Every finding on record at Memorial Care Center

Based on interview, observation, and record review, the facility failed to properly identify residents requiring Enhanced Barrier Precautions (EBP), to utilize Personal Protective Equipment (PPE) when required, and to provide hand hygiene during medication administration for 7 of 16 residents (R6, R11, R57, R67, R94, R99, R125) reviewed for infection control in the sample of 34.The findings include:1. R6's Face Sheet, undated, documents R6 was admitted to the facility on [DATE] with diagnosis of Osteomyelitis, Type 2 Diabetes Mellitus (DM) with foot ulcer, hypertension (HTN), panic disorder, and asthma. R6's Minimum Data Set (MDS), dated [DATE], documents R6 is cognitively intact. On 3/2/26 at 10:53 AM, R6 was observed in his room and stated that he has a peripherally inserted central catheter (PICC) line in his arm because he gets daily antibiotics for a wound to the ball of his left foot. There is no EBP sign posted on the door and there is no PPE outside his door. R6's Physician Order, dated 2/7/26, documents Standard Precautions and did not have an order for Enhanced Barrier Precautions. R6's Care Plan, undated, documents R6 is on Enhanced Barrier Precautions due to high risk of MDRO (Multidrug-Resistant Organisms) related to PICC line placement. Intervention: Staff to wear Gown and Gloves during high contact resident care activities. 2. R99's Face Sheet, undated, documents R99 was admitted to the facility on [DATE] with diagnosis of Osteomyelitis of vertebra. R99 has a PICC line in her right upper arm and a Jackson Pratt (JP) drain coming out of her back. R99's MDS, dated [DATE], documents R99 has a moderate cognitive impairment. R99's Physician Order, dated 2/16/26, documents Enhanced Barrier Precaution. Risk for MDRO r/t (related to) PICC. R99's Physician Order, dated 2/15/26, documents R99 is on Cefepime 2 G (grams) IV (intravenous) Q (every) 12hr (hours) for spinal abscess. R99's Physician Order, dated 2/17/26, documents R99 is on Metronidazole 500 MG (milligram) PO (oral) BID (twice daily) for spinal abscess. On 3/2/26 at 10:26 AM, R99 has an EBP sign posted on her door and a PPE cart outside the door. R99 stated she's on antibiotics due to an infection in her bones/spine. R99 stated the staff does wear a mask at times and usually gloves, but they don't put on a gown when caring for her. On 3/3/26 at 8:32 AM, R99 stated she now has a roommate (R94) who was just admitted and (R94) has a fever and cough. R99 stated she hopes that R94 doesn't have COVID or something bad because she already has an infection and doesn't want to be exposed. R99 has her central line (PICC) and is exposed to R94's illness. 3. R94's Face Sheet, undated, documents R94 was admitted to the facility on [DATE] with diagnosis of left hip fracture with left artificial hip joint and at the facility for aftercare following joint replacement surgery. R94's MDS has not been done yet, however, her Basic Interview for Mental Status (BIMS) was scored as a 12, indicating that R94 has a moderate cognitive impairment. A BIMS score of 0-7 indicates a severe cognitive impact, 8-12 indicates a moderate cognitive impairment, and 13-15 indicates an intact cognitive response. On 3/3/26 at 8:35 AM, R94 was observed lying in bed with a frequent cough noted. There is a sign posted on the door for EBP and PPE cart outside the door. Staff was observed going in and out of the room with no PPE on. On 3/3/26 at 10:40 AM, R94 and R99 still has a sign posted on their door for EBP and PPE available outside her room. R94's Progress Note Physician, dated 3/3/26 at 11:29 AM, documents in part Fever, unspecified fever cause (primary), assessment/plan: Viral panel ordered, check UA (urinalysis), CXR (chest x-ray), blood cultures. No leukocytosis, Encouraged IS (incentive spirometer), Will give prophylactic Tamiflu. Was asked to see the patient this am due to development of fever. Patient is lying flat in bed, is lethargic but arousable, reports developing a cough overnight without sputum production and significant weakness. Temp 101.1. On 3/3/26 at 10:50 AM, V4, Licensed Practical Nurse (LPN)/Infection Preventionist, stated that R94 (sharing room with R99) does have a cough and fever and they did a COVID test which was negative and other test, such as influenza, which is still pending. V4 stated she is putting R94 on both contact and droplet isolation because that is what their policy says to do when there is an unknown illness with symptoms. 4. R125's Face Sheet, undated, documents R125 was admitted to the facility on [DATE], with diagnosis of Osteoarthritis, dependence on supplemental oxygen (O2), chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, congestive heart failure, chronic respiratory failure, urinary tract infection, atrial fibrillation, abdominal aortic aneurysm. R125's MDS was not fully completed, however, R125's BIMS score was a 15 indicating that R125 was cognitively intact. On 3/2/26 at 10:37 AM, R125 was observed in his room on O2 at 4 L (liters) per NC (nasal cannula). There was no signage posted on his door for isolation or EBP and no visible PPE outside his door. On 3/3/26 at 8:45 AM, R125 was observed lying in bed with IV fluid of Normal Saline (NS) running wide-open. R125 is on Oxygen at 4 L/NC and a portable suction unit now at his bedside. R125 was seen coughing up sputum. V21, Respiratory Therapist (RT) was at R125's bedside assisting R125 with his sputum. V21 did not have any PPE on while caring for R125. On 3/3/26 at 8:53 AM, V11, LPN, stated that R125 became lethargic last evening, and they thought it was his pain medication, so they stopped his pain med and gave him Narcan but that did not work, and now he is running a fever and coughing up a lot of brown sputum. V11 stated they tested R125 for COVID and was negative and are waiting on further testing. There is still no EBP or isolation sign posted on R125's door and no PPE available outside his door. R125's Progress Note, Physician, dated 3/3/26 at 10:55 AM, documents (R125): SIRS (systemic inflammatory response syndrome) - fever, hypotension, leukocytosis, etiology unclear. Blood culture, CXR, urine culture, viral swab ordered. Start IVF (IV Fluids), Cefepime, Vancomycin. Check MRSA (methicillin-resistant Staphylococcus aureus) swab - if negative could consider stopping vancomycin. Updated son over the phone - confirmed DNR (do not resuscitate). Family requests to keep pt at (facility) and comfortable if he has a clinical decline. (R125): Osteoarthritis of spine with radiculopathy, lumbar region. S/p (status post) multilevel injections. Oxycontin held, Narcan given due to lethargy. Continue PRN (as needed) Oxycodone. (R125): Acute Kidney Injury. R125's Physician Order, dated 3/3/26, documents Patient Isolation. Contact and Droplet Precautions. Unknown origin related to Fever. 5. R67's Face Sheet, undated, documents R67 was admitted to the facility on [DATE] with diagnosis of Gastrostomy status, malnutrition, dysphagia oropharyngeal and pharyngoesophageal phase, and status post-surgery on the circulatory system - Coronary Artery Bypass Graft. R67 was discharged on the evening of 3/2/26. R67's Minimum Data Set (MDS), dated [DATE], documents R67 is cognitively intact. R67's Physician Order, dated 2/13/26, documents Patient Isolation: Enhanced Barrier Precaution. Risk for MDRO (Multidrug-Resistant Organisms) r/t (related to) G-tube. On 3/2/26 at 9:55 AM, R67 was seen lying in bed with V19, LPN, observed turning off R67's tube feeding, disconnected the feeding line from his g-tube, and then plugging the tube. There was no PPE seen at the entrance to the room and V19 did not don PPE prior to taking care of R67's G-Tube. On 3/3/26 at 10:45 AM, V4 stated EBP precautions or for any resident with a line going into or out of their body and for those with a urine catheter, or any drains, or a PICC line/Central line. V4 stated EBP should be done by any staff member doing direct resident care. V4 stated there should be signs posted with PPE available. V4 stated Contact Isolation is for residents who have Clostridioides difficile (c-diff), bed bugs, or any highly contagious illness. V4 stated if a resident is having a fever, cough, and congestion, they should be put on both contact and droplet isolation with signs for both, especially if the illness is unknown. On 3/5/26 at 10:00 AM, V22, LPN, stated if any resident has a g-tube or PICC line, they should be on EBP and staff should be wearing a gown, gloves, and a mask when caring for that resident. V22 stated when she is passing medications, she always does hand hygiene between each resident. V22 stated if a resident develops a sudden fever and cough, she will follow policy, and that resident would be put on EBP. On 3/5/26 at 10:06 AM, V11, LPN, stated if anyone has a g-tube or PICC line, they should be on EBP and staff should be wearing a gown, gloves, and a mask to care for that resident. V11 stated hand hygiene should be done between residents when passing meds - Gel-In/Gel-Out. V11 stated if a resident is having a cough and fever, they should automatically be put on EBP until we know what is going on. On 3/5/26 at 11:05 AM, V2, Director of Nursing (DON), stated she would expect the staff to be following the policies on EBP, tube feedings via g-tube, and hand hygiene when passing medications. The Facility's Infection Control - Standard and Transmission-Based Precautions Policy, dated 2/2024, documents in part It is the policy of (facility) residences to utilize Standard and Transmission-Based Precautions to reduce the potential for infections and disease transmission. Hand Hygiene remains the single most effective means of preventing infections and controlling disease transmission. Wash hands before passing medications or performing treatments and when each resident's care is completed. Transmission-Based Precautions are always used in addition to Standard Precautions. Infection risks will be balanced with the need for more than one occupant in a room. Considerations include but are not limited to: Cohorting residents with the same pathogen, the presence of risk factors that increase the likelihood of transmission (i.e., indwelling devices; pressure injuries or open wounds; immunocompromised. Information regarding the precaution to be utilized will be communicated through verbal reports, written in-house communication forms, and signage. Signage is to be placed in a conspicuous place outside the resident's room with precaution instructions. Appropriate PPE shall be readily available near the entrance to the resident's room. The Facility's Infection Control - Enhanced Barrier Precautions Policy, dated 2/2024, documents in part It is the policy of (facility) to implement enhanced barrier precautions to prevent transmission of novel or targeted multidrug=resistant organisms as defined by CDC to residents, staff, volunteers, visitors or any other individuals providing services under a contractual agreement. Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Clear signage will be posted outside of the resident's room indicating the type of precautions, required PPE, and the high-contact resident care activities that require the use of gown and gloves. Nursing staff may place residents with certain conditions or devices on enhanced barrier precautions empirically while awaiting physician orders. Make gowns and gloves available immediately outside of the resident's room. Face protection may also be needed if performing activity with risk of splash or spray. 6.R11's Facesheet documented she was admitted to the facility on [DATE]. On 3/3/26 at 8:01 AM, V10 registered nurse (RN) administered R11 her IV (intravenous) daptomycin 400 mg (milligram) via PICC (peripherally inserted central catheter) line to her RUA (Right Upper Arm) without completing hand hygiene prior to gloving up after entering her room. 7.R57's Facesheet documented she was admitted to the facility on [DATE]. On 3/3/26 at 8:22 AM, V13 licensed practical nurse (LPN) administered R57 without completing hand hygiene prior to gloving up after entering her room.

Based on interview, observation, and record review, the facility failed to flush a gastric-tube (g-tube) after giving a feeding bolus and properly label the bottle of tube feeding when hung for 1 of 1 resident (R67) reviewed for proper g-tube management in the sample of 34.The findings include:R67's Face Sheet, undated, documents R67 was admitted to the facility on [DATE] with diagnosis of Gastrostomy status, malnutrition, dysphagia oropharyngeal and pharyngoesophageal phase, and status post-surgery on the circulatory system - Coronary Artery Bypass Graft. R67 was discharged on the evening of 3/2/26. R67's Minimum Data Set (MDS), dated [DATE], documents R67 is cognitively intact and is dependent on staff for feeding. R67's Care Plan, dated 2/16/26, documents R67 is on tube feeding post open-heart surgery. Interventions: Osmolite 1.5, 275 ML (milliliters) 4 times a day, 115 ML water flushes 4 times per day. 2/26/26: given my weight drop from 125 lbs (pounds) before hospital stay down to 116.8 lbs on 2/25, my tube feeding amount will be increased from 325 ML of Osmolite 1.5 4/day to 350 ML of Osmolite 1.5 4/day. R67's Physician Order, dated 2/13/26, documents Tube feeding water bolus 115 ML Q (every) 6hr (hours).R67's Physician Order, dated 2/13/26, documents Patient Isolation: Enhanced Barrier Precaution (EBP). Risk for MDRO (Multidrug-Resistant Organisms) r/t (related to) G-tube.R67's Physician Order, dated 2/26/26, documents My Dining Tube Feeding. Osmolite 1.5 Cal (calorie) 350 ML QID (4 times day).On 3/2/26 at 9:55 AM, R67 was seen lying in bed with V19, Licensed Practical Nurse (LPN), observed turning off R67's tube feeding, disconnected the feeding line from his g-tube, and then plugging the tube. V19 stated R67 gets 350 ML bolus feeding and then it gets turned off. When asked about flushing R67's g-tube after disconnecting the feeding, V19 stated that R67 gets flushed four times a day and she had already done it this morning so she will do later. R67's tube feeding bottle is dated 3/1/26 with no time indicated when it was hung or started. The bottle had Osmolite written on the bottle with no rate of infusion. There was no PPE (Personal Protective Equipment) seen at the entrance to the room and V19 did not don PPE prior to taking care of R67's G-Tube. On 3/5/26 at 10:00 AM, V22, LPN, stated if she is giving a feeding through the g-tube, she always flushes it after the feeding. V22 stated the feeding bottle should have the date and time it was hung or started along with the rate. V22 stated if any resident has a g-tube or PICC line, they should be on EBP and staff should be wearing a gown, gloves, and a mask when caring for that resident. On 3/5/26 at 10:06 AM, V11, LPN, stated she always flushes a g-tube before and after giving a feeding. V11 stated the bottle of g-tube feeding should have the resident's name, date and time it was started and the rate of infusion. V11 stated if anyone has a g-tube or PICC line, they should be on EBP and staff should be wearing a gown, gloves, and a mask to care for that resident. On 3/3/26, at 3:35 PM, V2, Director of Nursing (DON), stated if giving a bolus of feeding, you should flush the tube with 30 ML of water afterwards. V2 stated she would expect the staff to be following the policies on EBP and tube feedings via g-tube.On 3/3/26 at 3:36 PM, V1, Administrator, stated after giving a resident a feeding through the g-tube, they should be flushed with at least 30 ML of water.The Facility's Tube Feeding and Pump Operation/Kangaroo E-Pump Policy, dated 9/2024, documents in part Purpose: To provide guidelines for proper enteral nutrition and the use of the Kangaroo E-Pump to provide optional fluid and nutrition. 1. Obtain physician's order, per dietician's recommendation, which includes tube feeding formula and the TOTAL volume needed to assure caloric needs are met. Order should also include the rate and flush volume/frequency. If tube feeding is to be off for certain activities, order must specify such. 14. Be sure tube feeding bottle/tubing are dated and initialed. Tube feeding bottle/bag must be labeled with the resident's name, formula and rate of instillation. Hang time for closed system is 48 hours.

Based on observation, interview and record review the facility failed to administer medications per physician's orders for 2 of 3 (R195 and R37) reviewed for medications given on time in a sample of 38. Findings include: 1. R195's Physician's Order Sheet (POS), dated 11/2024 documents diagnosis included diabetes with no diagnosis of rash. 11/21/2024 Tacrolimus topical 0.1% ointment BID (twice a day) for rash on legs. 11/21/2024 Clobetasol topical 0.05% cream BID for rash. 11/21/2024 Metformin 850 milligrams (mg) BID for diabetes. R195's Medication Administration Record (MAR), dated 11/2024 documents Tacrolimus 0.1% topical ointment BID (twice a day) for rash on legs 0 documented as not given on 11/22/2024 through 11/24/2024 8:00 AM dose and 11/22/2024 through 11/26/2024 at 8:00 PM. Clobetasol 0.05% topical cream apply BID to rash 0 documented as not given at 8:00 PM on 11/22/2024, 11/26/2024 and 11/27/2024. Metformin 850 mg BID 8:00 PM dose 0 documented as not given. On 12/5/2024 at 10:30 PM V12, R195's wife stated she did not bring any medications including creams or ointments to the facility and no staff asked her to do that. 2. R37's POS, dated 11/2024 documents no diagnosis listed for anxiety. A physician's order dated, 11/9/2024 Alprazolam 0.25 mg TID (three times a day) for anxiety. R37's MAR, dated 11/2024 documents an order dated 11/5/2024 Alprazolam 0.25 mg tablet TID for anxiety 8:00 AM, 2:00 PM and 8:00 PM 0 was documented as not given on 11/11/2024 at 8:00 PM dose. On 12/5/2024 at 10:00 AM V2, DON (Director of Nurses) stated when a resident is admitted to the facility from the hospital the hospital submits prescriptions for a few days then the facility physician has to send prescriptions to the facility and if the prescription is sent STAT it usually takes the pharmacy to deliver the medication within 4-6 hours and when the medication is not send STAT if the medication is ordered before 5:00 PM the medication is usually here by 10:00 PM and when the medication is ordered after 5:00 PM the medication will be delivered to the facility at 2:00 AM. V2 stated the facility has an emergency backup medication system but it does not hold controlled medications or creams/lotions and only holds certain medications which doesn't include Metformin 850 mg. The wound nurse has prescription creams/ointments on her wound cart but staff wouldn't be able to get a hold of the wound nurse and do not have access to her wound cart at 8:00 PM. When a medication is not available at the facility staff document a 0 on the resident's MAR and then write a note as to why the medication was not given and these missed medications were documented not available from pharmacy. On 12/5/2024 at 10:50 AM V2 stated she expects staff to follow the facility's medication administration policy and to notify nurse supervisor and the resident's provider when a physician prescribed medication is not available to see if there is an alternate medication to be administered. On 12/5/2024 at 11:19 AM V1, Administrator showed documentation V14, LPN/RN notified the afterhours telehealth provider that only prescribed patient 5 Alprazolam which he takes TID. Are you able to call in more. If not, I can try the afterhours telehealth provider again. Response was RX (physician prescribed medication) sent. There was no documentation of resident name or any other identifying information on the paper. V1 stated this was the only documentation of medications that were documented as not available from pharmacy/documented as not given for the residents and she expected staff to follow the facility's medication administration policy and to notify the nursing supervisor and the resident's provider when a medication is not available. The Facility's Administration of Medication Policy, revised 6/2023 documents purpose: to provide general guidelines for staff to follow in the administration of medications. Responsibility: it is the responsibility of all RNs, LPNs, and CMTs to understand and comply with this policy. It is the Nurse Manager's responsibility to maintain and enforce this policy. Policy: if the medication is unavailable any time, the Nursing Supervisor should be contacted and may obtain medication from the emergency drug supply or contact the physician to try to obtain an alternate order.

Based on interview and record review the facility failed perform antibiotic stewardship for 2 of 3 residents (R27, R39) reviewed for antibiotic stewardship in the sample of 29. Findings include: 1. R27 was documented on the Infection Control log, dated 1/3/2024, for a urine infection. The organism documented was Enterococcus aerogenes. R27's Progress Notes, dated 1/3/2024, documented, Patient with urinary retention, suprapubic discomfort at times, leukocytosis. UA (urinary analysis) positive. Awaiting final urine culture. Patient has a history of pyelonephritis with pansensitive E. coli. We will start cefdinir 300 mg (milligrams) for 7 days. Adjust if needed once culture available. R27's Culture and Sensitivity Report, dated of 1/2/2024 at 3:14 PM, documented, Organism 1L Enterobacter aerogenes, and documents the organism was resistant to cefdinir. R27's Medication Administration Record (MAR) for January 2024 documented, Cefdinir (Cefzon, Omnicef) 300 milligrams (mg) oral capsule, start date 1/3/2024. R27's MAR also documents R27 received a total of four doses, January 3-January 4,2024 for a urinary tract infection. 2. R39 was documented on the infection control log,dated 1/7/2024, for urine infection. R39's Progress Notes, dated 1/8/2024 at 1:08 PM, Urinary tract infection associated with indwelling urethral catheter, initial encounter (HCC). Assessment Plan: Urine cloudy, continues to have good output from catheter. Culture positive for probable pseudomonas growth, awaiting sensitivities. Continues cefdinir for now, will adjust medication if needed once sensitivities available. R39's Urine Culture report, dated 1/7/2024 at 11:35 AM, documented, Final report organism 1: Pseudomonas aeruginosa. Cefdinir (Cefzon, Omnicef). The organism was not documented as being sensitive or resistant to cefdinir. R39's MAR, dated January 2024, documented, Cefdinir 300 mg, 1 capsule two times a day for seven days. Start date 1/7/2024. it continued to document that R30 received four doses from 1/7/2024 to 1/10/2024. The facility's Antibiotic Report, dated January 2024, documented that Cefdinir as being resistant to pseudomonas aeruginosa. R39's MAR, dated January 2024, documented, a 1/9/2024 start date for Ciprofloxacin (Cipro 500 mg) oral tablet every 12 hours for urinary tract infection for 7 days. R39's MAR document R39 received 7 days of the medication. The facility's Antibiotic Report, dated January 2024, documented for R39 that Cipro as being Sensitive for pseudomonas. On 1/17/2024 at 4:46 PM, V3, Infection Control Specialist, stated, Sometimes the PA (Physician Assistant) will start the antibiotics before the Culture and Sensitivity comes back but they do a good job of following up with them and making sure they are the correct antibiotics once the culture has been returned. When the physician sees the C & S it shows up on their screen the exact name of the medications and if they are resistant or have sensitivity. I myself, when I get the report there is only one or two letters for the drugs. I have a sheet from the pharmacy documenting what drug is what. R27's MAR, dated January 2024, also documented an order, Sulfamethoxazole-trimethoprim, (Bactrim DS (double strength), 800 mg to 160 mg, oral tablet. Start date 1/5/2024. The Antibiotic Stewardship Program Policy, dated of 9/22, documented, To provide guidelines to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. It is the policy of this community to implement an Antibiotic Stewardship Program as part of the community's overall infection prevention and control program. It promotes the appropriate use of antibiotics and is a system of monitoring to improve resident outcomes and reduce antibiotic resistance. Antibiotics will be prescribed for the correct indication, dose and duration to appropriately treat the resident while attempting to reduce the development of antibiotic-residents organisms or other adverse consequences or outcomes. This program will be reviewed on an annual basis and as needed.

Based on interview and record review the facility failed to ensure residents who require supervision during toileting are supervised to prevent accidents for 1 of 3 residents (R3) reviewed for supervision to prevent accidents in the sample of 7. Findings include: R3's February 2023 Physician Order Sheet (POS) documents diagnoses of cerebral palsy, unspecified psychosis not due to a substance or known physiological condition. R3's Occupational Therapy Evaluation and Plan of Treatment dated 11/23/2022 document diagnoses of cerebral palsy, unsteadiness on feet, repeated falls, muscle weakness and need for assistance with personal care. R3's Minimum Data Set (MDS) MDS dated [DATE] documents R3 was cognitively intact for decision making. R3's MDS documents she required limited assistance for bed mobility and assistance of one staff for toileting. R3's Therapy Evaluation dated 11/23/2022 document R3 was moderately impaired for cognition and requires 1 to 2 staff persons for activities of daily living and toileting. R3's Fall assessment dated [DATE] document a score of 65, High Risk, forgets limitations. R3's Resident Profile Report, print date of 2/8/23, documents, I have a goal of increasing my independence. I require minimum assistance. I am a fall risk related to frequent falls at home with a diagnosis of cerebral palsy. The Resident Profile Report, print date of 2/8/23, documents fell on [DATE]. The Profile documents I had a fall when I slipped out of the wheelchair trying to take myself to the bathroom. Interventions: Engage in the post fall huddle with CNA (Certified Nurse's Aide), Primary Nurse, Charge Nurse, and any other pertinent staff immediately following a fall. Ensure call light and personal belonging are in reach. Offer to toilet every few hours. The Resident Profile Report, print date of 2/8/23, documents R3 fell on [DATE]. The Profile reported documented I had a fall when I threw myself out of bed because I was unhappy using the bed pan even though it is what I had been using previously at night. Initiate behavior management evaluation order for behavior tracking each shift. Initiate floor mats to prevent injury from falls from behaviors. The Resident Profile Report, print date of 2/8/23, documents R3 fell on [DATE]. The Profile Report documented I had fall with no injury after trying to transfer myself from wheelchair to bed without calling for assistance. Interventions: Ensure call light and personal belongings are within reach. Engage with the patient each time staff pass the room with reminders to use the call light. Initiate floor mats to prevent injury. The Resident Profile Report, print date 2/8/23, documents R3 fell on [DATE]. The Report documented I had fall with laceration to the right forehead requiring dissolvable sutures to be placed in the ED (emergency department). I fell while in the bathroom when I got up from the toilet unassisted. Ensure call lights and personal belongings are in reach. Make sure patient has on appropriate footwear/non-slip socks. Do no leave a patient who is a high risk alone in the bathroom for any reason. An undated written statement from V6, Certified Nursing Assistant (CNA), documented I (V6) put patient on toilet about 7:45 PM. She puts her light on but decided to get up before I got back, and she fell . R3's Post fall evaluation dated 12/26/2022, Patient yelled out and was found on the floor. A laceration was noted with bleeding from the right forehead. Nurse (V7) and Nurse (V11) assessed patient and provided first aid to the forehead laceration. No other injuries were noted. Physician called and instructed to call EMS (Emergency Medical Service) for ER emergency room for transfer for evaluation. EMS called. EMS arrived and transported patient onto stretcher and over to emergency room (ER). Sutures placed in ER and patient was able to return. CT of head was negative. Patient is not to be left unattended in the bathroom moving forward. On 2/8/2023 at 3:12 PM, V6 stated, (R3) was a patient that was very troubled at times. She would scream out a lot and was very confused. She was not able to walk and always needed staff assistance to help her. She could not take herself to the toilet. Staff are supposed to stay with her when she is on the toilet. One night I had taken her to the bathroom because she was wet and I told her I am just going to get you a diaper and I left the room and then another resident had put their light on and I entered their room and told them I would be right there as soon as I could and when I returned (R3) had fallen in the bathroom and had a cut on her forehead. They sent her out to the hospital, but I don't think she had any injury just a small abrasion. On 2/8/2023 at 1:11 PM, V10, Therapy Manager (V10) stated, Therapy will do an evaluation and (R3) was evaluated on 11/23/2022 and she was a 1-2 staff member assist for her activities of daily living. R3 was moderately impaired using our system versus the Minimum Data Set. We use a different system then the Minimum Data Set (MDS) and she scored a 14 out of 25 for her cognitive assessment. A score of 14 indicates she has moderate impairment for cognition. It would not be safe for her to be left on the toilet alone. She should not have been left alone on the toilet. The Fall Policy provided by the facility on 2/9/2023 at 10:00 AM, documents, Fall Management Reduction Program Purpose to provide guidelines to manage and attempt to reduce the incidence of resident falls. The point of accurately capturing occurrences of falls on the assessment is to identify and communicate resident problems and potential problems, so that staff will consider and implement interventions to help prevent falls and injuries from falls. At a score ABOVE 45, the resident is identified at a high risk of falls. A fall reduction program will be initiated.

Based on interview and record review, the facility failed to provide identifying information regarding abuse allegations in the initial report to Illinois Department of Public Health (IDPH) for 4 of 4 (R59, R170, R171, R220) reviewed for abuse reporting in the sample of 52. Findings include: 1. R170's Minimum Data Set (MDS), dated [DATE], documents that R170 is cognitively intact. An undated and untitled document provided by the facility documented on January 20, 2023, at 10:00 AM R170 notified V1, Administrator, that a staff member came in to take vital signs and slapped him across the face. On January 20, 2023, at 10:19 AM V1 reported the incident to IDPH. The initial report documented A reportable event occurred. A final report will be sent to the department within 5 business days. The Report documented the date of the incident as 1/20/23 and R170. The report did not document that this was allegation of abuse and a description of the occurrence. 2. An undated and untitled document provided by the facility documented on November 23, 2022, at 10:30 AM R171 reported that V15, Registered Nurse, grabbed her gown by the front and pulled her over to the bed in a rough manor on November 22, 2022. On November 23, 2022, at 11:00 AM V1 reported the incident to IDPH. The initial report documents A reportable event occurred. A final report will be sent to the department within 5 days. The Report documented the name of the resident as R171, date of birth of R171 and the incident date as 11/23/22. The report did not document that this was an allegation of abuse and a description of the occurrence, and the alleged perpetrator. 44556 3. R59's MDS, dated [DATE], documents she is cognitively intact. R59's Final Illinois Department of Public Health (IDPH) report, dated 01/17/23, documents On 01/12/23 at 10:30 AM, V13, Respiratory Therapist notified V1, Administrator that R59 alleged that she was punched in the stomach, foot stomped on and thrown onto the bed. The initial Illinois Department of Public Health Facility Reported Incidents dated 01/12/23 at 11:13 AM, documents A reportable Event occurred, a final report will be sent to the department within 5 business days. The report did not document this was an allegation of abuse or a description of the alleged occurrence. 4. R220's MDS, dated [DATE], documents she is cognitively intact. R220's Final IDPH Report, dated 01/31/23, documents On 01/24/23 x-ray was obtained of the right knee, upon review, x-ray resulted a mildly displaced peri-hardware fracture involving the right distal femur. Upon speaking with V14, Nurse Practitioner, she obtained the x-ray because patient states that on Sunday 1/23/23 when in the Hoyer lift, her leg slipped. The initial Department of Public Health Facility Reported Incidents dated 01/25/23 at 9:51 AM, documents A reportable Event occurred, a final report will be sent to the department within 7 business days. The report did not document that this was an injury of unknown origin. On February 2, 2023, at 1:55 PM V1, stated that she is the person that reports the abuse to IDPH. V1 stated that she has an open-door policy. V1 stated that residents, families, and staff report abuse. V1 stated that when she is made aware of the allegation of abuse, she makes sure that she gets the details of the allegation. V1 stated that she then sends an initial report to IDPH. V1 stated that she does not document the actual allegation in the initial report. V1 stated that she documents that there has been an incident. V1 stated that when sending the report, you must indicate if this the initial or the final. V1 stated that she just reports there's been an event, check what is abuse or accident. V1 stated that then she hits send me confirmation and that's that. V1 stated that she just sends over there is a reportable event. V1 stated that she doesn't send any more information. V1 stated this is what her corporate told her to do. The Facility's Policy and Procedure, Resident Abuse/Neglect/Exploitation, with a revised date of 09/22, documents PURPOSE: To provide guidelines for identifying, investigating and reporting resident abuse/neglect and exploitation, including any reasonable suspicion of a crime directed towards the resident. The Policy and Procedures documents 3. An investigation shall be initiated immediately. Any allegation of abuse must be fully investigated and self-reported to appropriate State Agency. The Policy documents Any incident of unknown origin needs to be immediately investigated. If cause cannot be determined within 24 hours, it must be self-reported to DHSS or IDPH.

Based on interview and record review, the Facility failed to ensure the Admission Comprehensive Minimum Data Sets (MDS) were completed by the Assessment Reference Date (ARD) for 4 of 12 (R119, R120, R168, R170) reviewed for comprehensive assessments in the sample of 52. Findings include: On 2/6/2023 at 11:41 AM, V12, MDS Nurse was questioned regarding the MDS assessment timeliness. V12 stated I just did the last of them today (MDS that were due). I was waiting on Social Services to do their parts. All of my sections were done last week but I can't submit them until all the sections are complete. I have several that are past due. I've been keeping track of it. The ARD (No later than the 14th calendar day of the residents' admission which is the admitted plus 13 calendar days) at the top is the due date. On 2/6/2023 at 12:15 PM, V12 provided a document dated 2/6/2023 and signed by V12. It documents, These are the last assessments for January 2023. This list included R119, R120, R168 and R170. R119's MDS ARD was 1/28/2023 and documents, Date RN (Registered Nurse) Assessment Coordinator signed assessment as complete 2/6/2023. R170's MDS ARD was 1/21/2023 and documents, Date RN (Registered Nurse) Assessment Coordinator signed assessment as complete 1/27/2023. R120's MDS ARD was 1/29/2023 and documents, Date RN (Registered Nurse) Assessment Coordinator signed assessment as complete 2/6/2023. R168's MDS ARD was 1/28/2023 and documents, Date RN (Registered Nurse) Assessment Coordinator signed assessment as complete 2/6/2023. On 2/6/2023 at 12:25 PM, V1, Administrator, stated, I am aware of some late MDS. We have talked about it during QAPI (Quality Assurance Performance Improvement). On 2/6/2023 at 1:40 PM, V12 stated, Everyone who is admitted and entered into our system has to at least have a 5-day assessment, even if they don't stay for 5 days. On 2/6/2023 at 1:53 PM, V1 stated, I would expect the staff to follow our policy regarding timeliness of MDS Assessments. The Facility's Resident Assessment Instrument/Minimum Data Set Protocol dated 10/2019 documents, All team members should complete their respective section of the MDS by the specified time frame so that the MDS coordinator/designee can coordinate and transmit within the appropriate time allowances.

Based on observation, interview and record review the facility failed to ensure food is stored and prepared in a manner which prevents potential contamination. This has the potential to affect 57 residents living in the facility. Findings include: On 12/05/18 at 9:42 AM, in the main dining room there is a refrigerator with a small freezer attached to the side. Inside the refrigerator are 2 clear containers with red gelatin and 2 clear containers with orange gelatin substance. None of the containers are dated or labeled. Inside the freezer there is an open package of an ice cream fudge bar that is half eaten and not covered and open to the air. There is a sign on the door of the refrigerator that documents, Please do not place personal items in this refrigerator, only items from the Dietary Department are to be stored in here. On 12/05/2018 at 10:01 AM, R5 opens the freezer and takes out the opened fudge pop and begins to eat it. On 12/05/18 at 10:45 AM, in the main kitchen the ice machine hose goes directly into the drain and there is no air gap. Above the stove the vents are dirty, shiny in appearance with dust in between the slants. On 12/05/2018 at 10:46 AM, V7, (Dietary Manger) stated, I did not realize there was a code for the ice machine and there needed to be an air gap. I will get it taken care of right away. We use the ice from the kitchen to keep things cold and fill containers but the ice is not used for the Facility they have their own ice machine. We have the hood in the kitchen serviced every 6 months but we do not have a cleaning schedule for the inserts above the hood. The inserts are cleaned by staff. I see the dirt in the inserts. We just recently had construction work in the kitchen and maybe that is how that all got in there. I will make sure it gets cleaned. The Facility's undated(NAME)and Filters Section Policy documents Hoods and filter are to be cleaned weekly, Monday-Wednesday-Friday. Stove Filters, empty grease trays, clean inside and outside of hoods located above the steamers, cook's stove and bakery area. The Facility's Resident Census and Conditions of Residents form dated 12/06/2018 documented the facility had a census of 57 residents.

Based on observation, record review and interview, the facility failed to address current care needs on admission in the baseline Care Plan for 1 of 15 residents (R106) reviewed for baseline care plans in the sample of 41. Findings include: 1. The Care Area Assessment (CAA) dated 12/09/2018, documents R106 fell at home prior to admission. The CAA documents, in part, (R106) told writer that she was walking and fell , that it was from sciatica, made her knee give out. The electronic health record (EHR) for R106 documents diagnoses, in part, as History of Fall, Debility, Sciatica and Generalized Weakness. On 12/07/2018 at 9:58 AM, V13, Certified Nurse Aide (CNA) applied a gait belt and assisted R106 to stand. At that time, R106 reported she fell at home, with no fracture and came here for rehab to gain back her strength. R106 stated I have not been walking by myself. When I stand up I am dizzy. A sign on wall near the foot of R106's bed reads, Independent in room with w/w (wheeled walker). After 5 (PM) encourage to use call light. R106's initial Plan of Care, dated 11/28/2018, has no documentation to address R106's problem of being a fall risk or any related interventions. The Progress Note from V14, Nurse Practitioner (NP) dated 12/06/2018 documents, in part, The patient does complain of postural dizziness. The facility's policy and procedure, revised 3/2018 and entitled Documentation of Nursing-Interdisciplinary Process documents in part, Patient/resident care planning starts upon admission. Baseline care plan will be developed within 48 hours of admission. A Nurse upon admission must assess the resident/patient's care needs and health status, developing an initial plan of care. All other disciplines assess as appropriate based on resident/patient's care needs and health status, documenting in the interdisciplinary plan of care. The interdisciplinary care plan is based on the 6 steps of the care plan process and is ongoing, based on the patient needs. The Interdisciplinary Care Area Assessments (CAA's) provide a direct link between the MDS (Minimum Data Set) and the plan of care.

Based on interview and record review, the facility failed to assess and document the arteriovenous fistula site for thrill and bruit and signs of infection and bleeding for 1 resident out of 3 (R16) reviewed for [MEDICAL TREATMENT] care in the sample of 41. Finding includes: R16's Minimum Data Set (MDS) documents a Brief Interview of Mental Status Score (BIMS) as 15 indicating R16 has intact cognition. On 12/06/18 at 9:17 AM, R16 stated she goes to [MEDICAL TREATMENT] 3 times a week and has a fistula in the upper inner arm. R16 further voiced the facility does assess the fistula site and listen to the thrill and bruit periodically but not daily. R16's Plan of Care dated 10/9/18 documents the [DIAGNOSES REDACTED]. Intervention: Check thrill and bruit to left arteriovenous fistula, notify MD of absence and abnormality. R16's flow sheet of assessing the ateriovenous fistula for bruit and thrill daily is without documentation on (MONTH) 19, 20, 21, 25, 28, 29; (MONTH) 3, 6, 8, 10,12, 17, 17, 21, 26, 27, 30; (MONTH) 2,4, and 5th, (YEAR). The facility's undated protocol for [MEDICAL TREATMENT] Ateriovenous Gortex Care, documents in part: General Rules Concerning Arm with Arteriovenous Gortex. Gortex Care: 1. Check thrill/bruit by palpitation or auscultation daily. If not present, notify [MEDICAL TREATMENT] center a soon as possible. The facility's policy titled Pre/post [MEDICAL TREATMENT] Patient Guidelines, dated (MONTH) (YEAR), documents in part: 1. Purpose: To ensure patients are properly prepared for and skin injury prevented during [MEDICAL TREATMENT] treatment. II. Guidelines: 9. Assess ateriovenous graft or fisutla daily for bruit and thrill and document in the patient record. On 12/07/18 at 11:14 AM, V1 (Administrator) stated The Nurses should be checking the site at least daily and documenting it on the flow sheet.

Based on interview and record review, the Facility failed to identify an allegation of abuse and initiate an investigation for 1 resident (R16) in the supplemental sample. Findings include: The facility's undated Service Recovery, Concerns, Abuse Log entry, dated 7/23/17, documents: Patient name: (R16) Informant: Pt (patient) reported to Nurse (E11) Concern Type: Bruising Summary: Pt reported that she has bruising on L (left) inner thigh. She stated the PT (Physical Therapist) did this to her the previous day. She stated the therapist grabbed her by her L groin area. Therapist notified of concern and stating she gave manual cues to move LLE (left lower extremity) and ankle. R16's Nurses Note, dated 7/23/17 at 12:38, documents, large purple bruise to left inner thigh, soft, not warm to touch. Doctor states if bruise starts to enlarge may use ice packs prn (as needed). On 11/15/17 at 3:00 PM, E1, Administrator, stated, I expect staff to interview residents and other staff members during an investigation of abuse. E1 further stated, IDPH should have been notified of the allegation of abuse immediately. On 11/16/17 at 9:54 AM, E1, stated, I was off on maternity leave so the charge nurse sent out an email to all department heads. She then spoke with, (E12) Physical Therapist, and notified the doctor. The charge nurse thought at the time that she had handled the situation to the fullest. (R16) was the last patient (E12) had that day.

Based on interview and record review, the facility failed to operationalize it Abuse policy by not identifying an allegation of abuse, initiating an investigation, and notifying the Department for 1 resident (R16) in the supplemental sample. Findings include: The facility's ABUSE PREVENTION PROGRAM policy and procedure with review date October 2017 documents, IV. Employees and volunteers are required to report any occurrences of potential mistreatment or injuries of unknown origin that they observe, hear about, or suspect to the Administrator immediately. Supervisors shall immediately inform the Administrator of all reports of potential mistreatment. Immediately on learning of the report, the Administrator shall initiate an incident investigation. V. Employees of this facility who have been accused of mistreatment will be removed from resident contact immediately until the results of the investigation have been reviewed by the administrator or designee. Employees accused of possible mistreatment shall not complete the shift as a direct care provider to residents. VII. During the course of an incident investigation, the Administrator, shall report to the resident's representative and the Department of Public Health all alleged violations or injuries of unknown source immediately. The facility's undated Service Recovery, Concerns, Abuse Log entry, dated 7/23/17, documents R16 reported to E11, Registered Nurse (RN), bruising on R16's left inner thigh from the Physical Therapist grabbing R16 by the left groin area the previous day. The Log also documents the Therapist was notified of the concern and stated she gave manual cues to R16 to move LLE (left lower extremity) and ankle. R16's Nurses Note, dated 7/23/17 at 12:38 documents, large purple bruise to left inner thigh, soft, not warm to touch. Doctor states if bruise starts to enlarge may use ice packs prn (as needed). On 11/15/17 at 3:00 PM, E1, Administrator, stated, I expect staff to interview residents and other staff members during an investigation of abuse. E1 further stated, IDPH should have been notified of the allegation of abuse immediately. On 11/16/17 at 9:54 AM, E1 stated, I was off on maternity leave so the charge nurse sent out an email to all department heads. She then spoke with, (E12) Physical Therapist, and notified the doctor. The charge nurse thought at the time that she had handled the situation to the fullest. (R16) was the last patient (E12) had that day.

Based on observation, record review and interview the facility failed to prevent cross contamination and perform proper hand hygiene for 5 of 13 residents (R3, R5, R7-R9) reviewed for infection control in the sample of 15. Findings include: 1. On 10/24/16 at 1:30 PM, E6, Registered Nurse (RN), performing a dressing change on R7. E6 placed a roll of tape on R7's bed linens. E6 was observed picking up the tape several times to secure a dressing to R7's back. After the care, E6 placed the roll of tape on the over the bedside table. E6 then picked up the red biohazard bag that was sitting on bed linens and containing the soiled dressing supplies and sat in on the over the bedside table. E6 put the tape that was sitting on the bed lines in a plastic bag with other dressing supplies and gave it to Z1, Family, to take to a physician appointment. This surveyor questioned E6 about the cross contamination and the tape being sent to the physician's office. E6 agreed there was cross contamination and stated the tape traveled and proceeded to dispose of the bag of dressing supplies and gave Z1 a new bag of dressing supplies. 2. On 10/24/16, at 2:20 PM, E6 performed a dressing change to R8's left heel. E6 put on a pair of gloves and cleansed R8's heel with Normal Saline and a gauze pad. E6 the picked up a tube of Santyl Ointment and a roll of tape that was inside an open drawer in the room and proceeded to apply the ointment to the heel and covered the area with a gauze dressing and applied tape. After the care, E6 placed the Santyl and tape back inside the drawer. E6 was not observed to change her gloves during this part of the wound care. 3. On 10/25/16, at 2:15 PM, E8, RN, administered medication into R9's gastrostomy tube. During this observation, E8's portable facility phone rang and E8 removed the phone from her pocket to answer the call and returned it back into the pocket. E8 continued with the gastrostomy medication administration and after completing the care proceeded to type information on the computerized medication cart in the room. E8 failed to change her gloves during the entire observation. 4. On 10/25/16, at 11:27 AM, E6 prepared R5's dressing supplies. E6 donned gloves and got mepliex and santyl ointment from treatment cart. With the same gloves, E6 retrieved a sani wipe and proceeded to wipe R5's bedside table with sani- cloth. E6 layed R5's dressing supplies on R5's bedside table and then removed R5's dressing from her coccyx, all with the same gloves. On 10/27/16 at 12:30 PM, E5, Charge Nurse, stated, I could go either way with changing gloves in this instant because it was a dirty dressing. 5. On 10/23/16 at 12:05 PM, while sitting next to R3 in the Dining Room, E4, Patient Care Tech, picked meat off of R3's chicken with her bare hands and then fed a piece of chicken to R3 with her bare hands. E4 then dipped a piece of chicken into R3's mashed potatoes and proceeded to feed R3 with her bare hands. On 10/27/16 at 10:10 AM, E1, Administrator, stated that she would not expect staff to have any bare hand contact with residents food, she would expect then to wear gloves or use utensils while feeding residents. The Facility's Infection Prevention Hand Hygiene Policy dated 09/2015 documents in part, II. Policy - All staff will practice effective and appropriate hand hygiene.

Based on record review and interview, the facility failed to recognize allegations of abuse and report to the Department the allegation of abuse for 1 resident (R16) in the supplemental sample. Findings include: 1. The Facility's Grievance Log titled Service Recovery, Concerns, Abuse Log documents on 6/24/16, R16 communication with pt (R16) Investigated concerns-resolved. A typed document provided by E1, Administrator on 10/25/16 documents: Complaint voice by (R16) on 6/24/16. (R16) stated that on 6/24/16, she was sitting up in the wheelchair in the hallway and an African-American Patient Care Technician (PCT), 'yelled at me and said sit down and shut up, don't make noise or you will get more punishment' while she (PCT) was poking her (R16) in her shoulder. On 10/25/16 at 1:45PM, E4, Registered Nurse-Charge Nurse (RN), stated she was involved in interviewing R16 with E2, Director of Nursing. E4 stated they interviewed R16 about allegation and R16 was confused and would start talking about other things. E4 stated she did not think it was abuse because R16 was confused and had history of hallucinations. E4 further stated E2 had everything written up and then they determined it was not abuse so they did not report anything to the Department. On 10/25/16 at 1:30PM, E1, Administrator, stated E2 and E4 had investigated the occurrence and had concluded after 2 hours that abuse had not occurred. E1 stated E2 had everything typed up and ready from the investigation but did not send anything to the Department because they felt abuse had not occurred. On 10/27/16 at 10:15AM, E1 stated the facility investigates all allegations and this was a glitch. E2 was unable to be interviewed as she was out of the building on medical leave.

Based on record review and interview, the facility failed to operationalize their abuse recognize allegations of abuse and report to the Department the allegation of abuse policy for 1 residents (R16) in the supplemental sample. Findings include: 1. The Facility's Abuse Prevention Program dated September 2016, documents: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. This will be done by: identifying occurrences and patterns of potential mistreatments; filing accurate and timely investigative reports. Verbal Abuse is the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or families or within hearing distance, or within hearing distance, regardless of their age, ability to comprehend or disability. External Reporting on record review and interview the facility failed to follow their Abuse Prevention porting of Potential Abuse; Public Health shall be informed that an occurrence of potential mistreatment has been reported and is being investigated. The Facility's Grievance Log titled Service Recovery, Concerns, Abuse Log documents on 6/24/16, R16 communication with pt (R16) Investigated concerns-resolved.' A typed document provided by E1, Administrator on 10/25/16 documents: Complaint voice by R16 on 6/24/16. R16 stated that on 6/24/16, she was sitting up in the wheelchair in the hallway and an African-American Patient Care Technician (PCT), yelled at me and said sit down and shut up, don't make noise or you will get more punishment while she (PCT) was poking her (R16) in her shoulder. On 10/25/1 she 6 at 1:45 PM, E4, Registered Nurse-Charge Nurse (RN), stated she was involved in interviewing R16 with E2, Director of Nursing. E4 stated they interviewed R16 about allegation and R16 was confused and would start talking about other things. E4 stated she did not think it was abuse because R16 was confused and had history of hallucinations. E4 further stated E2 had everything written up and then they determined it was not abuse so they did not report anything to the Department. On 10/25/16 at 1:30 PM, E1, Administrator, stated E2 and E4 had investigated the occurrence and had concluded after 2 hours that abuse had not occurred. E1 stated E2 had everything typed up and ready from investigation but did not send anything to the Department because they felt abuse had not occurred. On 10/27/16 at 10:15 AM, E1 stated the facility investigates all allegations and this was a glitch.

Based on observation, interview and record review, the facilty failed to change pressure ulcer dressings as prescribed by physician and to specifically identify all pressure wounds for 2 of 3 residents (R5 and R8) reviewed for pressure ulcers in the sample of 15. Findings include: 1. R8's October 2016 physician's orders [REDACTED]. R8 stated on 10/24/16 at 10:55 AM, occasionally the treatment to her left heel is not done daily. R8 stated one day it was missed because E6, Registered Nurse/RN/Wound Care Nurse, went home sick and another day E7, RN/Wound Care Nurse, did not have time to get to it. On 10/24/16 at 2:30 PM E6 performed a dressing change to R8's left heel. The dressing was dated 10/22/16. At this time, E6 stated the dressing change is to be done daily. E6 also stated if she does not get a dressing change done the floor nurses are to do the dressing change. The computerized Skin Flow Sheet dated October 2016 documents the dressing was not changed on 10/18/16, 10/21/16 and 10/23/16. 2. R5's current Electronic Medical Record system document R5 was admitted on [DATE]. R5's Minimum Data Set ((MDS) dated [DATE] documents R5 requires extensive assist of on staff member for Activities of Daily Living (ADL). R5's Care Plan dated 9/29/16 documents Coccyx/buttocks; incision/wound care. R5's Skin Flow sheet dated 9/30/16 documents Wound Measurement: 1x1. Integumentary comment: 4 areas to coccyx, 3 have red with some yellow slough noted, all 2 are 0.5x0.5x0. One is 0.2x0.2.0. One is red with purple surrounding tissue. The entire coccyx is red measuring 7x6. R5's Skin Flow sheet dated 10/5/16 documents: Buttock: skin impairment pressure ulcer, red, slough, wound measurement 1.7 centimeters (cm) x 2 cm. Coccyx: Skin impairment: pressure ulcer, red, slough, wound measurements 4 cm x 3 cm. This documentation did not identify each pressure ulcer to allow for monitoring and progress or decline of the pressure ulcer from one weekly assessment to the next. R5's Skin Flow Sheet Dated 10/12/16 documents: buttock: skin impairment pressure ulcer, red, slough, wound measurement 3.8 cm x 2.5cm. Coccyx: skin impairment pressure ulcer, red, slough, wound measurements 1 cm x 0.5 cm. This documentation did not identify each pressure ulcer to allow for monitoring and progress or decline of the pressure ulcer from one weekly assessment to the next. R5's Skin Flow sheet dated 10/19/16 documents: coccyx: 1.5 cm x 1.5 cm. This documentation did not identify each pressure ulcer to allow for monitoring and progress or decline of the pressure ulcer from one weekly assessment to the next. On 10/25/16 at 10:27 AM, E6, Registered Nurse, Wound Nurse, (RN) did a treatment to R5's pressure ulcer. A small dime-quarter sized area over R5's coccyx was noted. Minimal amount of yellow drainage noted to dressing. During this time, E6 stated R5's area was a revolving deep tissues injury. On 10/26/16 at 2:15 PM, E6 stated she did not have any way to identify the areas that were noted on the 9/30/16 documentation that stated there were 4 areas with measurements. When asked where the measurements or resolution of the initial 4 areas were, E6 stated she just measured the buttocks and coccyx. E6 further stated she just looks at the picture from the previous week to see if area looks better or worse. On 10/27/16 at 10:15 AM, E1, Administrator, stated the wound nurse from the hospital directs them that it is wound care standards and how it is practiced to not identify each area. E1 stated she expects staff to identify the part of the body correctly but not necessarily every wound in that area. The Facility's Wound Documentation Policy dated 2/2016 documents To ensure that appropriate wound assessment is performed as recommended and that documentation reflects results of the assessment findings. Policy: All wounds are assessed, measured and photographed upon admission or identification, weekly, if wound worsens and within 24 hours of discharge. Procedures: the following should be documented daily. 1. Location of wound. 1. Photograph: use measuring guide labeled with date, medical record and location of wound.

Based on observation, record review and interview the facility failed to properly flush a gastrostomy tube for 1 of 1 resident (R9) reviewed for gastrostomy care in the sample of 15. Finding includes: R9's October 2016 physician's orders [REDACTED]. On 10/25/16, at 2:15 PM, E8, Registered Nurse, administered medication into R9's gastrostomy tube. E8 administered 960 milligrams of liquid Tylenol and then flushed the tube with 120 ml of water. During this observation, E8 was not observed to flush the tube before the Tylenol administration. On 10/27/16 at 9:55 AM, E1, Administrator stated the facility staff must follow the physician's orders [REDACTED].

Based on observation, interview and record review, the facility failed to maintain safe hot water temperatures in areas accessible to residents for 3 of 15 residents (R1, R4 and R7) reviewed for safe and comfortable water temperatures in the sample of 15 and 2 residents (R16 and R17) in the supplemental sample. Findings include: On 01/05/15 at 3:22 P.M. the hot water temperature taken at the hand sink in R17's bathroom with a digital metal stemmed thermometer was 125 degrees Fahrenheit (°F). On 01/05/15 at 3:25 P.M. the hot water temperature taken at the hand sink in R16's bathroom with a digital metal stemmed thermometer was 122°F. On 01/05/16 at 3:52 P.M. the temperature at the hand sink in the 100 hall common use spa/shower room taken with a digital metal stemmed thermometer was 126°F. On 01/05/16 at 3:52 P.M. the temperature at the hand sink in the 200 hall common use spa/shower room taken with a digital metal stemmed thermometer was 126°F. While in the 100 hall common use spa/shower room on 01/05/16 at 3:52 P.M. E2, Director of Nursing (DON) stated, That surprises me they (water temperatures) are that high. We try and keep them around 110°F and someone checks temperatures in the Boiler Room every morning. On 01/05/16 at 4:08 P.M., E1, Administrator, stated that someone checks temperatures regularly and We have logs to track them. On 01/06/16 at 8:52 A.M. E6, Power Plant Operator, stated that he hadn't seen water temps be that high in the facility and that he tweaked the mixing valve yesterday when it was brought to his attention that the temperatures were high. E6 then stated that water temperatures get checked two times a week on Tuesdays and Fridays and that someone would have taken them yesterday morning. On 01/07/16 at 9:10 A.M., E10, Power Plant Supervisor stated that the facility runs off of a closed loop system that re-circulates water throughout the facility that runs off of one tank which is located in the Machine Room. E10 then stated that the hot water tank is set at 140°F and the water is directed through a mixing valve that is set at 110°F. E10 stated that the mixing valve is currently malfunctioning, possibly due to a bad seal which is causing too much hot water to leak through the system and not allowing cold water through. E10 stated that they currently have to manually adjust it to make sure temperatures stay within the proper range. E10 stated the facility tries to keep the temperature of the water between 105-108°F. E10 stated maintenance employees take temperatures on Tuesday and Friday morning and document them on a Maintenance Department Work Order Sheet. E10 stated the Work Order Sheet documents weekly tasks to be checked as follows: 20) Test water temp at the boiler room, one random patient room, and a random tub/shower room. 30) Record temperatures two times a week on the attached form. 40) In no case should the water temperature exceed 120 degrees. 50) 95 to 110 degrees for long term care. 60) Testing instr.-let water run for two (2) min. (minutes) over thermometer if temp.(temperature) exceeds 120 degrees adj.(adjust) temp. controls until below 120 degrees- then test five adjacent areas verifying temp is below 120 degrees. 70) Record all areas & temperatures daily on the attached document. On 01/07/15 at 12:15 P.M. E10 stated that per policy procedure Mechanical Rooms are visually inspected daily by trained staff and any problems or malfunctions found are documented immediately in a daily log on an ipad carried by staff. E10 stated once the deficiency is documented a work order is then generated to resolve the issue. On 01/06/16 at 10:00 A.M. during a group interview R1 stated, Sometimes I have noticed the water is too hot, but I usually let it run for a while. R1 then stated he noticed it was really hot one day last week but could not recall what day. On 1/6/16, E1 provided a list of residents who have showered in 100 hall and 200 hall in the last week. The list documents R4 and R7 have both received showers in the past week in the 100 and 200 hall spa/showers. The Facility's Routine Rounds Policy dated 07/16/15 documents in part, Policy, It is the policy of Facilities Management to visually inspect each equipment system daily to determine that it is operating with normal operating parameters, 6.0 Functional Responsibilities, 6.1) Routine rounds must be completed a minimum of once per day and be completed each shift when there are two or more personnel assigned to that shift , . 6.2.11) Check domestic hot water temp and log same on weekly PM (preventative measures) rounds.

Based on observation, record review and interview, the facility failed to change soiled gloves after providing incontinent care, and failed to adequately clean and disinfect multi-use medical equipment to prevent the spread of infection for 3 of 4 residents (R2, R8, R9) reviewed for incontinent care and infection control practices in the sample of 15, and 5 residents (R16, R17, R18, R19, R20) in the supplemental sample. 1. On 12/17/14 at 9:42 AM, E3, Certified Nurses Aide (CNA) transferred R2 to the toilet while wearing gloves. After R2 urinated, E3 used her left gloved hand to wipe R2's perineal area with toilet paper. While R2 was standing, E3 used the soiled glove to pull up R2's incontinent pad, elastic underwear and pants. Without removing or changing gloves, E3 assisted R2 to transfer back to the wheelchair, touching the gait belt, R2 and the wheelchair before removing the soiled gloves and washing her hands. 2. On 12/16/14 at 9:25 AM, E5, CNA had on gloves as she wiped liquid stool from R9's buttocks with a wash cloth, after his use of the bedpan. E5 continued using the same soiled gloves and touched the trash bag, urinal, pillow, blanket, sheets, call light, bed controls and R9's arms and legs as E5 repositioned R9. E5 pulled open R9's privacy curtains and moved R9's over bed table while still wearing the same soiled gloves. E5 removed her soiled gloves and washed her hands. 3. On 12/16/14 at 10:15 AM, on the initial tour of the Facility, E7, Registered Nurse (RN), stated R8 is on contact isolation for Clostridium difficile (C-diff). On 12/17/14 at 11:35 AM, E4,CNA, had on a gown and gloves as she assisted R8 to use the bedside commode to urinate. R8 stood up using her walker while E4 used her gloved hand and tissue to wipe R8's perineal area from front to back. E4 pulled up R8's pants, touched R8's arms, removed the gait belt, moved the walker, call light, bedside commode, and opened the bathroom door, using the door knob before E4 removed the soiled gloves. E4 donned new gloves and used a bleach wipe to wipe off the bathroom door knob. E4 removed her gown, gloves and washed her hands before exiting R8's room. On 12/17/14 at 11:50 AM, E2, Director of Nursing (DON) stated she expects glove changes during pericare when moving from soiled to clean areas. The facility's policy and procedure, entitled, "Infection Prevention, Standard Precautions (Body Substance Isolation)", revised 1/2014, documents, in part, "The Centers for Disease Control (CDC) and the Occupational Safety and Health Administration (OSHA) have recommended that all body fluids that may contain blood be treated as if they are potentially infectious. Guidelines-1. Hand hygiene. When visibly dirty, after touching blood, body fluids, secretions, excretions, or contaminated items; immediately after removing gloves; between patient contacts." 4. R8's physician's orders [REDACTED]. On 12/17/2014, at 7:25 AM, E6, Registered Nurse (RN) performed a blood glucose test on the finger of R8. An isolation sign was posted on R8's door. E6 gloved and gowned inside R8's room. After completing the glucometer blood sugar test, E6 removed her gloves and gown, took a bleach cloth, and wiped the front and back of the blood glucose monitoring machine. R8 placed the blood glucose machine on top of the medication cart. E6 rapidly wiped the glucometer, leaving it wet for less than 10 seconds. The glucometer did not remain wet for 4 minutes as specified in the directions by the bleach wipe manufacturer. On 12/17/2014 at 11:15 AM, E6 performed a blood glucose test on the fingers of R16, and R20 consecutively, and cleaned the glucometer with a disinfectant wipe, that did not contain bleach, after each use. E6 did not leave the glucometer wet with the disinfectant wipe as per the manufacturer's instructions to kill pathogens. On 12/17/2014 at 11:30 AM, E6 gowned and gloved and went into R8's room with the same glucometer she used for R16 and R20. After completing the blood test with the glucometer, E6 removed her gown and gloves in R8's room. E6 took a bleach cloth and wiped the front and back of the blood glucose monitoring machine used on R8 and disposed of the wipe. E6 again placed the machine on top of the medicine cart after wiping it for less than 10 seconds. The glucometer didn't remain wet for 4 minutes. The directions located on the bottle of bleach cloths documents for effectively kill[DIAGNOSES REDACTED] the surface of items must remain wet for 4 minutes. The directions located on the non-bleach wipe documented surface areas must remain wet for 4 minutes to kill viruses and bacteria. On 12/17/2014 at 11:30 AM, E6 stated R8, R16, R17, R18, R19, R20 all received blood glucose monitoring on 12/17/2014. E2, DON, on 12/17/2014 at 11:50 AM, stated each patient does not have their own dedicated blood glucose monitoring machine, and they don't have a machine dedicated to R8's isolation room. E2 expects the nurses to place a paper towel on surface, and then place the blood glucose monitoring machine on the paper towel. E2 also expects the nurses to wipe the machine with bleach wipes. E2 did not know how long the machine should remain wet, but she expects the nurses to follow the manufacturer's guidelines. The Facility policy, entitled, "Infection Prevention and Contact Isolation Precaution Policy" dated 2/2011, documents, in part, "Clostridium difficile- Do not share equipment, and ensure environmental cleaning with a hypochlorite solution (bleach)."

Based on observation and interview, the facility failed to ensure food is prepared under proper sanitary conditions. This has the potential to affect all 61 residents in the facility. Findings include: On 11/6/13 at 11:30AM, the hood over 2 large steam kettles and 2 steamers was dripping condensation into the kettles and onto the top and in front of and on top of the steamers. One kettle was 1/2 full of hot water and the other kettle was full of hot water. E6, Assistant Food Service Director and E7, the chef were present. E7 stated the hood is usually running and they don't have the condensation dripping from the hood. E7 stated the hoods were not working. When asked, E7 stated they were using the hot water to prepare food. E6 told E7 to get with maintenance and get the hood fixed. Also the sugar and flour storage container lids were soiled with a large amount of dried food debris and had scoop handles directly in the flour and sugar. The facility's Resident Census and Conditions of Residents CMS 672, dated 11/6/13 documents the facility has 61 residents living in the facility.