Every finding on record at Maple Lawn Senior Care

Based on observation, interview, and document review, the facility failed to designate a qualified person to serve as the director of food service to oversee the dietary department. This had the potential to affect all 33 residents.Findings include: Interview on 2/23/26 at 12:00 p.m., with the facility designated dietary manager (DM) revealed she was not certified. She had been enrolled but dropped the class this past December because of personal life issues that made it difficult for her to continue. She had not submitted any of her course work that was required to complete the class and currently was not enrolled in any program. Interview on 2/24/26 at 11:22 a.m., with the registered dietician identified she was the DM's preceptor and was available to her to help her with any questions and review her coursework, however, her understanding was the DM was out on medical leave and was unable to complete the course work, therefore she had dropped the class. Interview on 2/26/26 at 8:31 a.m., with the administrator identified she would have expected the DM to be certified for the position, but at minimum, be enrolled in the class and have a serve safe certification to safely oversee the department and staff. Review of the facility provided 10/20/21, Dietary Director Job Description signed by the dietary director on 3/28/23, identified qualification for the position included taking or willing to take the Dietary Managers Course and THAT STAFF must pass the sanitation test or be willing to take a course approved by the state.

Based on interview and record review, the facility failed to ensure a registered nurse (RN) was on duty a minimum of 8 consecutive hours per day, 7 days a week for 1 of 92 days reviewed. This had the potential to affect all 33 residents. Findings include: Review of the facilities November 2025, December 2025, and January 2026 schedules identified on 11/29/25 the facility had no registered nurse on duty. Interview on 2/26/26 at 8:23 a.m., with the director of nursing identified she was responsible for the licensed nurse schedule. She reported she was on duty Monday through Friday 8 consecutive hours and if she needed to leave early, she would ensure there was another RN to cover the 8-hour requirement. On the weekends she ensured there was a RN scheduled 8 consecutive hours and if the facility did not have an RN to work over the weekend, she or another facility RN would come in and cover the RN 8 consecutive hours requirement. She confirmed that there had been no RN coverage on 11/29/25. Review of undated, RN Coverage policy identified the facility would ensure the services of a registered nurse were provided onsite for 8 consecutive hours per day, 7 days a week. Review of the Sufficient and Competent Nurse Staffing Review pathway, located in the Surveyor Resources Folder at https://www.cms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/nursing-homes, identified Note: The rule of 4 or more days is used for the purposes of the PBJ Staffing Data Report. The expectation of CMS is that the survey team would consider issuing a citation when a minimum of one day is identified to not meet the nurse staffing requirement for both a Registered Nurse and Licensed nursing staff.

Based on interview and document review, the facility failed to ensure the ombudsman was notified following discharge from the facility for 3 of 3 sampled residents (R1, R3, and R41). Findings include: R1's 1/2/26, accepted discharge return anticipated Minimum Data Set (MDS) assessment identified he had an unplanned discharged to the hospital on [DATE]. Review of nursing progress note dated 12/17/25 at 1:47 p.m., identified R1 was sent to the hospital emergency department via ambulance for evaluation due to having poor color, lips cyanotic, and R1 was shaking. Review of nursing progress note dated 12/22/25 at 12:13 p.m., identified the facility had received a nurse-to-nurse report from the hospital. R1 was admitted to the hospital on [DATE], with diagnoses of acute hypoxia with respiratory failure. R1 returned to the facility on [DATE]. Confirmation of ombudsman notice of discharge was requested for R1; however, the facility did not provide one by the end of the survey period. R3's 2/16/26, accepted modified Minimum Data Set (MDS) assessment identified she had diagnoses including chronic obstructive pulmonary disease (COPD), dementia with moderate mood disturbance, Alzheimer's, congestive heart failure (CHF), A-fib, hepatic failure, CKD stage 3, anxiety disorder, type II diabetes, hypertension (HTN), and chronic respiratory failure with hypoxia. R3's 2/20/26 at 5:59 p.m. progress note identified beginning of a change in condition, and following notification of the MD and review of ordered laboratory results R3 was hospitalized on [DATE]. R41's 2/6/26, accepted discharge with return not anticipated, MDS identified R41 was admitted on [DATE] and discharged on 1/30/26. R41's1/30/26 at 10:00a.m. Discharge Summary identified R41's family arrived at the facility on 1/30/26 and reported they were taking R1 home without waiting for results of the home safety evaluation. R41 was discharged to home Against Medical Advice (AMA). Interview on 2/25/26 at 1:09 p.m. with the social services designee (SSD) reported she had not completed Ombudsman notifications since 2024. She stated, she thought she might have done some notifications in 2025 but had no record of doing so. She reported she was not aware of the requirement to provide notification of hospital admissions or facility discharges, and as a result she had not done so. Interview on 2/25/26 at 2:07 p.m. with the director of nursing (DON) identified she was aware of the regulation for notification of the ombudsman of hospitalizations and discharges, but not aware it was not being completed. Confirmation of ombudsman notice of discharge was requested for R1, R3 and R41; however, the facility did not provide documentation the ombudsman had been notified of the discharges by the end of the survey period.

Based on interview and document review, the facility failed to appropriately assess, document, and revise the care plan for 1 of 1 sampled resident (R8) who had restorative therapies identified on his care plan, but was not receiving or completing those therapies as indicated. Findings include: R8's 2/16/26, accepted quarterly Minimum Data Set (MDS) assessment identified R8's cognition was intact. R8 was noted to have impairments bilaterally on his upper and lower extremities. R8 used a wheelchair for mobility. R8 was independent with eating, required substantial assistance from staff for dressing, personal hygiene, and required total assistance from staff for toileting and bathing. R28 used a Sit to Stand mechanical device with substantial assistance from staff for transfers. R8 was not noted to ambulate. R8 had not participated in any formal type of therapy or restorative program. R8's 2/26/26, printed Medical Diagnosis list identified pulmonary disease, symptoms involving the musculoskeletal system, asthma, tremors, radiculopathy of lumbar region (compressed or irritated nerve roots in lower spine often referred to as sciatica), functional implants, emotional liability ( exaggerated, and uncontrollable swings in emotion), polyneuropathies (widespread damage of peripheral nerves, causing numbness, tingling, burning pain, and muscle weakness), Arthritis, high blood pressure, and restless leg syndrome. R8's 7/10/25, care plan identified R8 was at risk for weakness and loss of self-care and mobility independence. R8 would participate in an informal restorative program with staff assistance to maintain lower and upper body strength and ambulation through the review date. R8's exercises included 3-4 times a week dowel (a 3/4 inch rod or broomstick) exercises with 3 pounds while seated for 15 repetitions. R8 was also to perform seated legs exercises with a number 2 therapy band times 15-20 repetitions and had a walking plan for 5 times a week to ambulate with four-wheeled walker assisted by a restorative aid bringing the wheelchair along. Review of R8's Functional Abilities and Goals assessments identified:On 1/10/25, R8 used a walker and wheelchair. For mobility R8 required partial/moderate assistance with transfers and supervision or touching assistance for ambulation of up to 50 feet.On 7/10/25, R8 used a walker and wheelchair. R8 only walked occasionally with the restorative aides who walked with him bringing a wheelchair behind. For mobility, R8 required substantial/maximal assistance with transfers and was dependent on staff to ambulate 10 feet. R8 did not attempt to ambulate 50 feet due to medical conditions or safety concerns.On 10/18/25, R8 used a wheelchair. For mobility R8 was dependent on staff for transfers. R8 did not attempt to walk 10 or 50 feet due to medical condition or safety concerns.On 11/14/25, R8 used a wheelchair. For mobility R8 was dependent on staff for transfers. R8 did not attempt to walk 10 due to medical condition or safety concerns.On 2/11/26, R8 used a wheelchair. For mobility R8 required substantial/maximal assistance with transfers. Walking 10 feet was identified as Not applicable.There were no other assessments related to R8's restorative exercise abilities found in his medical record. Review of progress notes identified on:On 12/10/25 R8's restorative therapy plan was reviewed. R8's restorative program was changed to ambulate to breakfast in the morning as tolerated. There was no mention of why the restorative program was reviewed or details of the assessed program even though the 11/14/25 functional assessment identified R8 did not attempt to walk.On 12/17/25, Staff reported R8 was having more difficulty, and at times unable to stand as his legs buckled and then he would hang from the lift. R8 seemed weaker and less able to assist with his cares. There was no mention of any nurse assessing the reported difficulty with standing or safety concern of using the standing lift.On 1/8/26, R8 was uncooperative throughout the day, during a transfer he would repeatedly refuse to place his hands on the equipment handles as instructed. Only after 5 verbal prompts did R8 comply with assisting. R8 also refused to wear his shoes during the transfer process. Interview on 2/23/26 at 1:25 p.m., with R8 identified he did not participate in a restorative exercise program. He reported he squeezed a ball he had and that it worked just the same. R8 reported he used to go and exercise where he rode the bike; however, the facility had cut that to save money. Interview on 2/26/26 at 9:14 a.m., with nursing assistant (NA)-A identified that R8 never walked, he did have a walking restorative program, but he was very particular with his cares and how he wanted things, he refused to walk. R8 used a standing lift for all transfers with one staff assistance. If staff note a decline in a residents function the staff are to tell the nurse. The nurse would assess the resident and if needed the resident was seen by the physician if they did not get better. Interview on 2/26/26 at 9:21 a.m., with licensed practical nurse (LPN)-A identified R8 used to walk but he would not walk anymore. When he was participating in his restorative program, he did not want to walk and would tell staff he was just waiting to die. Staff would try to get him to walk, but he refused. R8 not wanting to walk, might have something to do with his leg issues. He has an implant in his back that needs to be charged in a special chair every week. When the battery in his implant is getting low sometimes his legs don't want to work, and they really start to bother him. All nurses could update a resident's care plan, however, registered nurse (RN)-A typically reviewed and made updates to care plans following the completion of a resident's MDS assessment. Interview on 2/26/26 at 9:44 a.m., with RN-A identified she reviewed care plans following completion of the MDS; however, all nurses were able to and should be updating the resident care plans as things change. R8 did have a restorative program and there was a task for staff to document on his completion of the restorative program however, she had removed the task that would identify staff were to ensure R8 completed his walking, as he was refusing to walk. R8 had been working with restorative therapy until the staff that worked in that department had resigned; however, she was unsure if he was walking with the restorative staff either. IF a nurse identified a need for a change in the residents care they were responsible for updating the care plan. She confirmed R8's care plan should have been updated to reflect his status. Review of R8's medical record lacked identification of refusals of his restorative exercises and lacked an updated assessment for identified restorative exercises or risk to benefit showing R8 was made aware of potential decline by not completing his restorative treatments. Interview on 2/26/26 at 9:58 a.m., with the director of nursing (DON) identified she had re-assessed R8's restorative program back in December 2025 and changed his program to walking once a day to breakfast with staff assistance. She reported R8 was walking at the time, but he kept refusing to walk. She confirmed she should have updated the care plan when she first changed his restorative program back in December 2025 and when she was made aware he was refusing to walk at all. The facility had a good formal restorative program back around November or December of 2025 with a couple of staff. When she and the administrator had spoken to the restorative staff about some charting concerns, both staff placed their resignation, and the program was no longer fully staffed at that time. The facility had the direct care staff complete as many of the restorative programs as possible and had a light duty staff recently returned to work that was working on restorative programs, but the facility was unable to staff a formal program. She confirmed the residents were getting their restorative therapy, but not as much restorative therapy as they should as the facility still needed to fill the restorative positions. She revealed there was room for improvement in the restorative program and with the new therapy department starting on 3/2/26, all residents would be re-assessed at that time. Review of January 2025, Care plans, Comprehensive Person-Centered policy identified that each resident would have a person-centered care plan that included measurable goals to meet the resident's physical, psychosocial and functional needs. The care plan interventions would be developed through assessments, gathering information from the interdisciplinary team, the resident/representative, and the attending physician. The care plan would include goals, treatments, specialized services, to aid in preventing or reducing decline in the resident's status and enhance optimal functioning while reflecting current standards of practice. The care plan should be developed or revised within 7 days of the completion of the MDS assessment.

Based on observation, interview, and document review, the facility failed to re-assess nursing interventions and communicate findings for skin wound for 1 of 1 sampled resident (42) once an open area had been identified by nursing. Findings include: R42's 2/24/26, admission Record identified that R42 was admitted to the facility mid-February 2026, from an assisted living facility. R42 had diagnoses of heart failure, diabetes, dementia, high blood pressure, and a history of stroke. Interview on 2/23/26 at 1:08 p.m., with R42 identified she had a sore on the back of her right leg that the nurse kept covered because otherwise she scratched it.'R42's 2/19/26, baseline care plan identified R42 required partial assistance of one staff for cares, transfers, and ambulation. There was no mention of wounds or risk of wounds on R42's care plan. R42's 2/20/26, Weekly Skin Audit/Bath Form identified 3 small bruises on her left arm, and some bruising was noted on her lower abdomen caused by insulin injections for her diabetes. The skin audit identified there were no open lesions, cuts, lacerations, open skin folds, or skin tears. There were also no identified blisters, open ulcers, no dry or flaky skin, and no edema. R42's progress notes from 2/19/26 through morning of 2/24/26 identified on: 2/19/26, an initial skin assessment was completed. No open areas were noted. 2/22/26, R42 received a small bandage to her right shin for a small broken scab, measuring less than 1 centimeter all around. The progress notes made no mention of a wound on the back of R42's right leg lacking evidence that the wound had been communicated for continued monitoring for healing. Interview on 2/24/26 at 9:59 a.m., with nursing assistant (NA)-B identified R42 did have dressing on the back of her leg but she was not sure what was under the dressing. R42's February 2025, treatment record and orders had no mention of a dressing to the back of R42's right leg. Interview, document review and observation on 2/24/26 at 12:58 p.m., with licensed practical nurse (LPN)-A and R42 identified LPN-A was unable to find in R42's medical record, any documentation R42 had a wound on the back of her right leg. There were no nursing or physician orders for wound treatment or monitoring. LPN-A also reviewed R42's last skin audit that was completed on 2/20/26 that only identified small bruises on arms and abdomen. She was unable to find any progress note about a wound since R42's admission the prior week however, she did find a note that a band aide had been applied to the front of R42 right shin. LPN-A then went to observe the back of R42's right leg and identified a self-adhesive padded dressing on R42 right calf that was dated 2/20/26 with no initials of who applied. The dressing was removed by LPN-A with a small amount of drainage on the bandage and a small open wound. LPN-A described as a possible scab that was scratched open. R42 at this time denied she scratched the back of her leg but maybe she had rubbed it on her recliner. LPN-A stated she had no clue R42 had an open sore on the back of her leg. LPN-A confirmed the nurse that identified the sore and applied the dressing should have made a progress note, set up a treatment, and updated the provider. Interview on 2/24/26 at 3:36 p.m., with director of nursing (DON) identified R42 had admitted from an assisted living facility and the day she arrived she refused to get undressed for the male staff. She was uncomfortable with the male staff completing the skin audit and that should have been delegated to another nurse. R42's wound was a recurrent one and it had just opened prior to her coming here and was one of the indications for her coming here as well. When the nurse identified the wound on the back of R42's leg the nurse should have contacted R42's primary provider for orders and set up the treatment. The DON revealed she would also expect a progress note of the wound assessment. Review of the undated, Pressure Ulcer/Skin Breakdown-Clinical Protocol policy identified newly admitted residents will have a skin examination done by the nurse to identify any existing pressure ulcers or other skin concerns.

Based on observation, interview, and document review, the facility failed to provide services to maintain and/or prevent decrease in range- of-motion (ROM) for 1 of 1 sampled resident (R35) reviewed for limited range of motion. Findings include: R35's 8/19/2025, comprehensive Minimum Data Set (MDS) assessment identified his cognition was moderately impaired. He had diagnoses of cerebral palsy (condition primarily affecting leg movement and muscle stiffness) and dementia. R35's 2/10/26, Functional Abilities and Goals assessment identified R35 was dependent on staff for Activities of Daily Living (ADL)'s. He had no impairment to his upper extremities but was impaired on both sides of his lower extremities and used a manual wheelchair for mobility. R35's current, undated care plan identified he was at risk for decline in his physical condition related to cerebral palsy (condition primarily affecting leg movement and muscle stiffness) and was dependent on a wheelchair for mobility. The goal was for R35 to participate in a restorative exercise program to maintain his upper body strength. On 6/30/25, staff were to begin assisting R35 with the use of an arm bike (used to maintain upper body strength while limiting lower body movement) with moderate resistance for 15 minutes daily. Interview on 2/23/26 at 2:11 p.m., R35 identified staff do not do any ROM exercises with him. Interview on 2/26/26 at 8:04 a.m., with nursing assistant (NA)-A identified staff sometimes do some restorative exercises but generally NA-B was responsible to do that. NA-A was unable to recall the last time she had completed restorative with R35. Interview on 2/26/26, at 8:20 a.m., with director of nursing (DON) identified the facility had recently started having NA-B complete some restorative exercises with residents. R35 was to have the arm bike offered to him daily, however, she was aware they had a gap, and it was unlikely R35's restorative exercise were getting done every day. Staff are just not getting it done. Re-education of staff and audits are needed as We know our restorative program needs work. Interview on 2/26/26, at 13:32 a.m., with NA-B identified she was on light duty following an injury. She previously had been the bath aid but was temporarily assisting residents with light restorative exercise. Mainly helping residents on and off the NuStep exercise bike. The DON gave NA-B a list of residents she was to assist with using the NuStep bike but R35 was not on the list, and she has not completed any restorative exercises with R35. Interview on 2/26/26, at 8:24 a.m., with the administrator identified she would expect staff to complete restorative exercises with residents as care planned. They recently discussed this and plan to hire restorative aid for the facility. Review of the facility provided, undated, Restorative Nursing Policy, identified restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services and promotes the resident's ability to adapt and learn to live as independently and safely as possible. Restorative goals and objectives are individualized, resident-centered, and are outlined in the resident's care plan. Restorative goals may include but are not limited to adjusting or adapting to changing abilities, developing, maintaining, or strengthening his/her physiological and psychological resources. Maintaining dignity, independence, and self-esteem; and participating in the development and implementation of his/her care plan.

Based on interview and document review, the facility failed to ensure the resident had a care conference to be able to participate in the planning process and development of interventions of their care for 1 of 1 sampled resident (R7) who had been at the facility for 3 months with no care conference scheduled. Findings include: R7's 12/01/25, accepted admission Minimum Data Set (MDS) assessment identified that R7 had admitted to the facility in the middle of November 2025. R7 cognition was intact. She used a walker or a wheelchair for mobility and required partial assistance with some activities of daily living (ADL's). She had diagnoses of arthritis, thyroid disorder, diabetes, renal disease, and hypertension. R7's plan was to remain living in the facility. Additionally, a 2/20/26, accepted quarterly MDS assessment was completed identifying again R7's cognition was intact. Interview on 2/23/26 at 2:33 p.m., with R7 identified, she had not been invited to or attended a care conference since coming to the facility. Review of R7's progress 11/12/25 through 2/22/26, had no mention of a care conference occurring since admission to the facility. Interview on 2/24/26 at 1:42 p.m., with the activity director identified that care conferences followed the MDS schedule. There was to be a progress note made and the multidisciplinary care conference form filled out by each department following a care conference. Review of R7's assessments lacked any assessment titled Interdisciplinary care conference and there were no assessments identified as a care conference form. Interview on 2/25/26 at 10:47 a.m., with registered nurse (RN)-A identified that typically a care conference was scheduled by the social service designee (SSD) within 2 weeks of the MDS assessment completion. The facility would document a care conference meeting on the care conference form under the assessment section in point click care (PCC) and make a progress note. RN-A confirmed she could not find documentation that a care conference had occurred for R7 since admission. Interview on 2/25/26 at 10:58 a.m., with SSD identified that when a resident admitted to the facility a care conference would be set up within the first 2-4 weeks of admission. Care conference would then take place every quarter after that. She confirmed that R7's initial care conference had been missed stating it was just an overlook but she did have one scheduled now in March, confirming that was 4 months after admission to the facility. Interview on 2/26/26 at 8:23 a.m., with the director of nursing (DON) identified she was unsure of when resident care conferences should take place and stated, I would have to reference our policy. Review of the undated, Care Plan Meeting policy identified each resident admitted to the facility would receive a person-centered, comprehensive care plan developed through the interdisciplinary team and the resident and/or representative. The care plan would be developed via assessments and consultation with the residents and/or representatives. The care planning meeting would be held, 7-10 days following the completion of the comprehensive MDS assessment and then quarterly thereafter. Care plan meeting shall also be held when there is a significant change in the resident's status, or when requested by the resident/representative or facility. The residents shall participate in the care planning process and if unable the representative will be involved. The care plan meeting would be documented and include the date and time of the meeting, who attended, and a summary of the meeting.

Based on interview and document review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 5 sampled residents (R28) reviewed for unnecessary medication review. Findings include: R28's 12/29/25, accepted quarterly Minimum Data Set (MDS) assessment identified R28's cognition was intact. R28 used a walker or wheelchair for mobility and required partial to moderate assistance from staff for activities of daily living (ADL's). R28 took a daily anticoagulant medication. R28's 2/25/26, printed diagnosis list identified persistent atrial fibrillation (abnormal heart rhythm), high blood pressure, history of broken wrist, long term use of anticoagulants (blood thinner) and a history of stroke. R28's 2/24/26, Order Summary Report identified R28 took Apixaban (anticoagulant medication to prevent blood clots or stroke for people with atrial fibrillation) 2.5 milligrams twice a day for atrial fibrillation. There was no order or mention of monitoring for side effects of the anticoagulant medication that can cause bleeding, nausea, and increased bruising. R28's September 2025, care plan identified R28 had potential for nutritional problems related to low body mass, high blood pressure, atrial fibrillation, irritable bowel syndrome, and gout. There was no mention that R28 took an anticoagulant medication or the need for staff to monitor any side effects of that medication. Interview and document review on 2/2/26 at 9:44 a.m., with registered nurse (RN)-A identified she completed a review and updated the care plan following completion of an MDS assessment. All nurses were able to and should be updating the resident care plans as things change as she was not the only one who updated care plans. She confirmed there was no mention on R8s care plan of anticoagulant medication or for staff to monitor for side effects on R28's care plan. She agreed that information should be on the care plan. Interview on 2/26/26 at 8:23 a.m., with the director of nursing (DON) identified any resident taking anticoagulant should have interventions and monitoring identified on the care plan and include the side effects of the medication. Review of January 2025, Care plans, Comprehensive Person-Centered policy identified that each resident would have a person-centered care plan that included measurable goals to meet the resident's physical, psychosocial and functional needs. The care plan interventions would be developed through assessments, gathering information from the interdisciplinary team, the resident/representative, and the attending physician. The care plan would include goals, treatments, specialized services, to aid in preventing or reducing decline in the resident's status and enhance optimal functioning while reflecting current standards of practice. The care plan should be developed or revised within 7 days of the completion of the MDS assessment.

Based on observation, interview, and document review the facility failed to discard food that had expired, ensure all foods were labeled and dated, and maintain a clean fan that blew in the direction of clean dishes. This had the potential to affect all 37 residents residing in the facility. Findings include: Observation and interview on [DATE] at 10:44 a.m., with the dietary manager (DM) during initial tour of the kitchen. An observation of the refrigerator next to the food prep area contained 2 half gallons of milk with best use by date of [DATE]. The DM stated the milk should have been tossed out on [DATE]. The walk-in cooler contained 4 dishes of dessert that was not labeled or dated and a pre-made salad in a bowl that was dated [DATE] and was brown in color. The DM stated the dessert appeared to be carrot cake, but she was unsure of when that was last served. She confirmed that the dessert and the pre-made salad needed to be discarded. Observation and interview on [DATE] at 11:35 a.m., with the DM of the dishwasher room where there was a fan hanging on the wall across from the dishwasher where dirty dishes went in one side and clean dishes came out other side and sat to dry. The fan was observed to have lint debris that was hanging off the fan and moving as the fan was running. The DM agreed that the fan needed to be shut off and cleaned as there was a potential for the debris to blow onto the clean dishes. She identified that the dietary department was not responsible for cleaning the fan and that maintenance took care of that. Interview on [DATE] at 1:20 p.m., with dietician identified for food items labeled with a best use by date she would allow that to be used another 48 hours but of course that also need to be at the discretion of the kitchen staff. For the milk dated best use by [DATE] she confirmed that should have been discarded by [DATE] if not before. She would expect all foods to be labeled and dated and any food items pre-made like the salad in the bowl should be discarded if it looked bad or after 48 hours. The maintenance department was responsible for cleaning the fan in the dishwasher room however, she would expect the kitchen staff to also keep an eye on that. She reported that she would add that to the weekly cleaning list to check the fan. Interview on [DATE] at 2:28 p.m., with maintenance supervisor identified maintenance did not document when they cleaned the fan in the dishwasher room. He revealed the fan was only cleaned as needed and he was surprised at how dirty it gets. He revealed to clean the fan correctly it needed to be taken down and cleaned not just dusted off. He was unsure when the last time the fan had been cleaned. Interview on [DATE] at 10:30 a.m., with director of nursing identified her expectation was that the kitchen staff monitored for expired food to prevent food borne illness just as she expected the nursing staff to monitor food in the resident room. She further reported she would expect that the kitchen was maintained in a clean sanitary manor including the fan in the dishwasher room. Review of November and December dietary shift cleaning check list had no mention of checking or cleaning the fan. Review of the [DATE], Dietary Cleaning and Sanitization policy identified all kitchen areas would be kept clean and free from debris. The dietary manager may create a specific cleaning list to ensure the kitchen was maintained in a clean and sanitary manner. There was no indication the policy had been reviewed and updated annually per the regulation. A policy was requested for monitoring for expired food and the facilities protocol for monitoring and ensuring items are labeled and dated however, no policy or protocol was provided.

Based on observation, interview and document review the facility failed to ensure 1 of 2 narcotic emergency kit (E-kit) containing controlled and/or narcotic substances did not have expired medications, and ensure the E-kit contents label was updated monthly and current. Findings include: Observation on 12/16/24 at 5:40 p.m., with contract registered nurse RN-(A) of the medication room, identified a large narcotic E-kit, with a red numbered tag of 882350. RN-A stated the red tag indicated the E-kit had not been opened. If the container had a green tag, nursing staff were to use the E-kit list that was taped to the inside of the medication cabinet as a guide to fax the pharmacy of the medications that had been removed from the container and would need to be replaced. Review of July 2023 E-kit medication log identified lorazepam (treats anxiety disorders) 0.5 milligrams (mg) had an expiration date of 1/27/24, warfarin (prevent blood clots) 1 mg tablets had no expiration date listed, prednisone (reduces inflammation) 10 mg tablet with an expiration date of 1/7/24, doxycycline (antibiotic) 100 mg tablets had an expiration date of 3/02/24, levofloxacin (antibiotic) 250 mg tablets had an expiration date of 1/27/24, and sulfamethoxazole/trimethoprim ss tablets had an expiration date of 4/9/24. Observation on 12/16/24 at 5:43 p.m., of the E-kit container identified the following: 1.) 6 lorazepam 0.5 mg tablets expired 12/15/24. 2.) 8 warfarin 1 mg tablets had expired 12/15/24. 3.) 8 sulfamethoxazole/tmp ss 400-80 mg tablets expired 12/15/24. 4.) 8 doxycycline 100 mg tablets expired 12/15/24. 5.) 8 levofloxacin 250 mg tablets expired 12/15/24. 6.) 8 prednisone 10 mg tablets had expired 12/15/24. During interview on 12/17/24 at 3:50 p.m., with the director of nursing (DON) was aware the local pharmacy would replace E-kit medications monthly and upon request. The consulting pharmacist would destroy expired medications, monthly but she was unsure if the clinical pharmacist had a process to review E-kit medications. DON stated the pharmacy had provided an updated E-kit medication log last year for nurses and was to be used as a resource to review the medications that were stored in the E-kit, however, had not received an updated medication log this year. Interview on 12/18/24 at 10:20 a.m., with consulting pharmacist supervisor stated the E-kit was the pharmacy's responsibility. The consulting pharmacist was expected to review the E-kit log and medications, monthly. In addition, the consulting pharmacist would replace E-kit containers, when expired medication had been discovered. Lastly, he would expect the facility to have an updated E-kit medication log that would reflect an accurate list of medications along with their expiration dates. Review of June 2022 Pharmacy Services Overview policy identified consultant pharmacist would maintain appropriate pharmacy services that support residents needs and would be consistent with current standards of practice to meet State and Federal requirements. Review of January 2023 Emergency medications policy identified pharmacy services would review nursing home emergency kits at a minimum of every 90 days. Pharmacy E-kits would include the name of the medication, quantity of medications, expiration of medications, date E-kit was last updated, tag number of lock used and initials of the pharmacist and/or technician who updated the E-kit.

Based on interview and document review the facility failed to obtain informed consent for psychotropic medication use for 2 of 5 residents (R32, R91) and further failed to establish a baseline assessment for monitoring abnormal involuntary movements for 1 of 1 resident (R91) who had been prescribed a new antipsychotic medication. Findings include: R32's 9/6/24, quarterly Minimum Data Set (MDS) assessment identified R32 had severe cognitive impairment, inattention, disorganized thinking, and altered level of consciousness. R32 was dependent for all cares and was frequently incontinent of bowel and bladder. R32 took a daily antidepressant, anticoagulant, and diuretic. R32's 9/17/24, diagnosis list identified Alzheimer's disease, generalized anxiety, and major depressive disorder. R32's December 2024, medication administration record identified orders for: 1) Depakote Sprinkles 125 milligrams(mg) take 2 capsules every morning for generalized anxiety disorder, unspecified dementia severe with agitation start date 11/12/24 2) Depakote Sprinkles 125 mg take 3 capsules every evening for generalized anxiety disorder, unspecified dementia severe with agitation start date 11/12/24. 3) Zoloft 75 mg every evening for major depressive disorder start date 9/25/24. R32's medical record had no indication of consent by the resident, family, or guardian for the use of psychotropic medications via a signed form, progress note, or care conference note. R91's 11/27/24, admission MDS assessment identified R91 had moderate cognitive impairment, required partial assistance with cares. R91 was frequently incontinent of bowel and bladder and had occasional moderate pain. R91 was on hospice and took a daily antianxiety, antidepressant, opioid, and hypoglycemic. R91's 9/17/24, diagnosis list identified generalized anxiety disorder and depression. R91's 12/11/24, physician progress note identified R91 was seen for his increased anxiety, agitation, and medication management. R91 had a history of anxiety and cognitive decline while he was in assisted living. The physician identified R91's Zoloft had been increased to 50 mg daily (had been 25 mg) but he proceeded to continue to have significant anxiety and agitation. R91 was started on Zyprexa 2.5 mg (antipsychotic) twice daily scheduled on 12/6/24 for his first dose. R91's December 2024, medication administration record identified orders for: 1) Zoloft 50 mg every day for depression start date 12/4/24. 2) Zyprexa 2.5 mg twice a day for unstable mood start date 12/6/24. 3) Buspirone HCI 10 mg three times a day for generalized anxiety disorder start date 11/21/24 4) Ativan (lorazepam) 0.5 mg as needed every two hours for anxiety or agitation start date 11/29/24. R91's medical record had no indication that the facility had establish a baseline assessment for monitoring abnormal involuntary movements upon the start of Zyprexa (antipsychotic) medication. The chart further had no indication of a consent by the resident, family, or guardian for the use of psychotropic medications via a signed form, progress note, or care conference note. Interview on 12/17/24 at 8:54 a.m., with director of nursing (DON) identified that the previous MDS nurse reviewed psychotropic medications at care conference and obtained consents but never scanned them in and now she was unable to find any of them. She reported the MDS nurse had left between 6 months and a year ago she could not remember exactly. She reported she was in the process of calling all the families and getting verbal consent and then planned to have families sign the consent at the next care conference. She stated she knew it was after the fact, but she was doing due diligence right now. She further reported that the assessment for involuntary movements was built into the quarterly and annual MDS assessment. She confirmed that a baseline involuntary movement assessment was to be completed when a resident was started on an antipsychotic medication and then assessed quarterly after that. She reported she had completed that for R91 yesterday. Interview on 12/18/24 at 10:14 a.m., with the consulting pharmacist supervisor identified that he would expect some type of baseline assessment for involuntary movements to be completed upon starting an antipsychotic medication. He further confirmed that the facility typically obtained consent from families for the use of psychotropic medications as there were several families that had declined medication that were ordered by the provider. He confirmed he would expect the facility staff to review the pros and cons of the psychotropic medication and obtain consent for use. Interview on 12/18/24 at 10:30 a.m., with the DON revealed she had completely forgot about the consents for psychotropic medication use and getting the assessment completed following R91's new order for an antipsychotic medication. She reported she covered the problem and had called all the families and obtained verbal consents yesterday and completed the involuntary movement assessment as soon as it was brought to her attention. She also had hung a note at the nurse's station with a list of antipsychotic medication that would need to have an assessment done and to notify her if anyone had been prescribed one of those medications. Review of the June 2022, Antipsychotic medication use policy identified the facility would complete an AIMS (involuntary movement assessment) initially at the start of an antipsychotic medication. Then complete the AIMS assessment quarterly, annually, or with a significant change assessment. There was no indication the policy had been reviewed and update annually per regulation.

Based on interview and document review, the facility failed to ensure data submitted to the QAPI committee was analyzed and documented to ensure areas identified had oversight for their perspective outcomes brought forth. This had the potential to affect all 41 residents. Findings include: Review of quarterly QAPI meetings from January 2023 through December 2023, identified the facility departments were submitting data to be reviewed by the committee. 2 Examples of failure to analyze and document that process identified in: 1. Quarter 2 April, may, and June of 2023, identified data brought forth that included pressure ulcers, falls, catheter use, and infections. The QAPI minutes failed to identify an analysis of that data to determine the need for improvement, a root cause, a measurable goal, or an action plan for improvement. 2. Quarter 3 July, August, and September 2023, identified data brought forth that included prevalence of falls, pressure ulcers, skin, infections, medication errors. The QAPI minutes lacked any indication that an analysis of the data had been completed to identify problem areas, a root cause, a measurable goal, or action plan for improvement. Interview on 2/14/24 at 10:38 a.m., with the administrator identified she would expect the QAPI minutes to include a thorough analysis of the data, problem areas to be identified, a root cause analysis, a measurable goal, and an action plan for improvement. She agreed that the facility QAPI was missing those components and identified that they were currently working to restructure their QAPI committee program. Review of the facilities 2024, Quality Assurance & Performance Improvement Plan identified the QAPI committee would identify problems and opportunities for improvement, systematically analyze underlying causes of systemic problems and adverse events and develop corrective action or performance improvement activities.

Based on interview and document review, the facility failed to develop and implement a comprehensive antibiotic stewardship program, with established monitoring, to help reduce unnecessary antibiotic use, reduce potential drug resistance, and help prevent the spread of infectious diseases for 5 of 12 residents (R1, R5, R17, R28, and R33) reviewed. Findings include: Review of the facility infection surveillance tracking log identified residents who had been identified as having an infection and being administered an antibiotic. The surveillance logs lacked any documentation that an antibiotic time out had been completed or the date that the infection had been resolved. 1.) R1 was identified as having a urinary tract infection (UTI), she was prescribed an antibiotic cefdinir oral capsule that started on 5/31/23. The surveillance log lacked indication that a 72 hour time out had been completed or when the infection had resolved. 2.) R5 was identified to have had a UTI, she was prescribed an antibiotic Cipro 500 mg on 8/15/23. The surveillance log lacked indication that a 72-hour time out had been completed or when the infection had resolved. 3.) R17 was identified to have had a UTI, she was prescribed an antibiotic Macrobid 100 mg twice daily for 5 days on 8/30/23. She was also identified to have a UTI and started another antibiotic cefdinir 300 mg daily for 7 days, the surveillance log lacked any indication the facility had completed a time out or if either infection had resolved. 4.) R28 was identified as having an upper respiratory infection (URI) and starting an antibiotic on 6/24/23. The surveillance log lacked indication that a 72-hour time out had been completed or when the infection had resolved. 5.) R33 was identified as having an unknown infection, he started an antibiotic amoxicillin 875-125 mg on 5/16/23. The surveillance log lacked indication of what the infection was, did not identify if a time out had been completed, and did not indicate when or if the infection had resolved. Interview on 2/14/24 at 1:34 p.m., with the director of nursing (DON) identified that the surveillance tracking log provided was a program used in the facilities electronic medical record system Point Click Care (PCC) that automatically pulled data when a new order for an antibiotic was entered. The DON stated, I can't say that I have evaluated or analyzed the data. She identified that the facility has an individual infection resident report that includes all the information such as resolve date and monitoring of symptoms, she reports she has not been completing these reports and states we just don't have enough hours. She reports she is not reviewing the information to see if there is a correlation to indicate a cause of infections or spread of infections but states I do look at shift report daily. The DON identified that she has not completed an antibiotic time out since she took the infection preventionist position several months ago. Review of the 1/31/2023, facility Antibiotic Stewardship Policy identified all clinical infections treated with antibiotics would undergo a review by the infection preventionist, or designee. The policy identified that the facility would complete an antibiotic time out 72 hours after the first dose is administered and report to the physician. The infection preventionist will review antibiotic utilization and identify specific situation that are not consistent with the appropriate use of antibiotics and notify the physician.

Based on interview and record review, the facility failed to report immediately but not later than 2 hours, allegations of potential abuse to the State Agency for 1 of 1 residents (R4). Findings include: Review of 1/21/24 at 10:40 p.m , report to the State Agency (SA) report identified earlier on 1/21/24 at approximately 12:01 a.m., nursing assistant (NA-E) informed licensed practical nurse (LPN-C) she refused to scratch R4's genital area as R6 requested. LPN-C found R4 crying in his room and R4 stated he asked NA-E to wash his genital area and NA-E refused. R4's 1/23/24 Significant Change Minimum Data Set (MDS) identified R4 had diagnosis of Aphasia, dementia, hemiplegia/hemiparesis, anxiety and depression. R4 was cognitively intact and required maximum assist for toileting and transfers. R4 took antidepressants daily. Interview on 2/14/24 at 8:35 a.m., with director of nursing (DON) stated she was made aware of the incident the next day and NA-E did not work at the facility after the incident. Interview on 2/14/24 at 4:44 p.m., with NA-E stated she worked on 1/21/24 on the night shift when R4 asked her to clean him. After cleaning him, she stated R4 asked her to scratch his genitals and she refused. R4 said to NA-E if she refused he would get the nurse. NA-E stated she left the room and informed LPN-C of the situation. NA-E stated she worked later that day on the evening shift on 1/21/24 and was approached by the DON who stated that R4 was afraid of me and I would not work the rest of my shift. Interview on 2/14/24 at 5:11 p.m., with LPN-C stated R4 had his call light on and found R4 in his room crying. LPN-C stated she cleaned and applied cream to R4's genital area. LPN-C stated R4 said he was upset at NA-E. LPN-C stated to R4 she would handle the situation. LPN-C stated she did not inform the DON of the incident until later that same day and assumed the DON would be notified by other staff who worked that night. Interview on 2/14/24 at 5:28 p.m., with R4 identified he felt NA-E mistreated him. R4 refused to answer any other questions and made no mention of the incident noted above. Interview on 2/14/24 at 6:13 p.m., with administrator (ADM) stated her expectations would be for staff to contact her of allegations of potential abuse of residents in the facility. Review of September 2023, Abuse Prohibition and Prevention policy indicated the facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment of resident property, are reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or no later than 24 hours if the events that cause the allegation do no involve abuse and do not result in serious bodily injury, to the director of nursing, administrator of the facility and to officials including the state agency.

Based on interview and document review the facility failed to comprehensively assess and develop individualized intervention for dementia and behaviors of dementia for 2 of 2 residents (R17 and R33). Findings include: R33's 12/21/23, quarterly Minimum Data Set (MDS) assessment identified R33 had severe cognitive deficits. He had difficulty focusing his attention, had disorganized thinking, and altered level of consciousness that fluctuated. R33 had physical and verbal behaviors towards others and had refused cares 1 to 3 days during the assessment period. R33's 2/14/24, diagnosis list identified Alzheimer's disease, vascular dementia severe with agitation, major depressive disorder, restlessness and agitation, emotional lability, history of stroke, and palliative care. R33's 9/21/23, cognitive loss/dementia Care Area Assessment (CAA) identified R33 had an actual problem related to dementia and not being able to understand, answer questions or process information. R33's ability to make himself understood had declined and he displayed disorientation, confusion, and forgetfulness. R33 had behavioral symptoms that had triggered however, no details were identified on the worksheet of the behaviors or contributing factors. The CAA worksheet identified that cognitive loss/dementia would be addressed on the care plan to slow or minimize decline, minimize risks, and avoid complications. Staff would need to anticipate R33's needs and adhere to his wishes when appropriate. R33's behavior symptoms CAA identified R33 had an actual problem as he acted out following a family visit. He had reached out and grabbed and tried to stand and walk away. R33 yelled at staff, and this was identified to occasionally occur. R33 displayed physical behaviors towards others such as kicking, hitting, scratching, grabbing, and pushing. He had verbal behaviors towards others such as cursing, threatening, and yelling. The assessment identified R33 had a long history of mental health problems and behavioral disturbances, he had sensory impairments such as vision and hearing that could exacerbate his behavior. R33 had a diagnosis of Alzheimer's disease. Behavioral symptoms would be addressed on the care plan to slow or minimize decline, minimize risk, and avoid complications. Staff would need to keep R33 safe from injury and re-approach later when he was agitated. Interview on 2/13/24 at 11:56 a.m., with nursing assistant (NA)-A identified R33 would fight a lot during cares. Normally staff did not get him up before 10:00 a.m., with his dementia as that worked best for him. She reported if staff got him up before he woke up on his own, he would have a lot more behaviors. R33 would strike out at staff, and he liked to bite. Staff really must be careful when putting his dentures in as he tries to bite you. She reported we always use 2 staff when completing his cares in the morning. She stated R33 typically had more behavior in the morning. Interview on 2/13/24 at 2:12 p.m., with NA-B identified that staff needed to approach R33 slowly and make sure they explained exactly what they were going to do before they started as that seemed to help prevent some of his behaviors. R33 really did not like anything cold touching him and she reported that she typically warmed the wipes by placing in warm running water before using them on him. Interview on 2/14/24 at 7:42 a.m., with NA-C identified if Nascar was on that was a must that staff set him up to watch, as he really liked watching Nascar he was a big fan. She reported it worked best to let him sleep and wake up on his own otherwise he had more behaviors. She stated if she went by his room and his eyes were open that meant he was ready to get up. If he was sleeping and staff knocked on his door and said his name and woke him up, he would have more behaviors. R33 was combative if staff did not go slow and really explain what they were trying to help him with, but once he was up for the day, he was pretty good. R33's care plan printed on 2/14/24, identified he had a fall related to poor comprehension and a diagnosis of dementia with behavioral disturbance. He was unaware of his safety needs. He would climb out of bed, stand, or go to the floor to fix things. He had a silent alarm and staff were to keep the bed in the lowest position with a fall mat next to bed when he was in bed. He was identified to have a care deficit related to Alzheimer's disease and was dependent on staff for bed mobility and transfers. R33 had behaviors consistent with Alzheimer's disease of resisting care non-combative, staff were to determine behavior cycle and event that triggered behavioral problems however, there was no triggers identified. Staff were to stop if R33 became resistant and document attempts and R33's response. Staff were to orientate to immediate surroundings and point out simple landmarks in the facility. R33 had a wander guard on his wrist. The care plan lacked identification of R33's behaviors of being combative. The care plan lacked identification that being woken up was a trigger for behaviors, or that using cold wet wipes was a trigger with no identified interventions to prevent those behaviors. The care plan had no mention that R33 really enjoyed watching Nascar and that he was a fan although staff were aware those interventions helped to calm his behaviors. Interview on 2/14/24 at 1:30 p.m., with registered nurse (RN)-A who reported she was the MDS nurse she was responsible to review the care plan and ensure the care plan reflected the resident and their needs. She identified that social service designee (SSD) was responsible for the dementia and behavior portion of the care plan, and she had been struggling a little with care planning. She further reported that she had been working with SSD on some training of writing care plans, and how the MDS triggered certain areas and those should be addressed on the care plan. RN-A stated if there was a triggered CAA for dementia and/or behaviors related to dementia she would expect to see that addressed on the care plan. The care plan was a working document and should be update any time the resident had a change. She reported that getting direct care staff input was part of her assessment process and she put out a form for each shift for the staff to document on what works, doesn't work and a place for comments for her to review and follow up on if needed. She was unsure if SSD interviewed direct care staff for insight but felt that was best practice as the front-line staff know the residents best. After review of R33's care plan she agreed that the care plan lacked individualization and addressed R33's dementia and behaviors related to his dementia. Interview on 2/14/24 at 2:02 p.m., with director of nursing (DON) identified that overall, the nursing department ended up covering everything but, she would expect each department to follow up and do more related to resident care plans and visit with the staff to help individualize them. The SSD had had been given tools to assist her with care planning and SSD has even watch YouTube videos on how to care plan. Her expectation was that if dementia was triggered on the MDS that it would be addressed on the care plan. 47497 R17's 12/8/23, Significant Change Minimum Data Set Assessment (MDS) identified R17's cognition was severely impaired, she had diagnosis of dementia, non-traumatic brain injury, anxiety, and bi-polar disorder. R17 had behaviors of rejection of care 1-3 days during the assessment period. R17's 12/8/23 Care Area Assessment (CAA) identified triggering conditions of Alzheimer's disease or other dementia and displayed characteristics of confusion, disorientation, and forgetfulness. R17's CAA identified that cognitive loss/dementia would be addressed on her care plan with an overall objective to slow or minimize decline, avoid complications, and minimize risks. Interview on 2/13/24 at 4:00 p.m., with nursing assistant (NA)-F identified when R17 is having a bad day they sit with her and visit, if she is upset or not talking or refusing care it helps to lotion her legs or visit with her about her family. She collects teacups and enjoys when we talk with her about that or talk with her about her grandson who is a doctor. NA-F identified that R17 sometimes had hallucinations of a small girl in her room, when that happens NA-F consoles her by telling her she is safe and that she is not alone. R17's current care plan printed on 2/13/24, lacked any indication of the interventions mentioned above, nor did it identify any other meaningful interventions for R17's diagnosis of dementia. Review of 10/26/23, Dementia- Clinical Protocol policy identified that the interdisciplinary team would evaluate residents with cognitive impairments and help identify symptoms. For residents with dementia the facility would develop an individualized care plan to maximize function and quality of life. The care plan would be reviewed for the effectiveness of interventions and revised as needed with the progression of dementia.

Based on observation, interview, and document review, the facility failed to ensure a system for monitoring the plastic lock on the emergency kit (E-kit) that contained controlled substances for 1 of 1 E-kits to detect potential diversion at each change of shift. Findings include: Review of the facility's ER KIT item list of what was located in the E-kit identified it contained the controlled medications of lorazepam 0.5 milligrams (mg) 6 tablets and morphine 20 mg/milliliter (ml) oral solution quantity, 15 milliliters. Observation and interview on 2/14/24 at 10:04 a.m., with licensed practical nurse (LPN)-A of the facility medication room. Locked in a cupboard was the facility E-kit with a red plastic lock with the number 882383. LPN-A revealed if the facility removed an item from the E-kit they had to fill out a form and fax it to the pharmacy. The staff would then place a green plastic lock on the E-kit those were located inside the E-kit. The pharmacy would then send a new E-kit and the facility would send the E-kit that had an item removed from it back to the pharmacy. LPN-A confirmed that the E-kit contained controlled medication. LPN-A revealed that the facility did not monitor the E-kit plastic lock number at all. LPN-A confirmed that during the shift narcotic count that the E-kit was not checked to ensure the plastic lock number was correct and had not been compromised. Interview on 2/14/24 at 10:26 a.m., with the director of nursing (DON) identified she was unaware that the facility should have been monitoring the E-kit plastic lock but agreed it made sense since the E-kit contained controlled medications. She stated, I just didn't think of that. She agreed by not monitoring the plastic lock on the E-kit there was potential for diversion. She agreed that if someone had removed the controlled medication from the E-kit it was likely that no one would notice until the E-kit had been returned to the pharmacy to be restocked for removal of another medication. She reported she would be implementing a tracking system immediately. Review of 9/19/23, Controlled Substances policy identified the facility would ensure a safe and secure storage system and mechanisms to minimize diversion or loss. Controlled substances that are stored in the locked medication room for emergency or on hand supply would be stored in a locked cupboard. The pharmacy would supply the container that the medication would be stored in with a numbered locking toggle system. At the end of each shift all controlled substances would be counted with the on coming nurse and nurse going off duty. There was no mention of monitoring the lock on the E-kit that contained controlled medications. Review of October 2023, Emergency Pharmacy Service and Emergency Kits identified the pharmacist would inventory the emergency kit every 30 days for expiration dates and ensure completeness. For controlled substances if a medication was removed from the emergency kit the nurse would reorder, obtain a handwritten prescription for physician and document the replacement of the controlled substance by the date and number of doses received. Accountability for controlled substances identified a inventory system would be used, with a separate sheet for each individual medication in the kit. Each dose used and replacement dose would be entered on the inventory sheet, with the amount remaining identified. The charge nurse going off duty and the charge nurse coming on duty would verify the inventory of controlled substance at each change of shift.

Based on interview and document review, the facility failed to ensure 3 of 5 residents (R1, R5, and R28) were offered and/or administered vaccination for pneumonia upon admission or when eligible. This had the potential to affect all 41 residents. Findings include: Review of the current Centers for Disease Control (CDC) pneumococcal vaccine guidelines located at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/pneumo-vaccine-timing.html, identified for: 1) 2) Adults [AGE] years of age or older, e) Received PCV-13 at Any Age AND PPSV-23 AFTER Age [AGE] years aa) Use shared clinical decision-making to decide whether to administer PCV20. If so, the dose of PCV-20 should be administered at least 5 years after the last pneumococcal vaccine. Review of 5 sampled residents for vaccinations identified: 1) R1 was [AGE] years old and was admitted to the facility in April of 2022. R2 was administered the PPSV-23 on 9/15/13, and the PCV-13 on 7/17/15. R1 should have been offered and/or provided the PCV-20 at least 5 years after the last pneumococcal vaccine per CDC guidelines. 2) R5 was [AGE] years old and was admitted to the facility in July of 2018. R5 was administered the PPSV-23 on 6/20/13, and the PCV-13 on 10/2/15. R5 should have been offered and/or provided the PCV-20 at least 5 years after the last pneumococcal vaccine per CDC guidelines. 3) R28 was [AGE] years old and was admitted to the facility in December of 2021. R28 was administered the PCV-13 on 10/26/15, and the PPSV-23 on 11/20/18. R28 should have been offered and/or provided the PCV-20 at least 5 years after the last pneumococcal vaccine per CDC guidelines. Review of the September 2022, facility Pneumococcal Vaccine Policy identified pneumococcal vaccines or re-vaccinations would be made in accordance with current CDC recommendations.

Based on interview and document review the facility failed to appropriately inform residents, their representatives, and families of those residing in facility by 5 p.m. the next calendar day following the occurrence of a single confirmed infection or when 3 or more residents or staff had new-onset of respiratory symptoms occurring within 72 hours of each other prior to and during facility's COVID-19 outbreak. That had the potential to affect the 39 residents, their families, and resident representatives. Findings include: Interview on 1/23/23 at 10:30 a.m., assistant director of nursing (ADON), identified the facility had one resident who had tested positive for COVID-19 and was on transmission based precautions (TBP). Observation on 1/23/23 at 10:35 a.m., of R5's room entrance identified he had personal protective equipment (PPE) stored outside of his room in a cart. R5 had a sign on his door identifying staff were to put on full PPE prior to entering his room. Review of the facility staff testing logs identified on 1/21/23, licensed practical nurse (LPN)-A tested positive for COVID-19. Interview on 1/23/23 at 3:45 p.m., with family member (FM)-A revealed they had been notified earlier that day of the positive COVID-19 case that occurred on 1/21/23. Interview on 1/23/23 at 4:00 p.m., with FM-B revealed he had never been notified of a positive COVID-19 case at the facility since the beginning of COVID-19 in 2020. Interview on 1/23/23 at 4:30 p.m., with FM-C revealed he had received a facility generated notification only 2 hours ago regarding the newly identified 1/21/23, COVID-19 positive case. Review of the undated, facility Automated Broadcasting Summary identified the notification to families and representatives of a COVID-19 had been newly created on 1/23/23 at 1:17 p.m. Interview on 1/25/23 at 3:22 p.m., with administrator identified she confirmed notifications to families and representatives had not been completed by 5:00 p.m., the next calendar day following a single occurrence of a confirmed positive COVID-19 case. The administrator revealed she was responsible to ensure notifications were sent out to families and representatives by 5:00 p.m. the next calendar day. Review of the 5/23/22, Coronavirus Disease (COVID-19)-Documenting and Reporting COVID-19 Testing policy identified the facility was responsible to report identified COVID-19 cases in the facility to residents, families, and representatives according to requirements. The policy lacked identification of a time frame for reporting positive COVID-19 cases.

Based on observation, interview, and record review, the facility failed to ensure an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: R11's Admission Record printed on 10/21/21, identified R11 had Alzheimer's disease, depression, dementia, restlessness, and agitation. R11's 8/4/21, annual Minimum Data Set (MDS) identified R11 had severe cognitive impairment with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R11 required limited assistance of 1 staff for Activities of Daily Living (ADL), used a wheelchair, was frequently incontinent of both bowel and bladder, had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R11 had a physical restraint used in a chair out of bed. R11's current, undated care plan identified R11 had impaired decision making skills related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R11 would continue to communicate her basic needs on a daily basis. Staff were to use an adaptive one-piece clothing to minimize public disrobing. If her one-piece clothing was not available, staff were to monitor for disrobing and assist as need by providing privacy and/or redirection. The care plan lacked identification the on-piece was considered a restraint and limited its criteria for use. There was no identified time when the one piece clothing (restraint) would be applied and used, the time and frequency the one-piece clothing was to be removed. There was no mention how staff were to identify the least-restrictive alternative for the least amount of time and document and monitor for ongoing re-evaluation of the need for restraints. R11's 8/4/21, Restraint Assessment identified options and/or devices recommended for R11 included a jumpsuit or a 1 piece clothing. The jumpsuit or a 1 piece clothing was to used as a restraint for disrobing in public as R11 was known to remove her pants and brief and enter the hallway. Staff had tried alternatives such as pull ups and distraction. The representative had been informed of the risk and benefits of the jumpsuit or a 1 piece clothing on 2/12/21. In addition. a provider order for the use of [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no mention the order included specific measurements on when it was to be applied, what other options were to be tried first, or how long the 1 piece was to be used each time to ensure it was not used in lieu of of appropriate supervision or solely for staff convenience. Review of the 2/17/21, fax to the R11's physician (NP)-A identified the director of nursing (DON) noted R11 went through a lot of pants and incontinent pads lately. R11 had been found in the recliner chair with wet pants on and no pad. The wet and dry pads had been found on floor under the sink. R11 argued with staff and insisted on changing her pad even if they were dry. The DON noted she asked staff if a pull-up would be better but other staff identified this would not matter as R11 would tear at it until she has gotten it off. The DON wrote she found an all-in-one jumpsuit in the basement to try on R11. She had noted she encouraged staff to get R11 to engage in activities throughout the day she would not be constantly thinking about toileting. R11's MD response was to begin [MEDICATION(S)] (anti-depressant) 50 milligrams 1 by mouth daily for agitation. There was no mention the MD had allowed for the use of the restraint. Review of the 3/3/21, fax to NP-A identified staff documented due to R11 taking the lower half of her clothing off and then wheeling self out into the halls, staff is putting a 1 piece jumper on R11. Staff noted R11's family was okay with the 1 piece clothing so R11 does not come out of her room half-naked. Since R11 cannot remove the jumpsuit on her own staff noted it was considered a restraint and facility would need an order. Staff noted If you agree may we have the following order: 1) okay for jumpers on resident due to dignity issue. The physician addressed as yes, and signed the order on 3/3/21. There was no mention how R11's behavior was evaluated to be a dignity issue versus a convenience or substitute for appropriate supervision. Staff failed to request specific monitoring or application parameters for use of the 1 piece jumper. R11's progress noted identified on: 1) 1/24/21, staff noted 3 x that evening shift, R11 had removed her bottom clothes and sat bare from the waist down calling out HELP until someone came and assisted to dress her again. Staff noted no further behaviors. 2) 2/2/21 at 1:33 p.m., staff noted R11 had removed her wet pull up 2 x and left them lay in the bathroom and had 1 time found wet slacks laying (on the ground). Staff failed to indicate what interventions they had tried, if increased supervision was warranted, if there was a potential for neglect, or a medial reason for R11's behavior. 3) 2/3/21 at 9:58 p.m., R11 was noted to be in her room. took herself to the bathroom, took her pants off, went back to her recliner and yelled help with no briefs or pants on. There was no indication staff had assessed R11 to ensure she was toileted or what could potentially be the cause of her behaviors. 4) 2/4/21 at 9:37 p.m., staff noted multiple times R11 would go to the bathroom and remove her wrap when it was dry and would throw it on the floor. She would then be bare under her pants. At 10:28 p.m., staff noted R11 had continued to remove her wrap, urinated in bed, and was insisting her bed needed to be changed. There was no indication staff had assessed R11 to identify what could potentially be the cause of her behavior. 5) 2/12/21 at 1:56 p.m., staff noted R11 was going though a lot of pads and pants lately. R11 was in her recliner that morning with wet pants and no pad on. R11 would argue with staff and insist on changing her pad, even if it was dry. Staff noted it wouldn't matter what type of incontinence product was used, as R11 would pull it off. Staff noted they found a 1 piece jumpsuit to try on R11. Staff did encourage other staff to get R11 out of her room, engage in activities throughout the day so she would not constantly think about the bathroom. Staff would discuss the use of the 1 piece with NP-A during rounds next week. There was no indication staff had identified a root cause to R11's behaviors and provided actual interventions and assess their appropriateness before applying a restraint. Staff noted no further behaviors for the month of February. 6) 3/3/21 at 8:37 a.m., R11's MD was noted to have approved the use of R11's 1 piece jumper restraint. Interview on 10/18/21 at 7:13 p.m., with nursing assistant (NA)-B identified R11 wears a one piece jumpsuit during the awake hours as she would strip her clothes off anywhere in the building and then remove her incontinent product and throw that. NA-B revealed R11 would at times walk around without clothes on if she was able to remove them before staff had seen her. NA-B identified the DON had gotten R11 her 1 piece jumpsuit and applied it. That had worked for her she is not able to take her clothes off in the public areas now. Interview on 10/19/21 at 11:02 a.m., with licensed practical nurse (LPN)-A identified R11 wore a 1 piece jumpsuit every day. You couldn't tell that unless you really look as it is a shirt and pants connected. She stated it looked like regular clothing. LPN-A was unsure if there was a order for the use of [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 10/19/21 at 4:19 p.m., R11 identified she was seated in the recliner in her room watching TV wearing a 1 piece jumpsuit. R11 would not be able to remove the jumpsuit on her own accord. Observation on 10/20/21 at 7:10 a.m., of R11 identified she continued to wear the 1 piece jumpsuit and wheeled herself in the hallway. Interview on 10/20/21 at 8:38 a.m., with nursing assistant (NA)-C identified the reason R11 had the jumpsuit was because she had been putting herself in the bathroom all the time. NA-C revealed R11 would have loose stools and would get that all over if you did not catch her in time. The jumpsuit was to prevent her from getting on the toilet and getting bowel all over. NA-C identified prior to the jumpsuit when R11 toileted herself, she would not get her clothes on appropriately after she took herself to the bathroom. NA-C confirmed R11 would remove her clothing and get herself on the toilet if she had regular clothes on. NA-C identified when R11 had no clean jumpsuit's she wore regular clothes and would go right back to taking herself to the bathroom and getting bowel all over herself. NA-C was unaware of alternative interventions or the need for increased supervision prior to R11 being placed into her restraint. Observation and interview on 10/20/21 at 10:35 a.m., with nursing assistant (NA)-A while she assisted R11 to the restroom identified NA-A placed a gait belt on R11 and wheeled her into the bathroom. NA-A donned gloves and assisted R11 to stand and hold the support bar while NA-A removed the 1 piece jumper off of R11's top half of her body, which left R11's breasts and upper half of her body exposed while she assisted her to sit on the toilet. When NA-A was asked about R11 being exposed while sitting on the toilet she replied she used to wear a bra but [R11] did not like that anymore. NA-A then checked R11's dresser drawer and found a white tank top to place on R11. NA-A revealed when R11 wore regular clothes she would undress and come out in the hall without clothes on. NA-A identified that the facility tried the 1 piece jumpsuit, use of pull-ups, scheduled toileting, and then went back to the jumpsuit. NA-A could not recall being advised to increase supervision of R11. NA-A identified R11 will still put herself on the toilet even with her jumpsuit on and think that she went to the bathroom. Staff were to keep a close eye on R11 so she does not transfer herself. NA-A revealed R11 was always incontinent. She was incontinent before she started to wear the 1 piece jumpsuit. Staff were to toilet R11 every 2 hours. If staff see her wheeling towards her room they were to take her [to the bathroom] then too. Interview on 10/20/21 at 1:38 p.m., with LPN-B identified she was unaware of any monitoring or documentation being done for R11 when she wore the 1 piece jumpsuit. LPN-B reported the family had been very happy with the one piece jumpsuit. Interview on 10/20/21 at 1:40 p.m., with LPN-A identified that R11 was to wear the 1 piece jumpsuit during the day and it was to be off during the night. LPN-A confirmed there was no charting being done during the day for when R11 had the jumpsuit on and when staff were to take it off. LPN-A reported the facility had an order from the physician to use the jumpsuit and it was care planned. Interview on 10/21/21 at 11:59 a.m., with the director of nursing (DON) identified staff would find R11 wheeling naked . sometimes fully naked and other times partially naked. R11 would take herself to the bathroom remove her incontinent product, and stick them in places. R11 had dementia and would not re-apply an incontinent product, but her main issue was her dignity. A discussion with the family revealed R11 had always been very [NAME] and proper and would be mortified if she knew she had been seen naked. The DON revealed she had suggested the 1 piece jumpsuit to NP-A. R11 had actually wiggled out of the 1 piece jumpsuit on once occasion. Staff were to anticipate her needs and keep her on a toileting schedule. This was difficult at times as R11 had dementia. You can take her to the bathroom and she will want to go right back on as she does not remember she just went. The DON revealed she was unaware of the criteria for restraint use and confirmed after reviewing the regulation, it made sense to specify when the restraint would be use, documenting when removed, and having an on-going assessment to evaluate its use so as not to be in lieu of staff convenience or lack of supervision. Review of the 1/19/21, Use of Restraints policy identified a restraint would only be used for well-being and safety of the resident and only following alternative interventions that have been unsuccessful. If the use of a restraint would be indicated, staff were to evaluate for the least restrictive option. A restraint would only be used if the resident had a medical symptom that could not be addressed otherwise. If a restraint would need to be used, staff were to ensure there was a specific medical symptom or reason for use, identification of how the restraint would be used to benefit the resident's symptom, obtain consent from representative, and obtain written physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The restraint was to be care planned and include measures to reduce or eliminate the need for the restraint with regular assessment of the need for the restraint. The documentation of the restraint was to include what led to the use of the restraint, description of the medical symptom, how the restraint would benefit the resident, what type of restraint would be used, when the restraint would be used, and when it needed to be removed for repositioning.

Based on interview and document review, the facility failed to ensure the resident, or resident's representative was provided written information regarding bed hold policy at the time of hospitalization for 1 of 3 residents (R239) reviewed for hospitalization . Findings include: R239's, 6/12/21, discharge with return anticipated, Minimum Data Set (MDS) assessment identified she had moderate cognitive impairment, required limited assistance with bed mobility, transfers, walking in her room, and extensive assistance with toileting and personal hygiene. R239's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R239's progress notes identified on 6/12/21 at 6:16 p.m., R239 was alert and oriented to person and time. R239's family (FM)-A was in attendance. FM-A voiced concern regarding R239's condition, R239's vital signs identified her blood pressure was 116/70 milligrams/mercury (mm/hg), her oxygen saturation (SpO2) was 88% on room air. Staff administered oxygen at 2 liters per minute. R239's SpO2 increased to 94% (normal 92-100%). R239 complained of chest pain and generalized aching. FM-A agreed to send R239 to the emergency department for evaluation. R239 left the facility via EMS at 6:40 p.m. and the facility was notified she was admitted to the hospital. There was no mention a bed hold was provided either verbally or in written form. On 6/14/21 at 2:16 p.m., staff noted they received a phone call from FM-A that R239 would not be returning to facility and instead was to be admitted to hospice house in another nearby town. Interview on 10/21/21 at 2:32 p.m. with the director of nursing (DON) identified the facility did not have record of a bed-hold being provided in either verbal or written format. She would have expected this to be completed when it was determined R239 was being admitted to the hospital. A policy on Bed Holds was requested, but not provided by the end of the survey period.

Based on observation, interview and document review, the facility failed to ensure staff utilized proper infection control practices to prevent and control the transmission of a highly infectious spore forming bacterium ([MEDICAL CONDITION], otherwise known as [MEDICAL CONDITION]) when caring for 1 of 1 resident (R35) who had a known case of this bacterium. The facility's lack of infection control precautions observed by nursing and housekeeping staff, resulted in an Immediate Jeopardy (IJ) with the potential for serious harm, injury or death for another 38 residents who were identified by the facility to be immunocompromised related to their [DIAGNOSES REDACTED]. In addition, the facility failed to implement appropriate infection control techniques for 1 of 1 resident (R5) during administration of medications via a gastrostomy tube ([DEVICE]). The Immediate Jeopardy (IJ) began on 12/16/18, when staff were observed providing care for R35 who was on contact precautions related to a [MEDICAL CONDITION] infection, without implementing appropriate infection control techniques. The administrator and director of nursing (DON) were notified of the IJ situation on 12/18/18, at 3:22 p.m. The IJ was removed on 12/19/18, at 2:45 p.m. however, non-compliance remained at the lower scope and severity of F, widespread, with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: R35's current [DIAGNOSES REDACTED].) R35 was diagnosed with [REDACTED]. Review of R35's nursing progress notes indicated that on 11/19/18, the infection control preventionist (ICP) placed R35 on [MEDICAL CONDITION] precautions until further notice after she saw her stool record in the progress notes and requested she be tested for [MEDICAL CONDITION] from nurse practitioner (NP)-A. The ICP was alerting other facility staff to potential infection. That same day, NP-A faxed an order stating, If diarrhea continues, send [MEDICAL CONDITION]. has to be pourable stool. R35's record indicated on 11/20/18 at 11:28 a.m., staff had sent a faxed notification to NP-A stating R35 continued to have putty-like stools. Staff asked if NP-A would see R35 on rounds that next day. A progress note dated 11/20/18 at 12:55 p.m., indicated R35 remained in her room all day because she had not been fever free for 24 hours. The notes indicated R35 had a very large foul smelling loose, watery green-like stool and staff were going to continue to monitor. Despite the resident having watery stools, the record did not indicate a stool collection for [MEDICAL CONDITION] had been sent to the lab. Further review of R35's nursing progress notes indicated: (1) 11/24/18, R35 was readmitted back to the facility from the hospital. (2) 11/25/18, R35 had 2 loose BM that shift.No adverse effects from the antibiotics. There was no mention staff collected a BM sample to test for [MEDICAL CONDITION]. (3) 11/27/18, Since her recent hospitalization s, resident has had a decline in appetite and lost weight. There was no mention staff had notified NP-A of R35's continued loose stools or suspected [MEDICAL CONDITION], or any precautionary transmission-based interventions were ever placed. (4) 12/1/18, although R35 continued to have (2) more loose stools, there was no indication staff had taken a sample to send to the clinic for testing. (5) 12/3/18, R35 had 4 loose stools that day. Greenish-brown in color. Staff held her stool softener and collected samples to be tested per previous NP-A order (which had been received two weeks previously). Review of the physician progress notes [REDACTED]. If diarrhea (and) smelly stool present, please bring sample to clinic for [MEDICAL CONDITION] (testing). Review of a stool sample laboratory report dated 12/3/18, revealed R35 had A positive [MEDICATION NAME] result with positive toxin, indicates that [MEDICAL CONDITION] is present and producing toxin. Treatment is suggested. Review of R35 physician's orders [REDACTED]. Difficile infection) were to be given 4 x per day x 10 days. R35's medical record indicated she continued to have loose stools until 12/16/18. There was no mention if R35 would be toileted or was found incontinent in her brief. There was no indication staff had implemented precautions at any time after 11/19/18. Review of R35's current nursing care plan revealed on 12/5/18, R35 made no mention R35 was diagnosed with [REDACTED]. Review of the current NA (nursing assistant) pocket care plan (a guide used by the NAs) to direct what type of care to give a resident) revealed no mention of R35's [DIAGNOSES REDACTED]. During observation and interview on 12/16/18 at 1:50 p.m., NA-D stated she was unaware of any residents down the 300 wing being on contact precautions. While pointing to the isolation (PPE) rack hanging on the wall outside R35's room NA-D stated, We don't use that. At that time, there was also no signage on the door to indicate what precautions staff were to use. R35 was observed to reside in a semi-private room with a roommate, R49. During observation on 12/16/18 at 2:57 p.m., NA-A was observed pushing a mechanical lift from room [ROOM NUMBER] directly to the storage area without appropriate disinfection. During observation on 12/16/18 at 3:10 p.m., NA-E was observed to push the mechanical lift out of room [ROOM NUMBER] to use immediately in room [ROOM NUMBER] without appropriate disinfection between resident use. During interview on 12/16/18 at 2:30 p.m., the director of nursing (DON) stated R35 remained on [MEDICAL CONDITION] precautions, and was currently still having loose stools. During observation and interview on 12/16/18 at 3:40 p.m., NA-E confirmed there was no signage outside R35's door notifying staff which precautions should be used, or alerting visitors to check with the nurse before entering the shared resident room. NA-E stated staff could look at the communication book at the nurses station to see if information was written regarding what type of precautions a resident required. In addition, NA-E stated all environmental items used in or around R35 were to be cleaned with bleach. During observation on 12/16/18 at 5:49 p.m., licensed practical nurse (LPN)- E was observed to administer medications to R35 in her room. LPN-E was observed to use only gloves as PPE. She applied gloves prior to entering the resident's room, administered R35 her medication, removed her gloves, washed her hands and continued down the hall to continue the evening medication pass. When questioned at that time, LPN-E acknowledged she had administered R35's medications without using any PPE other than gloves. During observation on 12/16/18 at 6:36 p.m., NA-E was observed to use only gloves as PPE while assisting R35 with eating in her room. NA-E was sitting in a folding chair next to R35 in the resident's room. Although NA-E was wearing gloves, she did not utilize gowning to prevent picking up and/or transmission of spores that may have been present on surfaces in the room. During observation on 12/17/18 at 7:11 a.m., there continued to be no signage outside R35's room to alert staff and visitors that precautions were needed. During interview on 12/17/18 at 7:40 a.m., registered nurse (RN)-C stated staff were at minimum supposed to utilize PPE including a gown and gloves when entering R35's room. RN-C stated staff were supposed to apply PPE prior to entering the room even to pass medications or feed R35. In addition, RN-C stated R35 was allowed to leave her room if her stool was contained within her brief. R35 was to be checked and changed as necessary. R35 finished her antibiotics on 12/14/18, but was still having loose stools. RN-C stated R35 had 3 loose stools that day. Staff were not to lift contact isolation precautions until she had no loose stools for 48-72 hours. RN-C agreed there was no signage placed outside the door regarding precautions and staff or visitors might not know what to do upon entering the room for R35. During interview on 12/17/18 at 7:58 a.m., NA-C stated she would not put on gloves or a gown to feed R35. NA-C stated she was only aware she needed to wear PPE when assisting R35 with toileting cares. In addition, when asked, NA-C was unaware how or when horizontal surfaces should be cleaned in the resident's room. During observation on 12/17/18 at 8:40 a.m., NA-F and NA-C were providing personal care to R35. Both NAs wore gowns and gloves and masked before entering the room. After washing R35's perineal area with a wash cloth and drying with a towel, NA-F proceeded to place the used washcloth and towel directly on the bedside table. NA-F also removed R35's outer bedding and placed it directly onto the same used washcloth and towel. NA-F put on new gloves without performing hand hygiene, and assisted NA-C with dressing R35. Once all tasks were completed, NA-F walked directly into the hallway outside R35's door, and removed her PPE. NA-F placed her PPE in the garbage just inside R35's door. With her then bare hands, NA-F pulled the garbage bag containing the contaminated PPE, and set it directly into the hallway. NA-C was observed to remove her PPE also, and to place it inside the garbage bag sitting in the hallway outside R35's room. R35's soiled clothing and linen were then placed inside another garbage bag and placed into a soiled linen container. Neither NA-C nor NA-F disinfected the bedside table prior to leaving R35's room. During interview 12/17/18 at 9:06 a.m., housekeeper (H)-A, and H-B who identified herself as the housekeeping supervisor, stated H-B had been cleaning rooms on the left side of the hall and H-A the right. At that time, it was observed the housekeepers were sharing a housekeeping cart. H-A and H-B verified they took cleaning supplies room to room. The housekeepers also verified a 3M Non-Acid Disinfectant quaternary cleaner was used on all surfaces in all resident rooms, including R35's. Upon review of the product labeling, it was learned there was no bleach or similar disinfectant appropriate to kill [MEDICAL CONDITION] listed on the bottle's label. H-A verified that product was used to clean door handles, and horizontal surfaces in each room. In addition, the mop handle was observed to house a 3M quaternary disinfectant cleaning product. The mop was observed to have a removable head. H-A stated each mop head was removed and placed into a bin on the housekeeping cart after each room had been cleaned, and the mop itself was transported room to room. H-A verified R35 had no designated equipment for cleaning her room while R35 required contact isolation. H-A stated she would use a bottle labeled with black marker that read Bleach if she was informed R35 had used the toilet. H-A said the bleach solution had been mixed on 12/16/18. When asked, H-A verified the housekeeping staff used the same toilet brush for cleaning from room to room. H-A remembered R35 had been on isolation precautions for about a week and a half during which time housekeeping staff were to wear PPE while cleaning R35's room. She stated the nurses would inform staff what to wear when entering the room. H-A was unaware of the concentration of the bleach solution, or how long it would be effective after mixing. A damp washcloth had been placed over the toilet brush on top of H-A and H-B's cart. When asked why the damp washcloth was there, H-A reached out with her bare hands and picked up the toilet wand container and touched the wet rag. H-A stated the toilet brush had been used in resident rooms and was not clean. H-A felt a washcloth would prevent germs from splashing out off the brush. H-A then touched her eyeglasses, on her face, with her bare contaminated hands. H-A stated she would scrub her hands before and after cleaning each resident's room. HA further stated, It's common knowledge bleach kills [MEDICAL CONDITION],. but would only use bleach when cleaning toilets. The housekeepers were unaware of any designated environmental cleaning of high-touch surfaces such as door knobs, counters or bedside stand equipment in R35's room. Following conversation with the surveyor, H-A was observed on 12/17/18 at 9:18 a.m., to put on a gown and gloves to clean R35's room. H-A removed the garbage from the wastebasket, tied it shut, and proceeded to leave R35's room with her gown and gloves on. H-A pulled the cart closer to R35's room, touching the handles with her contaminated gloves. H-A grabbed a plastic tote that contained the quaternary cleaner and went back into R35's room. H-A then brought the fall matt from the floor by R35's bed, into the hall and propped it up against the wall. H-A sprayed the matt with the 3M quaternary cleaner. H-A proceeded to go back into R35's room, wearing the same gown and gloves, and pushed R35's mechanical lift into the hallway. H-A stated, I hope the girls wiped it (the mechanical lift) down anyway. Without any additional disinfection, H-A pushed R35's mechanical lift into the hallway. H-A was observed to use a damp washcloth and sprayed the 3M quaternary cleaner on horizontal surfaces, including the bedside table in R35's room. When H-A came out of R35's room, she was still wearing the same gloves and gown, and carried the basket of supplies she'd brought into R35's room out and placed it back on the shared housekeeping cart. H-A finally removed her gloves and threw them into R35's garbage bag she had placed outside of the room. While still wearing the same gown, H-A touched the back of her gown, with her unwashed bare hands. H-A grabbed the mop bucket and mop while continuing to wear the same gown, and once again entered R35's room. H-A applied new gloves (without performing hand hygiene). H-A cleaned the floors with the quaternary cleaner. Once finished, H-A left the room with the mop while still wearing the gloves and gown and returned the mop to the cart. H-A then went back to the entrance of R35's room. She removed her gloves and gown. Once removed, H-A went back inside R35's room to use hand sanitizer. During interview on 12/17/18, at 9:31 a.m. NA-G confirmed R35 used the common bathtub for bathing. NA-G also stated she had never used any PPE when performing cleaning and disinfection of the whirlpool tub. NA-G stated she was unsure of any special precautions for disinfecting the whirlpool tub when R35 used it, and said she had never herself bathed R35. NA-G said she was the full time bath aide, and said R35's bath was scheduled for late morning on Thursdays. Review of the whirlpool bathtub instructions, posted inside the cabinet in the whirlpool bathroom revealed staff were to: (1) Place the chair in the tub and close the door. (2) Turn the knob to disinfectant and the control knob to on. (3) Turn off the control knob when 2 inches of disinfectant solution was in the well of the tub. (4) Lift the seat bottom off the chair and use the disinfecting solution to scrub the whirlpool tub. (5) Leave wet for 10 minutes. (6) Turn the knob to rinse and control knob to on. When clear water would come out of the outlet, turn the control knob to off. (7) Leave the blower on for 60 seconds to force remaining water out of the lines. (7) Rinse the tub. Review of the 12-12-18, Bath List hanging on the wall in the whirlpool tub room, indicated 3 of 50 residents were identified as receiving showers (R22, R40 and R300). All others received whirlpool baths. During interview with NA-B on 12/17/18 at 10:14 a.m., NA-B stated she had last given a bath to R35 over a month ago. NA-B said to disinfect the whirlpool tub after R35, she would use (3) cups of bleach in the tub but was unaware how much water to add. Review of Bleach Blast bleach indicated staff were to use 1 cup bleach per gallon of water for disinfection. NA-B stated she would turn the whirlpool on with the bleach solution in the whirlpool tub, and keep it running for anywhere from 5 to 15 minutes. NA-B stated she wore PPE when providing R35 a bath however, there was no PPE available to use in the whirlpool tub room. NA-B said staff were to retrieve the PPE from R35's door if needed. The facility staff provided a list 12/18/18, which identified R35, R49, R41, and R44 as at risk for infection from being immunocompromised related to health diagnoses. R41 and R44 shared a room directly across the hall from R35 and R49. Review of R41's medical record revealed an order from nurse practitioner (NP)-A on 12/5/18, requesting R41 be tested for [MEDICAL CONDITION] related to diarrhea. R41's medical record did not include evidence of the resident having been tested for [MEDICAL CONDITION]. However the record included documentation to verify R41 had experienced 3 loose stools within 24 hours from 12/9/18 to 12/10/18. Review of R44's medical record revealed she had experienced repetitive loose stools daily from 11/19/18 through 12/17/18. The record indicated R44 had experienced 3 loose stools within 24 hours on 12/3/18, the same day R35 tested positive for [MEDICAL CONDITION]. There was no documented evidence that contact precautions had been implemented during this period of time. Licensed practical nurse (LPN)-F was interviewed 12/18/18 at 11:48 a.m. LPN-F said NP-A had ordered [MEDICAL CONDITION] testing on several residents down the 300 hall due to concerns about the number of residents with diarrhea down that wing and directly across the hall from R35. During interview with NP-A on 12/18/18 at 12:16 p.m., NP-A stated she had ordered [MEDICAL CONDITION] testing for any resident down the 300 wing for suspected [MEDICAL CONDITION] infection if warranted. NP-A stated she'd been especially concerned with residents across the hall from R35, R41 and R44, as they also had loose stools. NP-A was not aware of R35's continued loose stools since 12/12/18. During interview on 12/18/18 at 3:22 p.m., the director of nursing (DON), the administrator and the facility's infection control. preventionist (ICP) (participating by phone), were informed of the ongoing concerns related to inadequate implementation of contact precautions, and concerns with room disinfection and cleaning practices for residents with active [MEDICAL CONDITION] infections. They were unaware testing had not occurred as ordered by NP-A to detect potential [MEDICAL CONDITION] infection for R41, R44, or any others down the 300 wing who exhibited signs and symptoms of [MEDICAL CONDITION]. The ICP stated testing had not been completed for R44 because staff had thought her diarrhea was from laxative use. They verified with no private room available, they had not considered temporarily re-locating R49 (R35's roommate) to prevent spread of infection. The DON agreed, per description of observations, staff were not appropriately wearing PPE or disinfecting the whirlpool appropriately. The DON stated she was unaware of the need to have designated cleaning supplies and equipment for residents who were positive for [MEDICAL CONDITION] to prevent potential spread of infection. During a follow up interview with NP-A on 12/19/18 at 10:15 a.m., NP-A stated she had been made aware of the immediate jeopardy concerns related to the [MEDICAL CONDITION]. NP-A agreed there was a system breakdown with relation to IC, prevention and detection for suspect [MEDICAL CONDITION]. NP-A also confirmed she had requested [MEDICAL CONDITION] testing for all residents down the 300 wing who were experiencing diarrhea. NP-A said she would have expected staff to have called her about the ongoing concerns with diarrhea, and would have expected the testing be completed as ordered. NP-A confirmed there were concerns related to improper IC techniques which would include: whirlpool tub cleaning, PPE use, etc. NP-A again stated staff should have called her with any concerns, and should use critical thinking if they were to suspect the potential spread of infection. NP-A felt communication needed to be improved so that all staff, including the medical doctor (MD) were aware of what was going on with residents. During a follow up interview with NA-G on 12/19/18 at 8:40 a.m., NA-G stated she was trained as a bath aide by another nursing assistant. The ICP had not provided any guidance on appropriate whirlpool cleaning and disinfection, or appropriate PPE while performing that task. NA-G had not had any regular competency check re., whirlpool tub disinfection to ensure she was performing that task appropriately. NA-G confirmed she should have worn PPE, washed her hands before and after tasks, and followed manufacturer's guidelines for a wet contact time of 10 minutes to ensure appropriate disinfection was achieved on tub surfaces. During interview with H-B on 12/19/18 at 8:57 a.m., H-B revealed she had worked at the facility for [AGE] years. She stated she'd had some training with relation to PPE use in (MONTH) (YEAR), but said she'd not received any specific training or education related to which chemicals should be used for cleaning and disinfection for residents with [MEDICAL CONDITION]. During interview on 12/19/18 at 3:00 p.m., the ICP stated the facility followed the Centers for Disease Control (CDC) guidance related to precautionary measures with [MEDICAL CONDITION]. The ICP stated she had placed R35 on precautions on 11/19/18, however verified she had not provided any retraining, nor verified competencies, to ensure staff were appropriately implementing IC measures to prevent the potential spread of [MEDICAL CONDITION] or other potential infections. The ICP further stated she expected nursing staff to follow appropriate infection control practices and not store graduate cylinders used for tube feeding, on the back of the toilet. The ICP agreed the facility had no efficient system in place to monitor, detect and conduct surveillance for the potential spread of [MEDICAL CONDITION]. Her expectation was that nursing staff should have implemented appropriate measures to prevent the spread of [MEDICAL CONDITION], and should have retrieved the specimen collections as ordered by NP-A. The ICP stated she had assumed staff had submitted testing, and was awaiting results of that testing back from NP-A The ICP confirmed she should have followed up and also confirmed nursing aide pocket care plans had not been updated to reflect [MEDICAL CONDITION] information or what precautions were required by staff to implement with cares. Review of the facility's 7/7/03, Personal Protective Equipment and Hazard Assessment policy, included: after appropriate PPE for each process and equipment has been selected, the employer must provide the equipment to employees and train them in its proper use. At a minimum, each employee using PPE must know: (1) When PPE is necessary. (2) How to put it on, take off, and adjust and wear PPE. (3) After employees have been trained, periodic assessment of the process and equipment should be conducted to ensure that the PPE is adequate and training is appropriate. (4) Retraining of employees's is required when observed inadequacies in an employees knowledge or use of assigned PPE indicates that an employee has not retained the necessary understanding or skill. Review of the (MONTH) 2014, [MEDICAL CONDITION] policy revealed: (1) [MEDICAL CONDITION] infection will be considered in residents with acute onset of diarrhea (3 or more unformed stools within 24 hours) or abdominal pain. (2) Residents considered high risk for developing symptoms associated with [MEDICAL CONDITION] include those with advanced age, gastrointestinal (GI) manipulation (tube insertion) (3) The primary reservoirs for [MEDICAL CONDITION] infected people and surfaces. Spores can persist on resident care items and surfaces for several months and are resistant to common cleaning and disinfection methods. (4) Steps toward prevention and early intervention include increased awareness of risk factors, Considering [MEDICAL CONDITION] in differential diagnosis, especially in those with high risk factors, frequent handwashing with soap and water by staff and residents, increased attention and education regarding IC techniques when providing tube feeding, disinfection of items with potential fecal soiling (bedpans, commode chairs, bedrails, etc) using a disinfectant recommended for [MEDICAL CONDITION]. (5) Suspected infection will be verified by evidence of positive lab results. (6) Testing will be performed on unformed stool only, unless illness is suspected. The IJ that began on 12/16/18, was removed on 12/19/18, at 2:45 p.m., when it could be verified by observation, document review and staff interview, the facility had educated all staff on proper PPE use prior to entering/leaving the resident room, had verified the use of an appropriate sporicidal cleaning product in the resident's room, had verified staff implementation of appropriate handwashing techniques, and had implemented infection control practices to prevent cross contamination to other residents who resided in the facility. Non-compliance remained at the lower scope and severity of (F) widespread, with potential for more than minimal harm that is not Immediate Jeopardy. R5 was admitted [DATE], with [DIAGNOSES REDACTED]. Review of R5's 12/1/18, quarterly Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) as not applicable related to severe cognitive impairment and inability to communicate. R5 required extensive assistance with Activities of Daily Living (ADLs) which included bed mobility, transfer, dressing, toileting and personal hygiene and required a feeding tube. R 5' s' current care plan indicated a feeding tube was in place and he received nothing by mouth. All food, liquids and medications were to be administered via [DEVICE]. In addition R5 has an indwelling Foley catheter related to a history of [MEDICAL CONDITION] and overactive bladder. R5's current care plan indicated a feeding tube was in place and he received nothing by mouth. All food, liquids and medications were to be administered via [DEVICE]. R5 had an indwelling Foley catheter related to a history of [MEDICAL CONDITION] and overactive bladder. On 12/16/18, at 2:02 p.m. nursing assistant (NA)-A was observed emptying R5's Foley catheter bag and providing catheter care. NA-A went into R5's bathroom, applied gloves and obtained a graduated plastic container from the back of the toilet, empted R5's catheter bag into the graduated container, noted the volume, empted the urine into the toilet, rinsed the container with water from the facet and returned the container to the back of the toilet. There were two identical plastic containers on the back of the toilet, neither of which contained any form of labeling indicating intended use. There were two identical plastic containers on the back of the toilet, neither of which contained any form of labeling indicating intended use. During observation on 12/17/18, at 10:20 a.m., licensed practical nurse (LPN)-A was observed administering medications and gastrostomy (G)-tube feeding via R5's [DEVICE]. LPN-A went into R5's bathroom and returned with a graduated container of water obtained from the bathroom sink. LPN-A had 4 medication cups containing individual crushed medications which she diluted with water in the graduated container. Once completed, LPN-A accessed R5's [DEVICE], inserted a 60 milliliters (ml) syringe into the [DEVICE] and poured approximately 30 ml of water from the graduated container into the syringe. LPN-A administered each of the cups of diluted medication, followed by 10-15 ml of water from the graduated container. Once the medications had been administered, LPN-A poured the remainder of the water from the graduated container into the syringe and attached R5's feeding tube. LPN-A went into the bathroom, obtained more water from the sink and put it into that same container and flushed R5's [DEVICE]. LPN-A was observed placing the syringe she had just used, into an existing 3rd graduated container that was found on the TV stand. LPN-A carried the 2nd graduated container she had used to flush R5's [DEVICE], and placed it back into the bathroom, upside down on the back of the toilet tank. Interview on 12/17/18 at 10:35 a.m., revealed LPN-A stated she obtained the container used for flushing R5's [DEVICE] from the back of the toilet in the bathroom, and not from the nightstand. Two graduated containers were noted on the back of the toilet and neither was labeled indicating their use or purpose. She retrieved the container used to flush R5's [DEVICE] from the back of toilet, instead of using the container found on the nightstand. LPN-A agreed she should not have utilized that container. Graduated containers were to be changed daily on the night shift. LPN-A agreed if the containers were changed on the night shift, staff would have likely used the new containers located on the back of the toilet tank for emptying R5's morning urine. The containers should be labeled and stored in a different location to avoid this type of occurrence in the future. Observation on 12/17/18 at 10:45 a.m. of LPN- A regarding R5 revealed she disconnected the feeding tube, and proceeded to take the tube and bag into R5's bathroom and drained the water from the bag into the toilet. The end of the tube was level with the inner ring of the toilet seat for rinsing. R5 was known to have had recent [MEDICAL CONDITION] infection approximately one week ago on 11/28/18. LPN-A was unaware of the risk for contamination from toilet water splashing onto the feeding tube. LPN-A agreed she should have emptied the feeding tube bag contents into the sink, rather than the toilet. LPN-A verbalized she had obtained the container from the back of the toilet and obtained the water from the bathroom sink. When asked if this was not the same container utilized to empty R5's Foley catheter bag, LPN-A indicated she did not know, and that she should not have utilized this container, but used the one on the TV stand in which the syringe was kept. LPN-A indicated the graduated containers are changed on the night shift, but she had no way of knowing if this container had been utilized for emptying R5's catheter bag, and again stated she should not have used that container for the [DEVICE] administration. LPN-A indicated the containers should be labeled and stored in a different location to avoid this type of occurrence in the future. Interview on 12/18/18 at 9:32 a.m., LPN-A indicated she only had received training on [DEVICE] feeding and medication administration from nursing school in 2001. LPN-A had no additional training or competency evaluation related to [DEVICE]s. Containers utilized for Foley catheter care were usually stored under the bathroom sink. Containers for tube feeding use were to be placed on the night stand in the resident's room. The facility had no process in place for labeling of containers to identify their intended use. R5 was known to be toileted for bowel movements and used the toilet regularly. The facility had no process in place for labeling of containers to identify their intended use. R5 was known to be toileted for bowel movements and used the toilet regularly. R5 was previously on [MEDICAL CONDITION] precautions which had been removed 12/11/18 with MD signature dated 12/12/18. During interview on 12/18/18 at 9:51 a.m., NA-A indicated the graduated container for emptying of the Foley catheter was usually kept in the bathroom under the sink. Frequently staff would instead place them on the back of the toilet instead. R5 had used his toilet during time he was known to have [MEDICAL CONDITION]. indicated the graduated container for emptying of the Foley catheter is supposed to be stored in the resident's bathroom under the sink, but some staff placed them on the back of the toilet. NA-A confirmed R5 is placed on toilet in the mornings and before going on outings, which he does frequently with his wife. Registered nurse (RN)-A was interviewed on 12/18/18, at 10:33 a.m R5 received tube feeding twice daily. [DEVICE] equipment including the syringe and calibrated container was to be s (TRUNCATED)