned to work any shifts on the COVID-19 negative unit. Surveyors completed onsite verification on the removal of the IJ and confirmed immediacy was removed as of 10/8/20 at 10:00 PM. On 10/9/20 at 2:35 PM, the Administrator, DON, and the ICP were verbally informed the immediacy was removed based on onsite verification the IJ removal plan was implemented. 2. The facility's Coronavirus Surveillance policy, dated 9/2/20, stated heightened surveillance activities would be implemented to limit transmission of COVID-19, including staff. The policy stated staff were to be screened for 1) signs and symptoms of a respiratory infection, 2) whether staff had contact with someone with a confirmed [DIAGNOSES REDACTED]. The policy stated staff with signs and symptoms of a respiratory infection shall not report to work and staff that develop signs and symptoms while on the job will immediately stop work, put on a facemask, and self-isolate at home. The facility's screening form for staff, undated, stated all staff were required to answer the questions on the form prior to beginning each shift. The screening form also stated if a staff responded yes to having a fever they must put on a mask and call either the administrator, DON, or ICP and an action must be documented on the back of the form to determine if they were eligible to work. The screening form questions were: - Cough, congestion, shortness of breath or sore throat present? - Nausea, diarrhea, lack of taste of smell (sic)? - Contact with person with COVID-19 or under investigation? - Travel in the past 14 days to an area with community spread COVID? - Are you or do you intend to work anywhere outside this facility? The form also included a column for documentation of staff temperatures. The facility's daily staff screening forms, dated 9/13/20 - 10/8/20, did not include documentation of the action taken by the facility to determine work eligibility when staff answered yes to questions. There were also screening forms with no documentation of staff temperatures. Examples include: - 9/17/20: One staff member marked yes to the question nausea, diarrhea, and/or lack of taste or smell. There was no documentation on the back of the form related to the action taken by the facility to determine work eligibility. -9/21/20: No temperature was documented for 1 staff. - 9/22/20: No temperature was documented for 2 staff. - 9/23/20: No temperature was documented for 1 staff. - 9/24/20: No temperature was documented for 1 staff. - 10/1/20: Five staff members marked yes to the question Contact with person with COVID-19 or under investigation? One staff member answered yes to the question, Are you or do you intend to work anywhere outside this facility? There was no documentation on the back of the form related to the action taken by the facility to determine work eligibility. - 10/2/20: One staff member marked yes to the question Cough, congestion, shortness of breath or sore throat present? Four staff members marked yes to the question Contact with person with COVID-19 or under investigation? There was no documentation on the back of the form related to the action taken by the facility to determine work eligibility. - 10/3/20: Two staff members marked yes to the question Cough, congestion, shortness of breath or sore throat present? One staff member marked yes to the question Nausea, diarrhea, lack of taste of smell? One staff member marked yes to the question Contact with person with COVID-19 or under investigation? and marked yes to the question Are you or do you intend to work anywhere outside this facility? There was no documentation on the back of the form related to the action taken by the facility to determine work eligibility. - 10/6/20: One staff member marked yes to the question Nausea, diarrhea, lack of taste or smell? Seven staff marked yes to the question Contact with person with COVID-19 or under investigation? Two staff members marked yes to the question Are you or do you intend to work anywhere outside this facility? There was no documentation on the back of the form related to the action taken by the facility to determine work eligibility. - 10/8/20: One staff member marked yes to the question Cough, congestion, shortness of breath or sore throat present? Three staff members marked yes to the question Contact with person with COVID-19 or under investigation? Two staff members marked yes to the question Are you or do you intend to work anywhere outside this facility? There was no documentation on the back of the form related to the action taken by the facility to determine work eligibility. On 10/8/20 at 12:35 PM, the ICP stated if staff answered yes to screening questions, then their temperature would determine whether they could work. The ICP stated she reviewed the forms almost every day and the back of the screening forms were to be completed by those staff who answered yes. On 10/8/20 at 1:03 PM, the Administrator and DON stated staff were not screened on the COVID-19 positive unit because the staff were all positive anyway. 3. The CDC website, accessed 10/14/20, included a section titled, Using Personal Protective Equipment (PPE), dated 8/19/20, instructed healthcare personnel on How to Put on (DON) PPE Gear which stated when putting on an isolation gown to tie all of the ties on the gown. On 10/8/20 at 10:11 AM, RN #1 was observed donning a gown and entering Resident #5's room, without tying the gown at her waist. RN #1 administered oral medications and a nebulizer treatment (a fine mist of liquid medication to be inhaled) to Resident #5. RN #1 had her back, back side, and the back and sides of her legs exposed. RN #1 stated she should have also tied the gown at her waist. On 10/8/20 at 4:08 PM, the DON stated RN #1 should have tied the gown at her neck and waist.

Based on observation and staff interview, it was determined the facility failed to ensure nursing staff followed professional nursing standards of practice, medications were dispensed and administered by one licensed nurse in the COVID-19 positive unit. The facility's failure placed all 3 residents (#1, #2, and #3) in the COVID-19 positive unit at imminent risk of significant medication errors and subsequent serious harm, impairment, or death. Findings include: The Potter & Perry Fundamentals of Nursing, Eighth Edition, textbook, under Professional Standards in Nursing Practice states under the section Legal Guidelines for Recording, nurses should only chart for themselves, are accountable for information they enter into a patient's chart, and nurses were never to chart for someone else. The Nurse.com website, dated 12/16/15, and accessed on 10/13/20, documents, One of the first general principles in medication administration that a nurse must adhere to is to personally prepare any medications properly ordered for a patient and to personally administer those medications. Although there may be instances in which more than one healthcare provider may be required to administer a single medication, such as in a code, it is not generally acceptable practice to prepare any type of medication for another person to administer. Nor is it acceptable practice to administer a medication that another has prepared. The reasons for this strict rule are numerous. First and foremost, because preparation and administration are fraught with potential for error, relying on another nurse to prepare a medication that you administer is dangerous at best. According to the Agency for Healthcare Research and Quality article, Medication Administration Errors, updated on 9/7/19, errors in medication administration can occur through failures in any of the five rights: right patient, right medication, right time, right dose, and right route. The article states such errors may be the result at the individual-level but may also result from system-level failures such as understaffing and poor process. On 10/8/20 at 1:26 PM, RN #1 stated when she was scheduled on the COVID-19 positive unit on 10/1/20, 10/2/20, and 10/5/20, the nurses that worked the North hall, located outside of the COVID-19 positive unit, prepared the medications and delivered them to her in the COVID-19 positive unit to administer to the residents. RN #1 stated the medications were placed in medicine cups with the resident's room number handwritten on each medicine cup by the licensed nurse from the North hall. The medicine cups were placed on a bedside table located inside the COVID-19 positive unit. RN #1 stated she could not verify the medications were administered at the right dose, right medication, right resident, right time, and by the right route (e.g. oral, injection, rectal). RN #1 stated she did not sign in the Electronic Medical Record (EMR) for the medications she administered. RN #1 stated if a resident refused medications, she notified the licensed nurse working the North hall of the resident's refusal and that nurse documented the refusal in the resident's EMR. On 10/8/20 at 5:20 PM, RN #2 stated she worked the North hall and dispensed the medications of the 3 residents (#1, #2, and #3) on the COVID-19 positive unit into medicine cups, documented the medications as given in the EMR, and delivered the medication cups to RN #1 working in the COVID-19 positive unit. On 10/8/20 at 5:30 PM, the DON stated the licensed nurses scheduled to work the North hall on 10/1/20, 10/2/20, and 10/5/20 dispensed the medications, signed the EMR as given, and delivered the medications to RN #1 who was working in the COVID-19 positive unit for the residents there. The DON stated RN #1 was unable to verify the medications for each resident with the 5 rights (right dose, right medication, right time, right person, right route). The medications were not individually labeled and did not include sufficient information to identify which resident the medications were intended for. The licensed nurse who received the medications on the COVID-19 positive unit did not verify the medications or the resident they were intended for prior to administering them. These negative facility practices placed Residents #1, #2, and #3 on the COVID-19 positive unit at imminent risk of significant medication errors resulting in serious harm, impairment, or death. On 10/8/20 at 7:18 PM, the facility Administrator, DON, and ICP were verbally informed of the Immediate Jeopardy (IJ) determination at F684 and written notification was emailed to the facility on [DATE] at 11:49 AM. On 10/9/20 at 1:45 PM, the facility provided a plan to remove the immediacy. The facility alleged the immediacy was removed on 10/8/20 at 10:00 PM. The removal plan was received on 10/9/20 at 12:42 PM and was accepted on 10/9/20 at 1:45 PM. The facility's IJ removal plan included: - Licensed nurses were scheduled to work the COVID-19 positive unit to administer and document medications for all shifts. A medication cart was delivered and accessible by the licensed nurses to administer medications for residents located on the COVID-19 positive unit. A laptop was accessible to document medications were dispensed and administered by the licensed nurse that was scheduled in the COVID-19 positive unit. Surveyors completed onsite verification on the removal of the IJ and confirmed the IJ was removed as of 10/8/20 at 10:00 PM. On 10/9/20 at 2:35 PM, the Administrator, DON, and the ICP were verbally informed the immediacy was removed based on onsite verification the IJ removal plan was implemented.