Every finding on record at New Summit Rehabilitation and Healthcare

Based on interviews, and record review, the facility failed to create and implement/follow a comprehensive care plan to ensure resident safety. This failure affected one resident (R3) of three (R1, R2, and R3) in the sample. A Certified Nursing Assistant failed to follow the care plan interventions requiring continuous supervision/ total assistance during care for R3, resulting in R3 being left unattended and, subsequently, falling to the floor.Findings include:R3 is an [AGE] year-old resident with an admitting diagnosis of a fractured left femur and radius. R3 has diagnoses including but not limited to epilepsy, unsteadiness on feet, and history of falling.On 07/06/2026 at 11:30 AM, R3 was interviewed and stated they sustained a fall on 07/03/2026 within their bathroom in their room. R3 stated they are still very weak since their original injury and require assistance with getting around. On the day of the fall, R3 stated V6 (Certified Nursing Assistant) came into their room to assist them to the bathroom. R3 stated they had to tell V6 to use the gait belt during the transfer. At that time, V6 placed the gait belt and assisted with the transfer from the wheelchair to the walker, and then into the bathroom. V6 assisted R3 to the toilet, and then R3 stated they requested assistance to the sink to brush their teeth. R3 stated V6 put toothpaste on their toothbrush and left the bathroom, despite how unsteady they were on their feet. At this time, R3 was trying to separate two paper cups, and due to the cast on their left arm, they could not properly brace themselves when they felt themselves lose their balance and fell to the ground. R3 stated they were unsure if their left arm was used to try to break their fall and stated the pain in that arm remained the same as prior to the fall, but also stated they have a high pain tolerance. R3 stated they had and currently have a femur fracture and the pain remained constant, in that area, after the fall, as well. R3 then asked this surveyor, shouldn't my CNA have remained with me because I am so unsteady?On 07/06/2026 at 12:19 PM, V2 (Director of Nursing) stated when a care plan states, total assistance, their expectation is that facility staff remain with the residents for the duration of the ADL tasks being performed and that these residents require assistance with all personal hygiene tasks. When asked about R3's fall, V2 stated V6 (Certified Nursing Assistant) should have remained in the bathroom with R3 during the entirety of their toothbrushing task and not left them unattended to go to the hallway's linen cart.On 07/06/2026 at 1:27 PM, V6 (Certified Nursing Assistant) was interviewed regarding R3's fall on 07/03/2026. V6 stated they typically work one day per week in the facility and worked with R3 on the day of their fall. V6 stated they used a gait belt to transfer resident from chair to walker and assisted R3 to the washroom. After R3 was finished using the toilet, they requested to be taken to the sink to brush their teeth. V6 was in the hallway and heard R3 yelling for help inside the bathroom. V6 stated they came into the bathroom and R3 was sitting on the floor. V6 stated they called V8 (Registered Nurse) to come into the washroom to assist R3 off the floor; V6 stated both assisted R3 off the floor. V6 stated V8 performed assessments on R3 and R3 stated they did not hit their head and did not have new pain. V6 was unaware of R3's care plan parameters at this time.On 07/06/2026 at 3:30 PM, V8 (Registered Nurse) stated the expectation for R3's ADL care is for a staff member to remain with R3 during the entirety of their ADL tasks, per the care plan that states total assistance for ADL tasks. V8 stated V6 (Certified Nursing Assistant) should not have left the room while R3 was performing personal hygiene in the bathroom due to R3 having a care plan that states total assistance.On 07/06/2026 at 4:00 PM, V9 (Medical Doctor) stated their expectation for a resident listed as total assistance for ADL tasks within their care plan, is to have a staff member present during the entirety of the ADL task. V9 stated their expectation is that care plans and nursing interventions are being followed by all staff members working with their residents.Record Review of R3's electronic health record: MDS dated [DATE] for R3 states supervision or touching assistance with oral hygiene.Care Plan dated 06/27/2026 for R3 states in part but not limited to: Personal Hygiene - Total assistance w/personal hygiene care.

Based on observations, interviews, and record review, the facility failed to prevent a resident from falling. These failures affected two (R3) of three residents (R1, R2, and R3) reviewed for falls. This failure caused R3 to fall while being left alone to perform a personal hygiene task, instead of being supervised for the entire activity of daily living task. Findings include:R3 is an [AGE] year-old resident with an admitting diagnosis of a fractured left femur and radius. R3 has diagnoses including but not limited to epilepsy, unsteadiness on feet, and history of falling.On 07/06/2026 at 11:30 AM, R3 was interviewed and stated they sustained a fall on 07/03/2026 within their bathroom in their room. R3 stated they are still very weak since their original injury and require assistance with getting around. On the day of the fall, R3 stated V6 (Certified Nursing Assistant) came into their room to assist them to the bathroom. R3 stated they had to tell V6 to use the gait belt during the transfer. At that time, V6 placed the gait belt and assisted with the transfer from the wheelchair to the walker, and then into the bathroom. V6 assisted R3 to the toilet, and then R3 stated they requested assistance to the sink to brush their teeth. R3 stated V6 put toothpaste on their toothbrush and left the bathroom, despite how unsteady they were on their feet. At this time, R3 was trying to separate two paper cups, and due to the cast on their left arm, they could not properly brace themselves when they felt themselves lose their balance and fell to the ground. R3 stated they were unsure if their left arm was used to try to break their fall and stated the pain in that arm remained the same as prior to the fall, but also stated they have a high pain tolerance. R3 stated they had and currently have a femur fracture and the pain remained constant, in that area, after the fall, as well. R3 then asked this surveyor, shouldn't my CNA have remained with me because I am so unsteady? R3 stated they yelled out for help and V6 (Certified Nursing Assistant) and V8 (Registered Nurse) came into the room to assist. R3 stated it took both staff members to get them up off the floor. R3 stated that V8 asked if they hit their head and they said they did not. R3 stated they did not have new pain but that they still had pain and asked if they were going to go out to get evaluated at the hospital. R3 stated that V8 advised they would speak to the physician for guidance; R3 said no one came to talk to her again about the possible evaluation or about the fall, in general.R3 stated they believe they should have been sent out for imaging due to the unknowns of what's going on under the cast or inside their leg, since they very recently had sustained a fall with multiple fractures. R3 stated they were worried that their injury could have worsened, and no one would know due to lack of re-imaging.On 07/06/2026 at 12:19 PM, V2 (Director of Nursing) stated when a care plan states, total assistance, their expectation is that facility staff remain with the residents for the duration of the ADL task being performed and that these residents require assistance with all personal hygiene tasks. When asked about R3's fall, V2 stated V6 (Certified Nursing Assistant) should have remained in the bathroom with R3 during the entirety of their toothbrushing task. V2 stated that instead, V6 left the bathroom to go to the linen cart in the hallway.On 07/06/2026 at 1:27 PM, V6 (Certified Nursing Assistant) was interviewed regarding R3's fall on 07/03/2026. V6 stated they typically work one day per week in the facility and worked with R3 on the day of their fall. V6 stated they used a gait belt to transfer resident from chair to walker and assisted R3 to the washroom. After R3 was finished using the toilet, they requested to be taken to the sink to brush their teeth. V6 stated R3 requested washcloths to wash their face and V6 left the bathroom to go to the hallway to get the washcloths. V6 stated they offered a wheelchair for them to sit in while they went into the hallway but R3 refused offer; V6 stated they did not feel R3 appeared weak at this time. V6 was in the hallway and heard R3 yelling for help inside the bathroom. V6 stated they came into the bathroom and R3 was sitting on the floor. V6 stated they called V8 (Registered Nurse) to come into the washroom to assist R3 off the floor; V6 stated both assisted R3 off the floor. V6 stated V8 performed assessments on R3 and R3 stated they did not hit their head and did not have new pain. On 07/06/2026 at 2:09 PM, this surveyor asked V2 if there is any way of knowing if their recent fracture was affected if it is covered in a cast or if there was a change inside their leg. V2 stated there is no way of knowing if there are any changes to these current injuries without re-imaging being done.On 07/06/2026 at 2:20 PM, V7 (Medical Doctor) was interviewed regarding expectations when a fall occurs in the facility. V7 stated when a fall occurs, the expectation is to perform an assessment, and ensuring resident safety is their top priority. V7 stated if a resident were to fall while having current fractures, imaging would be ordered, due to not being able to know what's happening under the cast or inside the body without imaging being done. V7 stated a fall with current fractures could cause a delay in healing or further damage to the current fracture and should be addressed right away.On 07/06/2026 at 3:30 PM, V8 (Registered Nurse) was interviewed regarding R3's fall on 07/03/2026. V8 stated they came into the room when they heard V6 (Certified Nursing Assistant) calling for assistance. V8 stated they perform a head-to-toe assessment, neuro check, and take vitals when a resident sustains a fall. V8 stated R3 verbalized that they did not hit their head and did not have new pain, therefore V8 referred to V9 (Medical Doctor) for further guidance. V8 stated if someone falls and has current fractures, there is no way of knowing what's going on under their cast or inside their body without imaging being done. However, in this situation, they referred to the doctor for guidance. V8 stated the expectation for R3's ADL care is for a staff member to remain with R3 during the entirety of their ADL tasks, per the care plan that states total assistance for ADL tasks. V8 stated V6 (Certified Nursing Assistant) should not have left the room while R3 was performing personal hygiene in the bathroom due to R3 having a care plan that R3 requires continuous supervision with ADL tasks.On 07/06/2026 at 4:00 PM, V9 (Medical Doctor) stated their expectation for a resident listed as total assistance for ADL tasks within their care plan, is to have a staff member present during the entirety of the ADL task. V9 stated their expectation is that care plans and nursing interventions are being followed by all staff members working with their residents.Record Review of R3's electronic health record: MDS dated [DATE] for R3 states supervision or touching assistance with oral hygiene.Care Plan dated 06/27/2026 for R3 states in part but not limited to: Personal Hygiene - Total assistance w/personal hygiene care.

Based on observation, interview and record review the facility failed to have fall interventions in place for a resident at risk for fall and failed to ensure a resident was transferred safely for 2 of 20 residents (R33 and R36) reviewed for safety and supervision in the sample of 20. This failure resulted in R36 falling and sustaining a right ankle fracture that required surgical repair. The finding include: 1. R36's Face Sheet shows that she admitted to the facility on [DATE] with diagnoses of: cellulitis of right and left lower limbs, unsteadiness of feet, abnormalities of gait, reduced mobility and morbid obesity. R36's Functional Status Note dated 4/29/25 shows that R36 requires partial/moderate assistance to stand from sitting and transfer from bed to chair. On 6/9/25 at 11:35 AM, R36 was lying in bed. R36 had a cast on her right lower leg. R36 said that she fell in the bathroom and broke her leg. On 6/10/25 at 10:20 AM, V34 (R36's Spouse) said that he came in on 5/11/25 and R36 was sitting on the bathroom floor and had fallen. V34 said that a couple days later, R36's right leg was bruised, and her foot was pointed in an abnormal position. V34 said that eventually R36 had an X-ray and it showed that she had a fracture in two areas, and she had surgery. On 6/10/25 at 12:19 PM, V22, Certified Nursing Assistant (CNA) said that on 5/11/25, R36 had a fall in the bathroom. V22 said that he brought R36 into the bathroom to transfer to the toilet. V22 said that he instructed R36 to hold the grab bar and stand. V22 said that as R36 stood up, she lost her balance and started to fall. V22 said that he tried to place the wheelchair under her before she fell but was unable to. V22 said that when R36 fell, her right knee hit the floor, but she was still holding onto the grab bar and standing on her left leg. V22 said that he guided her to a sitting position on the floor. V22 said that when she was in the sitting position on the floor, her left leg was extended in front of her, and her right leg was under her weight, so he moved her right leg from under her and placed it in front of her. V22 said that he did not have a gait belt on R36 when the fall occurred because he did not have one but one was put on her when V32 came to help get her up off of the floor. On 6/11/25 at 12:51 PM, V32 said that V22 had requested her assistance to help with R36. V32 said that she entered R36's room and R36 was on the floor in the bathroom. V32 said that they applied a gait belt and lifted her up off the floor and into her wheelchair. On 6/11/25 at 12:52 PM, V22 was re-interviewed at the request of V4 (Director of Nursing) V22 stated, I do believe I did have a gait belt on before the fall. V22 explained the fall again in detail. V22 was then notified that this surveyor had spoken to V32 and V32 said that they applied the gait belt to R36 before they lifted her to her wheelchair. V22 stated, To be honest, I don't remember the scenario whatsoever. I do not remember exactly when the gait belt was put on. On 6/11/25 at 10:38 AM, V4 (Director of Nursing) said that R36 was a one person assist with a gait belt for transfers. V4 said that staff should always use a gait belt for the resident's safety. V4 said that it is likely that R36 received a small fracture during her fall on 5/11/25 but it worsened due to participation with therapy. V4 said that R36 had no other incident that had happened between R36's fall and the finding of the fracture. R36's right ankle X-ray results from 5/21/25 shows, There is an acute fracture of the distal fibula and of the medial malleolus with subluxation of the tibia on the talus medially There is soft tissue swelling diffusely. R36's Orthopedic Surgery Consult Note dated 5/22/25 shows, Patient is a 69 y.o. female who presents with right ankle fracture. She presented to my clinic today for this issue. The patient fell at her rehab on Mother's Day (5/11). She states that she had pain and swelling to the ankle over the past week and then they eventually got x-rays after she was in too much pain to ambulate with PT (Physical Therapy) there is moderate swelling to the ankle diffusely. There is tenderness medial and laterally Assessment: Right ankle bimalleolar fracture subluxation .Plan for ORIF (Open Reduction Internal Fixation) right ankle 5/23. The facility's Final Investigation Summary dated 5/23/25 shows, Resident Injury-Confirmed Fracture Post-Fall Based on the clinical record and timeline, no localized symptoms or signs of ankle injury were evident immediately following the assisted fall on 5/11/25 or in the days afterward However, the subsequent right ankle fracture confirmed on 5/21/25 may reflect an initially minor or hairline fracture caused by the assisted fall. Factors supporting this possibility include: The resident's high pain threshold and non-localized chronic lower extremity pain masking early injury. Morbid obesity contributes to mechanical stress and potential progression of injury. The facility's Gait Belt Policy revised on 1/2025 shows, Staff will use a gait/transfer belt on residents who need limited to total assistance with transfer or walking. 2. R33's facility assessment dated [DATE] showed R33 is a [AGE] year-old female with impaired cognition and was admitted to the facility on [DATE] with diagnosis which include dementia and unspecified disorientation. On 6/9/25 at 9:05 AM, R33's door was closed at this time. Upon entering R33's room, R33 was lying in bed diagonally across the mattress with her right foot off the edge of the bed and her head near the upper left bed mobility rail. Several fall mats were across the room leaning against the opposite wall from the bed. R33's bed was approximately two and a half to three feet above the ground which is not the bed's lowest position. On 6/10/25 at 1:20 PM and at 6/11/25 at 9:00 AM, R 33 was in bed with the fall mats stacked against the opposing wall from the headboard. On 6/10/25 at 1:25 PM, V26 CNA stated R33's fall mats should be next to the bed. On 6/11/25 at 9:44 AM, V35 CNA stated we are usually notified by the nurse or during morning report if a resident is a fall risk. V35 stated R33 does have fall mats, and they should be next to her bed when R33 is in it. R33's medical records showed R33's last Fall Assessment was completed on 9/11/24. R33 is listed as having a moderate risk for falls. R33's Care Plan showed R33 has a risk for falls with an intervention of having fall mats landing pads in position while in bed and have the bed in the lowest position. R33's Physician Orders has an order for floor mats and low bed position with a start date of 10/3/24. On 6/11/25 at 11:35 AM, V2 Director of Nursing stated a residents fall interventions should be in place when a resident is in bed (fall mats, bed in low position, door open etc.).

Based on observation, interview and record review the facility failed to ensure a cervical neck collar and ace wraps were in place as ordered, failed to clarify physician prescribed medication orders to ensure a resident received the medications and failed to perform an assessment immediately after and following a fall for 4 of 20 residents (R36, R52, R47 and R299) reviewed for quality of care in the sample of 20. The findings include: 1. On 6/9/25 11:35 AM, R36 was lying in bed and had a cast on her right lower leg. R36 said that she had a fall in the bathroom and broke her leg. On 6/10/25 at 10:20 AM, V34 (R36's Spouse) said that he came in on 5/11/25 and R36 was on the floor of the bathroom. V34 said that a male and female staff member came in and lifted her back up into her wheelchair. V34 said that a couple days later, he noticed that her leg was bruised, and her foot was pointed in an abnormal position. On 6/10/25 at 12:19 PM, V22, Certified Nursing Assistant (CNA) said that on 5/11/25, R36 had a fall in the bathroom. V22 said that R36 was holding the grab bar in the bathroom, and she began to fall. V22 said that she put her right knee onto the floor and was still standing on her left leg. V22 said that he assisted her into a sitting position and when he did that, her right leg was stuck under her weight, so he pulled her right leg out from under her to make her more comfortable. V22 said that he then went and got V32 (CNA) to assist him in getting R36 off of the floor and into her wheelchair. V22 said that V32 was in front of R36, and he was behind R36, and they lifted her off the floor and into her wheelchair. V22 said that after they got R36 into the wheelchair, he went and told the nurse, and she came in and did an assessment. On 6/11/25 at 12:51 PM, V32 said that V22 had requested her assistance to help with R36. V32 said that she entered R36's room and R36 was on the floor in the bathroom. V32 said that V22 and herself lifted R36 up from the bathroom floor with a gait belt and placed her into her wheelchair. R36's Nursing Incident Note dated 5/11/25 at 6:44 PM shows, CNA informed writer patient had slid off her WC (wheelchair) while transferring from toilet to wheelchair. Writer immediately proceeded to assess patient. Upon entering room patient on sitting up WC On 6/11/25 at 10:38 AM, V5 (Director of Nursing) said that once a resident falls, the staff should immediately call the nurse before moving the resident so the nurse can do a thorough assessment. V5 said that the resident should not be moved until the nurse does an assessment and feels it is safe to move the resident. V5 said that it is their policy for the nurse to complete a fall assessment in the computer and do follow up fall assessments every 8 hours for the next three day. V5 said that the follow up fall assessments entail asking the resident if they are having pain, checking their vitals, assessing for any bruising or other symptoms, checking for a change in mental status, mobility or change in sleep. V5 reviewed R36's electronic medical record and said that she does not see that any fall follow up assessments were completed after R36's fall. R36's Nursing Notes from 5/12/25 to 5/20/25 were reviewed. There were no nursing assessments documented. R36's Nursing Note dated 5/21/25 shows, Patient returned from therapy c/o (complains of) increased pain in right ankle. Patient states it started last night and is worse now after therapy Ankle is swollen and looks abnormal, but that is the patient's baseline. Ankle elevated with pillow and ice pack placed by nurse to decrease swelling. Physician contacted and X-ray ordered R36's right ankle X-ray results from 5/21/25 shows, There is an acute fracture of the distal fibula and of the medial malleolus with subluxation of the tibia on the talus medially There is soft tissue swelling diffusely. R36's Fall Care Plan shows, Monitor/Document/Report PRN (as needed) x 72h (hours) for MD (Physician) for s/sx (signs and symptoms): Pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. The facility's Assessing Falls and Their Causes Policy revised 3/2018 shows, If a resident has just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities If an assessment rules out significant injury, help the resident to a comfortable sitting, lying or standing position and then document relevant details Observe for delayed complications of a fall for approximately forty-eight (48) hours after an observed or suspected fall, and document findings in the medical record. Document any observed signs or symptoms of pain, swelling, bruising, deformity and/or decreased mobility; and any changes in level of responsiveness/consciousness and overall function. Note the presence or absence of significant findings. 2. R52's Podiatry Note dated 6/3/25 shows, Edema Control- Ace Wrap BLE (Bilateral Lower Extremities) On 6/9/25 at 11:50 AM, R52 was sitting in his wheelchair in his room. R52's lower extremities were swollen and reddened. R52 had socks on. R52 had ace wraps located on his windowsill. R52 said that he sees a podiatrist due to wounds on his legs. R52 said that the podiatrist is concerned about the swelling in his legs. R52 said that he used to wear support stockings on his legs, but they were too tight. R52 said that the last time that he went to the podiatrist, they put ace wraps on his legs, and it felt a lot better than the support stockings. R52 said that when the nursing staff at the facility changed his dressing, they did not re-apply the ace wraps. R52 said, I am not sure why they do not put them back on, maybe they think that I don't need them. On 6/10/25 at 10:00 AM, R52 was sitting in his wheelchair. R52's legs were swollen, and he did not have ace wraps applied to them. R52's June Medication Administration Record (MAR) shows an order for Tubigrip (elasticated tubular bandage) on right and left lower extremities in the morning every Monday, Wednesday, and Friday. These were signed out as applied on 6/9/25 at 9:00 AM. There was no order for ace wraps to be applied on R52's MAR. R52's Physician's Order Sheet printed on 6/9/25 does not show an order for ace wraps. On 6/11/25 at 10:35 AM, V14 (Wound Care Nurse) said that when R52 returned from his podiatry appointment, the ace wrap orders should have been entered into the computer by the nurse. V14 said that if a resident comes back to the facility with new wound orders, they should either put the orders into the system or notify the wound nurse. V14 said that she did speak to the nurse regarding the order, and it was a communication issue. V14 said that the nurse did see the order but never put it into the computer. On 6/10/25 at 11:02 AM, V4 (Director of Nursing) said that if a resident goes out to a doctor's appointment, it is the floor nurse's responsibility to enter any new orders into the computer system. 4. R299's admission Record showed R299 was admitted to the facility on [DATE] with a diagnosis of a cervical vertebral fracture of his neck due to a fall. R299's physician order dated 6/8/25 showed R299 was to wear a soft cervical collar around his neck, at all times, as treatment for his vertebrae fracture. On 6/9/25 at 9:06 AM, R299 was in bed, lying on his back. A soft, cervical neck collar was noted in R299's bed, however the collar was not secured around R299's neck. The collar laid loosely on R299's pillow. On 6/9/25 at 9:33 AM, V6 Certified Nursing Assistant (CNA) began providing incontinence care to R299. R299's neck collar laid loosely on his bed; not secured in place around R299's neck at any point. When V6 repositioned R299 on his right side in bed, R299 complained of neck pain as his head fell back towards the pillow, during the repositioning. After completing incontinence care on R299 and as V6 repositioned him on his back in bed. R299 again complained of neck pain with repositioning. On 6/10/25 at 10:34 AM, V5 Director of Nursing (DON) stated R299 should have a cervical collar in place around his neck at all times especially when doing cares and repositioning him to support his neck. V5 stated, I believe he has the collar because he fell and fractured his neck. The collar should be secured in place around his neck. 3. R47's face sheet shows he was admitted to the facility on [DATE] from a local community hospital. R47's After Visit Summary from the hospital provided to the facility on admission shows he had an order for mirtazapine (Remeron) 15 milligrams (mg.) to be given every night at bedtime for 30 days. R47's Order Summary Report shows an order for mirtazapine 15 mg. to be started on 4/6/25 and ended on 5/6/25. On 6/9/25 at 9:22 AM, V13 (R1's daughter and Power of Attorney) said she had a concern at the facility because R47 had been taking Remeron at home for an appetite stimulant and to help him sleep and the facility just stopped the medication for a couple of weeks. V13 said she is not sure why the medication was stopped no one could tell her but he is taking the medication again now. A physician note completed on 4/7/25 by V17 (R47's Primary Care Physician) shows he was aware that R47 was taking mirtazapine 15 mg at bedtime and documented the medication should be reviewed for an indication for use. A physician note completed on 4/14/25 by V11 (Psychiatrist) shows she spoke with V13 who had told her that R47 had been taking mirtazapine (Remeron) for 4 years for insomnia and for a weight stimulant. V11's note states, Continue Remeron 15 mg QHS, which he has been on for 4 years and tolerated well for insomnia and help with appetite. V11's note does not specify a stop date. R47's 5/1/25-5/31/25 Medication Administration Summary (MAR) shows his mirtazapine was stopped on 5/5/25 and restarted on 5/25/25. A provider note completed on 5/22/25 by V12 (Psychiatric Nurse Practitioner) shows V12 documented for R47's mirtazapine to be restarted at 7.5 mg. every night for appetite and depression. On 6/10/25 at 10:09 AM, V5 (Director of Nursing) said what happened with R47's mirtazapine was that he came in with a hospital order for it to only be for 30 days and that nurse who admitted him was new and did not know they shouldn't enter admission orders for only 30 days. V5 said facility nurses should also clarify with a physician the duration the medication should be given. V5 said V17 is out of the country and not reachable by phone but V4 (Medical Director) is available to speak with. On 6/10/25 at 12:53 PM, V4 said in his opinion this is a provider and hospital issue that the medication was only initially ordered for 30 days. The physician who assessed and documented the medication should have continued it and also should have specified how long they wanted the medication for. V4 said a verbal order for the medication should have been given. On 6/11/25 at 8:46 AM, V11 (Psychiatrist) said she could not recall if she gave a verbal order to continue the medication to any nurses when she saw R47 on 4/14/25, and typically when she sees residents at the facility she will go back and document the note in the residents Medical Record. V11 said she was not able to comment for the facility about why the medication was discontinued. On 06/10/25 at 1:45 PM, V30 (Registered Nurse) said when residents are admitted orders need to be clarified and if a medication is suddenly stopped, they have to contact the physician to clarify if the medication should be stopped especially for psychotropic medications. The facility provided Medication and Treatment Orders policy last revised on July 2016 shows that medication orders should include start and stop dates and if an order does not contain those and a stop order becomes effective due to the medication not having a stop dated the supervisor on duty must contact the prescriber or attending physician to determine if the medication should be continued.

On 6/9/25 at 1:41 PM the refrigerator in the kitchenette of the 2nd floor north bistro area, contained an opened box of thickened prune juice dated 5/2/25. At 1:42 PM, the refrigerator in the kitchenette of the 1st floor north bistro area, contained 2 opened boxes of thickened water dated 4/25/25, and a box of thickened apple juice dated 5/30/25. The boxes of water and apple juice said, after opening discard after 7 days. On 6/10/25 at 9:10 AM, the opened prune juice dated 5/2/25 remained in the refrigerator in the 2nd floor north bistro area kitchenette. There was no other date or opened date. At 9:15 AM, the opened boxes of thickened water dated 4/25/25 and the box of apple juice dated 5/30/25 remained in the refrigerator in the 1st floor north bistro area kitchenette. There was no other date or opened date. On 6/10/25 at 10:00 AM, V28 Dietary Manager said the boxes of thickened liquids are dated when they are received. V28 said when the staff opens the box, they should label the box with opened and the date the box was opened. V28 said once the boxes area opened, they should be discarded after 6 days. V28 said there is no policy for this, this is just the recommendation from the manufacturer. V28 said if the boxes of liquid are not labeled with an open date they should be discarded because there is no way to know how long they have been opened. The facility's Diet Type Report for Nectar thick liquids dated 6/10/25 shows R65, R298, R199, and R80 are on thickened liquids. Based on observations, interviews, and record reviews the facility failed to ensure resident refrigerators were monitored and maintained, and failed to ensure perishable foods were dated which applies to 7 of 7 residents (R33, R55, R67, R65, R298, R199, R80) reviewed for safe food handling in a sample of 20. The findings include: On 6/9/25 at 9:00 AM, R33's room refrigerator thermometer read 55 degrees Fahrenheit (F). The refrigerator had yogurt and other personal food products in it. R33 was eating a yogurt of the same brand at that time. On 6/10/25 at 1:20 PM, R33's refrigerator thermometer read 50 degrees F. V26 Certified Nursing Assistant (CNA) was present at that time and verified the temperature reading on the thermometer. V26 stated they were pretty sure that was too high. On 6/9/25 at 9:15 AM, R55's room refrigerator had no thermometer in it. The refrigerator had 10 small foam food containers with no dates on them. R55 stated their daughter brought food from home for him all the time. R55 did not know how long the different items had been in the refrigerator. On 6/9/25 at 10:15 AM, R67's refrigerator had no thermometer in it. The refrigerator had opened packages (no open date) of hot dogs and lunch meat in it. R67 stated they had to have staff help get the food out of the refrigerator since they could not get it themselves (stroke). R67 stated he was not sure the last time anyone came in and checked the refrigerator. On 6/10/25 at 1:35 PM, V27 Environmental Services Director stated he uses the thermometers in the residents' refrigerators to check the temperatures. V27 stated the refrigerators should be kept between 33-41 degrees Fahrenheit. The rules for food in residents' refrigerators is the same as the kitchen. Open items should have some type of date on it. V27 stated opened and prepared food containers should be discarded between 5-7 days depending on the food type. On 6/11/25 at 9:30 AM, V36 (R55's Daughter) stated she has brought food from home. V36 stated she had not been asked to check in the food with the staff or put a date on it when it was made. The facility's Brought in Food Policy dated 2/2014 showed perishable foods need to be in containers and in the refrigerator. The food containers should be labeled with the resident's name and dated (use by date). This policy showed staff are responsible for discarding perishable foods on or before the use by date and if a package is past due expiration dates.

4. On 6/9/25 at 11:35 AM, R36 was lying in bed. R36 said that she is getting treatment for the wounds on her buttock. R36's room door did not have a sign on it saying she was on EBP (Enhanced Barrier Precautions) nor was there PPE (Personal Protective Equipment) outside of R36's room. On 6/9/25 at 11:37 AM, V7 (Infection Preventionist) put an EBP sign on R36's door and a cart of PPE outside of the door. On 6/9/25 at 2:25 PM, V7 said that she did just put R36's EBP sign on her door that day. V7 said that she was reviewing charts and noticed that R36 came back from the hospital with multiple wounds and should have been placed on EBP upon her re-admission. R36's Physician's Order Sheet printed on 6/9/25 shows that she re-admitted to the facility on [DATE] and an order for EBP for wounds was placed on 6/9/25. R36's Wound assessment dated [DATE] shows that she has an unstageable pressure injury on her left hip, right hip and buttock and a stage 3 pressure injury on her left lower buttock. The facility's Enhanced Barrier Precautions Policy shows, EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds EBPs remain in place for the duration of the resident's stay or until resolution of the wound signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. Based on observation, interview and record review the facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a gastrostomy tube (G-tube) and a resident with a wound. The facility failed to inform a resident's private caregiver the resident was on Contact Isolation for an infection and failed to educate the caregiver on wearing PPE (personal protection equipment) in the resident's room. The facility failed to ensure staff changed their gloves and washed their hands to prevent cross contamination. These failures apply to 4 of 20 residents (R299, R301, R300, R36) reviewed for infection control in the sample of 20. The findings include: 1. R299's admission Record showed R299 was admitted to the facility on [DATE]. R299's admission care plan showed R299 required Enhanced Barrier Precautions due to R299 being admitted to the facility with a gastrostomy tube (G-tube) in place for nutrition/enteral feedings. On 6/9/25 at 9:06 AM, no EBP isolation sign hung on or around the door/doorframe to R299's room. Upon entrance to R299's room, V10 Licensed Practical Nurse (LPN) was holding R299's G-tube in her hand. V10 wore gloves but no gown. V10 LPN stated she had just finished giving R299 his morning medications via his G-tube. On 6/9/25 at 9:33 AM, V6 Certified Nursing Assistant (CNA) donned gloves and began to provide incontinence care to R299 as he was incontinent of urine. V6 CNA wiped R299's perineal area and repositioned him on his right side. V6 CNA wiped R299's buttocks and removed his soiled incontinence brief. Without changing her soiled gloves, V6 CNA then picked up R299's personal cell phone, that was lying next to R299 on the bed, and placed the phone on the bedside table. Without changing her soiled gloves, V6 CNA proceeded to place R299 in a clean incontinence brief and gown. Upon completion of these cares, V6 CNA removed her gloves. On 6/10/25 at 10:34 AM, V5 Director of Nursing (DON) stated residents that require Enhanced Barrier Precautions are residents with wounds, urinary catheters, G-tubes, and drains. V5 stated staff are to wear PPE, which includes a gown and gloves, when providing high-contact cares to a resident's G-tube. The facility Enhanced Barrier Precautions policy dated August 2022 showed, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms to residents . EBP's employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply . Examples of high-contact resident care activities requiring the use of gown and gloves for EBP's include: device care or use (central line, urinary catheter, feeding tube, tracheotomy/ventilator, etc.) . 2. R301's admission Record dated 6/7/25 showed R301 was admitted to the facility with a diagnosis of colitis due to a Clostridium Difficile (c-diff) infection of her stool. R301's physician order dated 6/7/25 showed R301 required Contact Isolation Precautions due to her c-diff infection. On 6/9/25 at 9:35 AM, a Contact Isolation sign hung on the doorway of R301's room. V8 (Private Caregiver for R301) was seated in a chair in R301's room. R301 was asleep in bed. V8 wore no PPE, no gown or gloves. On 6/9/25 at 10:13 AM, V8 (Private Caregiver for R301) stood beside R301's bed. V8 held a cup to R301's mouth as she drank from the cup. V8 wore no PPE, no gown or gloves. On 6/9/25 at 11:40 AM, V7 Infection Control Nurse educated V8 (Private Caregiver for R301) on the importance of wearing PPE while in R301's room, while she was on Contact Isolation. On 6/9/25 at 2:20 PM, V8 (Private Caregiver for R301) stated, No one told me I had to wear a gown and gloves or that (R301) was on isolation until (V7 Infection Control Nurse) told me this morning. On 6/10/25 at 10:34 AM, V5 DON stated all staff are to don PPE, including a gown and gloves, prior to entering the room of a resident on Contact Isolation. V5 stated private caregivers and any visitors are to don and wear PPE while in the room of a resident on Contact Isolation. V5 stated when staff observe a visitor and/or caregiver not wearing the required PPE in an isolation room, staff are to immediately educate and ask them to don the required PPE to attempt to stop the spread of an infection. The facility's Isolation-Categories of Transmission-Based Precautions policy dated September 2022 showed, Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment . The policy showed staff and visitors must wear a PPE gown and gloves when in the room of a resident on Contact Isolation. 3. On 6/9/25 at 9:14 AM, R300 was in bed, R300 was on supplemental oxygen via a nasal cannula attached to his nose. On 6/9/25 at 9:15 AM, V6 CNA donned gloves and began providing incontinence care to R300 as he was incontinent of urine. V6 cleansed R300's groin and buttocks and removed R300's soiled incontinence brief. Without changing her soiled gloves, V6 removed the nasal cannula from R300's nose and placed the cannula on the bedside table. V6 CNA proceeded to place R300 in a clean incontinence brief, shirt, and shorts without changing her soiled gloves. V6 CNA then transferred R300 from his bed to the wheelchair. Upon completion of these cares, V6 CNA removed her soiled gloves. On 6/10/25 at 10:34 AM, V5 DON stated staff must change their gloves anytime gloves are soiled and prior to touching anything clean.

Based on interview and record review the facility failed to ensure a resident's assessment was completed accurately for 1 of 20 residents (R95) reviewed for assessments in the sample of 20. The findings include: R95's Minimum Data Set (MDS) dated [DATE] shows Discharge status: short term General Hospital (acute hospital). R95's Progress Notes dated 3/28/25 at 4:28 PM shows Resident discharged home with granddaughter, to receive home health care. Resident discharged with all scripts, paperwork and belongings. On 06/11/25 at 10:25 AM, V5 Director of Nursing said R95's MDS was done in error, R95 was not hospitalized she went home with family per the progress notes. On 06/11/25 at 11:53 AM, V1 Chief Executive Officer said the facility doesn't have a policy on assessments, they just follow the Resident Assessment Instrument (RAI) procedure and are to submit MDS assessments timely and accurately.

2. R299's admission Record showed R299 was admitted to the facility on [DATE]. R299's Wound Assessment Details Report dated 6/8/25 showed R299 was admitted to the facility with a, DTI (deep tissue injury) to left buttock and blanchable redness to coccyx and right buttock. Patient noted in bed, very bony. NPO (eats nothing by mouth)- has G-tube (gastrostomy tube) feeding. Low air loss mattress ordered. The report showed R299's left buttock DTI measured 3.0 cm (centimeters) x 3.0 cm x 0.0. R299's Skin/Wound progress note dated 6/8/25 showed R299 was also admitted to the facility with blanchable redness to both of his heels. The note showed, Heel boots applied, educated on wearing them in bed to offload heels . A physician order for R299, dated 6/8/25, showed an order for R299 to have a low air loss mattress. A facility invoice receipt showed a low air loss mattress, for R299, was delivered to the facility on 6/8/25. On 6/9/25 at 9:33 AM, R299 was in bed, lying on a standard mattress. The mattress on R299's bed was not a low air loss mattress. On 6/10/25 at 8:14 AM, R299 was in bed, lying on a standard mattress. No heel boots were noted to R299's heels. R299's heels rested directly on the mattress. R299's heel boots noted on a chair next to the bed. On 6/10/25 at 10:56 AM, R299 was in bed, lying on a standard mattress. No heel boots were noted to R299's heels. R299's heels rested directly on the mattress. On 6/10/25 at 10:34 AM, V5 Director of Nursing (DON) stated residents that have wounds, are mostly bed-bound, and/or are failure to thrive require a low air loss mattress to help prevent skin breakdown. V5 stated heel boots are to be worn by residents, while in bed, to prevent skin breakdown to the heel area. V5 stated, Our low air loss mattresses are connected to a machine that regulates the air pressure of the mattress based on the resident's weight. Our wound nurses assess the resident and make the determination if the resident needs a low air loss mattress. The wound nurse orders the mattress from an outside company. It is usually delivered to the facility within 24 hours. On 6/10/25 at 1:09 PM, R299 was asleep in bed on a low air loss mattress. V9 (Family of R299) was in R299's room. V9 stated, He just got this new mattress today. V9 was asked about R299's heel boots, V9 stated, I visit him everyday. I have never heard him refuse to wear those boots. The facility's Pressure Ulcers/Skin Breakdown-Clinical Protocol dated April 2018 showed, Treatment/Management 1. The physician will order pertinent wound treatments, including pressure reductions surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents . Based on observation, interview and record review the facility failed to ensure a resident had a dressing on a pressure injury and failed to ensure pressure prevention interventions were in place for 2 of 6 residents (R47, R299) reviewed for pressure injuries in the sample of 20. The findings include: 1. R47's Wound Assessment Details Report completed on 6/7/25 shows he has a stage 4 pressure injury to his left heel. The report shows his wound measures 1.00 centimeter (cm.) length x 1.00 cm. width x .20 cm. depth with a light amount of drainage. R47's Physician Order Summary shows he has treatment orders for medi-honey and a dry dressing over the wound bed. On 6/9/25 at 9:50 AM, V14 (Wound Care Nurse) and V15 (Wound Care Nurse Practitioner) were completing a wound assessment on R47's left heel wound. When V14 pulled off R47's sock there was no dressing on his left heel. V14 said R47 should have a dressing on his wound and he has orders for dressing changes 3 times a week and as needed. V14 said any nurse can reapply the dressing to R47. The facility provided Pressure Ulcers/ Skin Breakdown policy last revised April 2018 shows the facility will identify and implement treatment interventions for pressure injuries/ulcers with the wound care physician.

Based on observation, interview and record review the facility failed to ensure indwelling urinary catheter bags were kept below the level of the bladder and off of the floor to prevent infections for 2 of 3 residents (R148 and R47) reviewed for indwelling urinary catheters in the sample of 20. The findings include: 1. On 6/9/25 at 9:08 AM, R148 was being transferred from her bed to a shower chair with a mechanical lift. R148 had an indwelling urinary catheter in place with cloudy yellow urine present in the tubing. V19 and V20 (Certified Nursing Assistants) placed a mechanical lift sling under R148. V19 and V20 attached the sling to the mechanical lift and then hung R148's catheter bag on the sling strap which was above R148's bladder. R148's urine in her catheter tubing was seen backflowing into R148's bladder. On 6/10/25 at 11:02 AM, V5 (Director of Nursing) said that urinary catheter bags should always be kept below the level of the bladder. V5 said that hanging the bag from the straps of the mechanical lift sling is not appropriate. R148's Care Plan shows, Position catheter bag and tubing below the level of the bladder and away from entrance room door. The facility's Urinary Catheter Care Policy revised on 8/22 shows, Position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder. 2. On 6/9/25 at 9:30 AM, R47's was lying in bed his indwelling urinary catheter bag was lying on the floor on the right side next to his bed. At 9:50 AM, V14 (Wound Care Nurse) and V15 (Wound Care Nurse Practitioner) came into R47's room to do a dressing change. V15 raised up R47's bed did the wound care measurements and when the wound care was completed, he lowered the bed. R47's catheter bag remained on the floor. On 6/9/25 at 11:57 AM, R47's catheter bag was still laying on the floor on the right side of his bed. On 6/10/25 at 11:03 AM, V5 (Director of Nursing) said catheter bags should not be on the floor. The facility provided Catheter Care policy revised August 2022 says catheter bags should be kept off the floor.

Based on observation, interview, and record review the facility failed to monitor residents to ensure medications were administered completely which applies to 2 of 2 residents (R1, R4) reviewed for medication administration in a sample of 20. The findings include. 1. R1's Facility assessment dated [DATE] showed R1 to be a [AGE] year-old female resident with severe cognitive impairment admitted with diagnoses which included dementia. On 6/9/25 at 10:55 AM, R1 was resting in their wheelchair in the common area near the nurse's station. When R1 went to speak 2 partially dissolved pills fell out of R1's mouth. R1 was appeared very tired and had some confusion when asked when they had taken their pills. On 6/9/25 at 11:00 AM, V29 Registered Nurse stated R1 had received their medications with the morning medication pass around 9 AM. V29 stated they thought R1 had swallowed all their pills. V29 stated they did not check for pocketing after the medications were given. On 6/10/25 at 10:00 AM, V16 Licensed Practical Nurse (LPN) stated when giving medications to a resident the nurse should make sure the resident has swallowed the pills. On 6/10/25 at 1:00 PM, V2 VP of Operations stated nurses should make sure residents swallows their pills as part of the medication administration. The facility's Medication Administration Policy dated 4/2019 showed medications should be administered in a safe and timely manner, and as prescribed. 2. On 6/9/25 at 9:00 AM, R4 was asleep in her room. On her overbed table and nightstand were multiple bottles of medications including 2 bottles of Naso Gel spray for dry noses, a Fluticasone nasal spray and Systane eye drops. On 6/10/25 at 8:45 AM, R4 had the same bottles of medications at her bedside. V16 (Licensed Practical Nurse/LPN) said residents have to have an order to be able to self- administer medications and R4 is not able to administer her own medications. On 6/10/25 at 10:38 AM, V5 (Director of Nursing) said that residents have to be assessed for the ability to self-administer medications and have medications at the bedside. V5 said she does not believe anyone on the second floor has orders to be able to self-administer medications and nurses monitor this and there should not be medications left in resident rooms, they should be taken out. On 6/10/25 at 1:31 PM, The same medications were still at R4's bedside and R4 said that she takes these medications nasal sprays and eye drops by herself when she wants too usually one time a day. R4's Physician Order Summary (POS) does not show an order for medications to be stored at her bedside and self-administered. R4's POS shows an order for both Fluticasone 50 micrograms (mcg) spray in both nostrils every 6 hours as needed for nasal congestion and for Saliene Nasal Gel 1 spray in both nostrils 4 times a day for soothing and moisturizing. There was no order for Systane eye drops. On 6/11/25 at 10:10 AM, V5 said R4 did not have any order for her to self-administer the medications or have them at her bedside prior to the evening of 6/10/25. The facility provided Administering Medications policy last revised April 2019 shows that residents can only self- administer medications if it has been approved and assessed by the attending physician and treatment team.

Based on observation, interview, and record review the facility failed to ensure a call light was within reach for a high fall risk resident which applies to 1 or 6 residents (R1) reviewed for safety in a sample of 16. The findings include: R1's Admission Record printed on 3/10/25 showed R1 is an eighty five year old female resident admitted to the facility with diagnoses which include post surgical amputation, reduced mobility, needing assistance with personal care, absence of left leg below the knee. R1's Fall assessment dated [DATE] showed R1 is at High Risk for Falling. On 3/10/25 at 11:50 AM, R1 was sitting in their wheelchair with the bedside table across them eating lunch. R1 stated she was admitted to the facility after having her left lower leg amputated after having blood flow complications in her leg. R1's call light was wrapped around the bed rail on the opposite side of the bed from R1. R1 stated she would not be able to reach that. R1 demonstrated by leaning towards bed. The call light was approximately 2-3 feet away. On 3/10/25 at 12:00 PM, V11 Certified Nursing Assistant stated R1 needs assistance with transfers to the wheelchair and toileting. R1 uses a sit to stand mechanical lift device for the transfers. V11 stated before you leave a resident's room their call light needs to be placed where they can reach it. On 3/10/25 at 12:10 PM, V2 Director of Nursing stated residents call lights should be placed with in the resident's reach. The facility's Call light Policy dated 9/2022 showed call lights need to be accessible to the resident when in bed, from the toilet, from the shower or bathing facility, and the floor.

Based on interview and record review the facility failed to ensure treatment orders were performed for a resident with a stage 3 sacral pressure injury. This applies to 1 of 3 residents (R1) reviewed for pressure injuries in the sample of 6. The findings include: R1's face sheet shows she is a [AGE] year-old female with diagnoses including spinal stenosis, history of falling, quadriplegia, unspecified injury at C4 level of cervical spinal cord, neuromuscular dysfunction of the bladder, neurogenic bowel, reduced mobility, muscle weakness and history of malignant neoplasm of the breast. R1's Wound Progress note dated 8/22/24 documents a stage 3 pressure wound to the sacrum, full thickness, measuring 7.1 cm (centimeters) x 4.5cm x 0.2 cm with moderate serous drainage. R1's Wound Progress note dated 8/29/24 documents a stage 3 pressure wound to the sacrum, full thickness, measuring 3.2 cm x 2.1 cm x 0.2 cm with moderate serous drainage. R1's Medication Administration Record (M.A.R.) dated August 2024 shows treatment orders to sacrum pressure injury. Cleanse with wound cleanser, apply skin barrier to periwound, apply silver calcium alginate and cover with silicon foam dressing daily. R1's M.A.R. shows there was no documentation the treatment was provided for 5 out of 23 days. On 9/11/24 at 1:30 PM, V2 (Director of Nursing) said V3 (Former Wound Nurse) was not documenting wound treatments that's why he is no longer here. Treatments should be documented at the time it was changed. Treatments promote wound healing. The facility's Wound Care Policy dated 2010 states, The purpose of this procedure is to provide guidelines for the care of wounds to promote wound healing .the following information should be recorded in the resident's medical record; the type of wound care given, the date and time the wound care was given, the name and the title of the individual performing the wound care .the signature and title of the person recording the data

Based on observation, interview and record review the facility failed to initiate Enhanced Barrier Precautions (EBP) for residents with an increased risk of contracting a Multi-drug Resistant Organism (MDRO) during high contact activities for 8 of 10 residents (R198, R292, R22, R287, R190, R301, R203, R291) reviewed for infection control in the sample of 14 and 7 residents (R29, R202, R30, R294, R204, R200, R201) outside the sample. The findings include: The facility Matrix provided on 5/7/24 showed the following residents had invasive medical devices and/or pressure ulcers: R287, R198, R291, R190, R202, R30, R301, R203, R201, R22, and R200. The facility's Wound Report dated May 2024 showed the following residents had chronic wounds (pressure ulcers, venous stasis ulcers, or diabetic ulcers): R198, R292, R29, R202, R30, R294, R204, R22, and R200. A facility wide tour was conducted on 5/7/24 and 5/8/24, the residents listed above did not have EBP signs on door, nor did they have an isolation cart with PPE (Personal Protective Equipment) outside their rooms. On 5/7/24 at 11:06 AM, R301 was in his wheelchair in his room. R301 had a below the knee amputation. R301 said he had a problem with his right leg for years. R301 said he had a history of infections in his legs that he was taking IV (intravenous) antibiotics for. R301 said the reason for the amputation was he had three infections in his leg and blood. R301 has a PICC (Peripherally Inserted Central Catheter) in his arm and an IV pump in his room. R301 said the facility had changed his stump dressing earlier today and the staff wore a mask and gloves. R301 said the staff never wore a gown during his care. R301's door didn't not have a EBP sign on it, nor was there an isolation bin with PPE supplies near R301's door. On 5/8/24 at 9:59 AM, R301 had IV antibiotics running into the PICC line in his left arm. V15 (Registered Nurse - RN) was at R301's bedside with a mask and gloves on. V15 said R301 gets antibiotics twice a day at 9 AM and 9 PM. V15 said R301 was on antibiotics for an infection in his blood and because of his recent amputation. V15 did not done a gown before providing care to R301's PICC line. R301 removed the IV tubing from R301's PICC line and placed a cap on R301's PICC line. R301's Face sheet dated 5/8/24 showed he was admitted on [DATE] with diagnoses to include, but no limited to: orthopedic care following a surgical amputation; acute osteomyelitis of right ankle and foot; acquired absence of right foot; Methicillin susceptible staphylococcus aureus infection; peripheral vascular disease; bacteremia (systemic infection of the blood); atrial fibrillation; reduced mobility; generalized muscle weakness; Charcot's Joint in right foot/ankle; history of brain cancer; major depressive disorder; and seizures. R301's facility assessment dated [DATE] showed he was cognitively intact and had central IV access. R301's Physician Order Sheet (POS) did not contain orders for EBP. This document did show orders for an antibiotic (Vancomycin) IV every 12 hours for bacteremia and orders for PICC line maintenance. R301's Provider Note dated 5/8/24 showed R301 was admitted to the facility following a hospitalization for a right foot infection. This document showed R301 underwent a right below the knee amputation for chronic osteomyelitis and non-healing right foot ulcers. This document showed R301 was on IV Vancomycin for MRSA bacteremia. On 5/8/24 at 9:30 AM, V6 (RN) was preparing medications to administer through R198's G-tube (gastrostomy tube). There was not a EBP sign on R198's door, nor was there an isolation cart with PPE supplies. V6 prepared 16 medication cups for administration and entered R198's room at 9:50 AM. V6 explained the procedure to the resident, washed her hands and applied gloves. V6 did not put on a gown. R198 was in a bariatric air bed and had a G-tube to his abdomen. V6 leaned against R198's bed to check the placement of the G-tube, moved about his room, and administered each of the 16 medications cups. Each time V6 reached for the medication cups or fluid for flushing the G-tube her legs and abdomen came in contact with R198's bed. V6 administered R198's G-tube medications for the next 20 minutes and did not wear a gown the entire time. R198's Face sheet showed he had diagnoses to include, but not limited to: CHF (congestive heart failure), diabetes, Parkinson's disease, ischemic cardiomyopathy, severe chronic kidney disease, and gastrostomy (G-tube) status. R198's POS did not show an order for EBP. R198 had more than 20 medications ordered daily to be given through the G-tube. (R198's G-tube would be accessed numerous times throughout the day to administer these medications.) On 5/8/24 at 10:27 AM, V11 (Lead CNA - Certified Nursing Assistant) provided incontinence care, catheter care, and emptied R190's catheter. V11 was wearing a mask and gloves. V11 did not have a gown on during this care. R190's door did not have an EBP sign and there was not an isolation cart with PPE supplies outside the room. R190's Face sheet dated 5/8/24 showed diagnoses to include, but not limited to: corticobasal degeneration, Parkinson's disease, need for assistance with personal care, reduced mobility, dysphagia, anxiety, and contracture of left upper arm. R190's POS dated 5/8/24 had orders for an indwelling catheter, but no orders for EBP. On 5/8/24 at 11:56 AM, V9 (CNA) and V10 (PTA - Physical Therapy Assistant) provided incontinence care, rolled R203 from side to side in the bed, emptied his catheter, and transferred him with a mechanical lift. V9 and V10 did not put gowns on during this high contact care. R203's door did not contain a sign for EBP and there was not an isolation bin with PPE supplies near his door. R203's Face sheet dated 5/8/24 showed diagnoses to include, but not limited to: multiple sclerosis; infection and inflammatory reaction due to indwelling catheter; functional quadriplegia; anxiety; need for personal assistance with cares; reduced mobility; and generalized muscle weakness. R203's POS showed orders for an indwelling catheter, but no orders for EBP. On 5/8/24 at 2:46 PM, V3 (Infection Control Nurse) said the facility had a good supply of PPE. V3 said the facility used washable, white gowns and they would be kept in a bin outside the room, labeled, Clean gowns. V3 said the gowns are single use gowns and should be placed in the soiled laundry after each use. V3 said the facility may initiated EBP if a resident had a history of infections, especially MDRO's or was at high risk for infection with an MDRO. V3 said a EBP sign would be posted on the resident's door and the isolation cart and PPE supplies would be outside the resident's room. V3 said a resident isn't placed on EBP just because they have an invasive medical line, but if there were signs of infection at the site, then EBPs would be started. V3 said EBP are used to protect the residents and staff against MDRO infections. These practices keep everyone safe and prevents the spread of infections. On 5/9/24 at 10:29 AM, V2 (DON - Director of Nursing) said she didn't realize that residents with chronic wounds and residents with invasive medical devices needed to be on EBP. The facility's Enhance Barrier Precautions Policy dated 2022 showed, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. Policy Interpretation and Implementation: 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of MDROs to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply . 3. Examples of high-contact resident care activities requiring use of gown and gloves for EBPs include a. dressing; b. bathing/shower; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and h. wound care . 5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization . 9. Staff are trained prior to caring for residents on EBPs. 10. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. 11. PPE is available outside of the resident rooms . The Centers for Medicare & Medicaid Services' QSO-24-08-NH Memo titled Enhanced Barrier Precautions in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), showed effective 4/1/24, facilities must implement EBP. This document showed, .EBP are indicated for residents with any of the following: Infection or colonization with CDC-targeted MDRO when Contact Precautions do not otherwise apply; or Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized. Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage (i.e., Band-Aid) or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. A peripheral intravenous line (not a peripherally inserted central catheter) is not considered an indwelling medical device for the purpose of EBP. EBP should be used for any residents who meet the above criteria, wherever they reside in the facility .

Based on observation, interview, and record review the facility failed to ensure a resident received showers for 1 of 1 resident (R203) reviewed for activities of daily living in the sample of 14. The findings include: R203's face sheet printed on 5/8/24 showed an admitted [DATE] and diagnoses including but not limited to multiple sclerosis, quadriplegia, cervical disc disorder, and need for assistance with personal care. R203's facility assessment dated [DATE] showed no cognitive impairment or memory problems. The assessment showed R203 is totally dependent on staff for showers and bathing. The same assessment showed it is very important to R203 to choose between a bath or a shower. On 5/7/24 at 11:00 AM, R203 was lying in bed and covered up to the waist with a light sheet. R203's hair was greasy and uncombed. R203 stated he has not been offered a shower since he was admitted (18 days ago). R203 said staff have quickly wiped him down with peri wipes once or twice but that is about it. R203 said he has asked for a shower, but staff won't do it. R203 said he must use a bed pan for bowel movements and wants to be cleansed more frequently than just a wipe under the arm pits and buttocks. R203's bath schedule and bath sheets were reviewed from the day of admission on 4/19/24. The daily shower schedule showed Wednesdays and Saturdays as his scheduled shower days. Skin Observation Worksheets/shower sheets showed refusals on 4/20 and 4/24. The bed bath was given on 4/27. The dates of 5/1 and 5/4 were missing. (4 of the 5 scheduled days were missing showers or bed baths.) R203 was given a bed bath on 5/8, during the survey. On 5/8/24 at 9:39 AM, R203 and his wife stated he never refuses showers or bed baths. R203 said he is not even offered them, so how in the world could he refuse. R203 said he was shocked he got a bed bath today and that was the first one in quite a while. On 5/8/24 at 12:17 PM, V11 (Certified Nurse Aide) stated R203's wife visits almost every day and is aware of the care he gets daily. V11 said R203 is alert and fully aware of what is going on around him. On 5/9/24 at 9:11 AM, V16 (Registered Nurse) said residents should be receiving showers as they are scheduled, at least two times per week. If a resident refuses, they should be offered on the next day or when they prefer it. V16 said R203 has no memory problems and can express his wishes. On 5/9/24 at 9:30 AM, V2 (Director of Nurses) said all residents should be showered twice a week and as needed. they should be getting showered based on their preference. It is important for infection prevention, dignity, wound prevention, and feeling better about oneself. Good hygiene maintains overall good health. The facility's Activities of Daily Living (ADL) policy revision dated 3/2018 states: 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care).

Based on observation, interview, and record review the facility failed to ensure a physician ordered dressing was in place for a resident at risk for skin breakdown for 1 of 3 residents (R203) reviewed for pressure ulcers in the sample of 14. The findings include: R203's face sheet printed on 5/8/24 showed an admitted [DATE] and diagnoses including but not limited to multiple sclerosis, quadriplegia, cervical disc disorder, and need for assistance with personal care. R203's facility assessment dated [DATE] showed no cognitive impairment or memory problems. The assessment showed R203 is totally dependent on staff for showers, bathing, lower body dressing, and transfers. The same assessment showed R203 is at risk for developing pressure ulcers. R203's pressure ulcer risk assessment dated [DATE] showed a moderate risk. R203's order summary report showed an order start dated 4/23/24 for: Sacrum-cleanse with NS (normal saline), apply foam dressing every day shift every Tues, Thurs, Sat for protection. R203's care plan showed a focus area start dated 4/19/24 for risk for impaired skin integrity. Interventions included provide skin care per facility guidelines and as needed. On 5/7/24 at 11:00 AM, R203 was lying in bed and covered up to the waist with a light sheet. R203 stated he had a chronic sore on his backside for a long time and it has healed before he arrived at the facility. R203 said it was a stage 4 pressure ulcer. R203 said the nurses had been putting a thick bandage on the area to keep it from breaking down again. R203 said he has a catheter for urine collection, but he uses a bed pan for bowel movements. R203 said the nurses change the bandage sometimes but he was unsure how often. R203 said for some reason they haven't been doing it lately. On 5/8/24 at 11:56 AM, V9 (Certified Nurse Aide) and V10 (Physical Therapy Assistant) changed R203's brief and rolled him from side to side. R203's sacrum (upper buttocks) area was observed and there was no foam dressing present. The sacrum had a grapefruit size, circular reddened area. On 5/9/24 at 9:19 AM, V2 (Director of Nurses) stated R203 is at a high risk for skin break down. He needs the foam dressing on his sacrum to protect the bony area. The dressing should be monitored and in place at all times. Staff should report any soiled, wet, or missing dressing right away. It is important to prevent any future breakdown. V2 was asked to provide documentation of the dressing being changed as ordered. At 10:48 AM, V2 stated there was no record of the dressing changes being done. The facility's Pressure Ulcers/Skin Breakdown policy revision dated 4/2018 states: The physician will order pertinent wound treatments, including pressure reduction surfaces, .dressings (occlusive, absorptive, etc.) . The policy states: In addition, the nurse shall describe and document/report the following: d. current treatments, including support surfaces .

Based on observation, interview, and record review the facility failed to ensure a drainage bag was not laying on the bed, was kept below the level of the bladder, and a dignity bag was used to cover the drainage bag. The facility failed to ensure catheter tubing was not kinked or occluded. This applies to 3 of 3 residents (R287, R22, R190) reviewed for catheters in the sample of 14. The findings include: 1. On 5/7/24 at 9:44 AM, R287 was laying on her back in bed with her catheter tubing kinked and occluded under her right leg. There was cloudy yellow urine present in the catheter tubing. R287 stated she did not know why she had a catheter and has had it since she was in the hospital. On 5/08/24 at 1:34 PM, V2 DON stated there shouldn't be any kinks in the catheter tubing. The resident shouldn't be laying on the tubing because it can cause urinary retention. The urine needs to have good flow to get out and if it doesn't it can lead to a urinary tract infection and sepsis. It puts them at higher risk for infection. The Order Summary Report dated 5/8/24 for R287 showed diagnoses including chronic obstructive pulmonary disease, acute and chronic respiratory failure, myocardial infarction, hypertension, rheumatoid arthritis, type 2 diabetes mellitus, atherosclerotic heart disease, anxiety disorder, sepsis, acute and subacute endocarditis. R287 did not have a diagnosis for the use of the urinary catheter. The Care Plan dated 5/2/24 for R287 showed she has a urinary catheter. Check tubing for kinks during care and change position. The facility's Urinary Catheter Care policy (2022) showed check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter tubing free of kinks. 2. On 5/7/24 at 11:16 AM, R22 was laying on his back in his bed with the catheter drainage bag laying on his bed. V12 CNA (Certified Nursing Assistant) came into R22's room and stated she was going to get R22 up. R22's catheter drainage bag was pointed out to V12 who stated the drainage bag is not supposed to be in the bed for infection control. On 5/8/24 at 9:18 AM, R22 was sitting up in bed with drainage bag on lower side of bed that was visible from the hallway. There was a dignity bag hanging on his bed next to the catheter drainage bag. At 9:21 AM, V13 CNA came into R22's room and stated R22's catheter drainage bag should be covered because that is what his daughter requests. V13 stated R22's daughter wants the drainage bag covered when he is in bed and up in his chair. On 5/8/24 at 1:34 PM, V2 DON (Director of Nursing) stated the catheter bag should always be below the bladder. V2 stated she recommends the dignity bags be used all of the time. There isn't a specific policy about it. The CNAs know to use the dignity bags. V2 stated the drainage bag should not be laying in the resident's bed; there is a risk of backflow of urine. It is also for infection control. The Urinalysis Report dated 5/3/24 for R22 showed a high amount of protein, white bloods cells, and bacteria present; trace ketones, positive for nitrite, moderate blood and leukocytes present. The Nurses Note dated 5/3/24 for R22 showed the urine culture and sensitivity report was received, had escheria coli present. The results were relayed to the physician and the resident was started on macrobid 100 mg twice a day for 7 days. The Face Sheet dated 5/8/24 for R22 showed diagnoses including traumatic subdural hemorrhage, cerebral infarction, paraplegia, osteomyelitis of vertebra, hypertension, urinary retention, and paroxysmal atrial fibrillation. The Care Plan for R22 dated 4/22/24 showed he has a urinary catheter. Position catheter bag and tubing below the level of the bladder and away from the entrance room door. The facility's Urinary Catheter Care policy (2022) showed position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder. 34891 3. R190's face sheet printed on 5/8/24 showed diagnoses including but not limited to corticobasal degeneration, Parkinson's disease, monoplegia of left upper limb, and dysphagia. R190's facility assessment dated [DATE] showed no cognitive impairment and dependent on staff for oral and personal hygiene. R190's order summary report showed an order dated 4/18/24 for a foley catheter due to urinary retention. R190's care plan showed catheter interventions including: Position catheter bag and tubing below the level of the bladder and away from entrance room door. On 5/7/24 at 10:09 AM, R190 was lying in bed and the urinary drainage bag was hanging on the bed railing. The bag was facing the doorway and fully visible from the hall. At 12:29 PM, the drainage bag was in the same position. On 5/8/24 at 9:50 AM, the drainage bag was still on the bed rail, uncovered and facing the door to the hall. At 10:27 AM, V11 (CNA-Certified Nurse Aide) performed catheter care for R190. The catheter stat lock (device used to secure and prevent tubing from pulling out) was not secure. The device was damp, curled under at the edges, and not attached to the thigh in any way. V11 laid the drainage bag on top of R190's feet and rolled her from side to side to change the incontinence brief. The tubing was pulling and tangled at her feet during the process. V11 emptied the drainage bag into a urinal and tapped the tubing against the edge. V11 reinserted the tubing into the bag holder without any sanitation or cleansing. On 5/9/24 at 9:34 AM, V2 (Director of Nurses) stated the statlocks are needed to secure the tubing to the inner thigh. It is needed to keep if from kinking up or pulling out during care. Any statlocks that are soiled, wet or damaged should be reported and replaced immediately. Drainage bags should remain below the level of the bladder at all times to prevent backflow into the bladder. Infection and retention problems are a big potential for residents with catheters. Proper drainage bag technique includes keeping the tubing clean and uncontaminated. It should be sanitized if it touches anything. Privacy bags should be used to maintain resident dignity. The facility's Catheter Care policy revision dated 8/2022 states: 3 . Avoid splashing and prevent contact of the drainage spigot with the nonsterile container. The facility's Dignity policy revision dated 2/2021 states: 12. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: a. helping the resident to keep urinary catheter bags covered .

Based on observation, interview, and record review the facility failed to ensure oxygen was administered at the physician prescribed rate for 1 of 1 resident (R192) reviewed for oxygen in the sample of 14. The findings include: R192's face sheet printed on 5/8/24 showed diagnoses including but not limited to chronic obstructive pulmonary disease, chronic diastolic heart failure, burns, left radius fracture, and hypertension. R192's facility assessment dated [DATE] showed supervision or touch assistance needed from staff for oral hygiene, toileting, showers, and personal hygiene. The same assessment showed no cognitive impairment. R192's order summary report shows a physician order start dated 4/27/24 for: Apply oxygen 2L/min (liters per minute) as needed to keep O2sat (oxygen saturation level) above 92% every shift for sob (shortness of breath). On 5/7/24 at 10:17 AM, R192 was seated in a wheelchair in his room. An oxygen line with the nasal cannula was inserted in his nose. The portable oxygen tank on the back of the wheelchair showed the level set at zero liters per minute (off). R192 stated he did not think the oxygen was running and was unsure if anything was coming out of the tubing. R192 said he wears it all day to help his breathing. At 12:34 PM, R192 was still in the wheelchair in his room. R192 was audibly wheezing and breathing in a labored manner. R192's oxygen was still set at zero liters. V8 (RN-Registered Nurse) was asked to verify the oxygen setting. V8 said it is not on at all and it is likely due to the therapy department turning it off earlier in the morning. V8 said R192 needs it set at two liters continuously or else he will desaturate (low blood oxygen level). V8 said R192 has breathing issues and the oxygen is necessary to keep his levels correct. On 5/9/24 at 9:07 AM, V16 (RN) said resident's oxygen should be set at the level ordered by the physician. Too low of a level can cause issues like labored breathing, shortness of breath, and heavy use of abdominals. Oxygen settings should be checked during all care. It is important to ensure it is at the correct level for resident safety and overall good health. On 5/9/24 at 9:32 AM, V2 (Director of Nurses) stated it is important oxygen is administered as ordered to prevent hypoxia, shortness of breath, or respiratory distress. Low oxygen levels can cause confusion, falls, and low brain function. The facility's undated Oxygen Administration policy revision dated 10/2010 states: 10. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered.

Based on observation, interview, and record review the facility failed to honor a resident's food preference and find an appropriate alternative for 1 of 1 resident (R300) reviewed for food preferences in the sample of 14. The findings include: On 5/8/24 at 9:14 AM, R300 stated she got eggs this morning for breakfast. R300 stated she can't even stand the smell of eggs; it makes her sick to her stomach. R300 stated she keeps getting eggs for breakfast even though she told staff that she doesn't like them and is allergic to them. R300 stated she just eats the oatmeal that is sent up. On 5/8/24 at 9:25 AM, V13 CNA (Certified Nursing Assistant) stated, R300 is not allergic to eggs; she doesn't like eggs. V13 stated they bring her eggs, and she won't eat them; she usually just eats her oatmeal. V13 stated R300 was not the only resident that doesn't like eggs and doesn't want them. V13 stated there are other residents on the second floor that don't want the eggs. V13 stated they have called the kitchen to let them know R300 doesn't want eggs, but they don't listen. On 5/8/24 at 9:54 AM, V14 RD (Registered Dietician) stated everyone that comes into the facility she meets with and will go over the menu with them. V14 stated she obtains likes and dislikes, will put them in her progress notes and then lets the dietary manager know. V14 stated when a resident comes in, they are given an orange welcome bag with the menu in it, and she goes over the menu. V14 stated if there is something the resident doesn't like, she will suggest an alternative and then lets the dietary manager know. V14 stated she talked to R300 and gave an alternative to the kitchen for R300's eggs but she needed to follow up on that. The Week 1 facility menu (no date) showed on Sunday, Monday, Tuesday, Wednesday, Thursday, and Saturday eggs are served for breakfast. The Week 2 facility menu (no date) showed on Sunday, Monday, Tuesday, Wednesday, Thursday, and Saturday eggs are served for breakfast. The Face Sheet dated 5/8/24 for R300 showed diagnoses including type 2 diabetes mellitus, hypertension, acute kidney failure, and bacteremia. The Nutrition Form dated 5/3/24 for R300's admission on 5/1/24 showed she is on a carbohydrate controlled diet, has no known food allergies and dislikes eggs. The summary showed R300 is able to feed herself and verbalize food choices, which are provided. The Care Plan dated 5/3/24 for R300 showed, potential nutritional problem due to diagnosis of diabetes mellitus; therapeutic diet. Monitor tolerance of diet. RD educated guest on importance of adhering and reason for therapeutic diet. RD to evaluate and make diet change recommendations as needed. The facility's Food Preference policy (2021) showed, the food item requested by the residents will be provided as requested and in accordance with residents' diet orders. A designated person will monitor to make sure that food preferences are honored at all times.

Based on observation, interview and record review the facility failed to assess a resident's skin condition for 1 of 3 residents (R1) reviewed for non pressure skin condition in the sample of 5. The findings include: R1's electronic medical record shows R1 is [AGE] year old with diagnoses of dementia, osteoporosis, and history of falling. On 1/16/24 at 9:45 AM, V3 (Wound Nurse) said there was one resident (R1) that has a skin rash at the facility. This surveyor and V3 checked R1's skin. R1 was noted to have rashes on their buttocks and peri areas. V3 said R1's rashes were due to R1 being incontinent. V4 (R1's daughter) was also with R1. V4 said she now goes to the facility daily to monitor R1's care after R1 was noted to have developed a bad rash at the facility. V4 said R1 sits in her chair for long periods of time. V4 also said she was concerned if R1 was being checked if she was soiled to prevent her from having further rashes. On 1/16/24 at 10:30 AM, V3 (Wound Nurse) said on 1/5/24, he was the one who called R1's physician for antifungal cream since he was told R1 had rashes. V3 said R1's rashes were due to R1 being incontinent. R1's skin was not assessed at that time. V3 said the last skin assessment done on R1 was 12/31/23. V3 said he'll do a skin assessment to check R1's skin condition and rashes today. R1's admission skin assessment dated [DATE] shows R1 has redness to the right and left buttocks. An assessment was done on 12/31/23 (readmit) showing R1's skin was intact with blanching erythema (redness) on the sacral area. R1's skin was not assessed since 12/31/23. R1's medical record did not show further skin assessments. On 1/16/24 at 2PM, V2 (Director of Nursing) said Residents skin should be assessed every incontinence care, every week or as needed to check their skin conditions that include non-pressure wounds and rashes. R1's careplan did not address R1's skin condition of rashes to the buttocks and peri areas. The Facility Policy entitled Wound Care-Non Pressure dated 7/18 stated: The purpose of this procedure is to provide guidelines for the care of non-pressure wounds to promote healing. Wounds include any area that is not a pressure ulcer-this may include rashes .A clinical note will be completed weekly to address healing .

Based on observation, interview and record review the facility failed ensure staff wore hairnets in the kitchen. The facility failed to store dry foods in a manner to prevent contamination. The facility failed to sanitize/wash dishware in a manner to prevent cross contamination. The facility failed to ensure food storage areas were clean and free of debris. These failures have the potential to affect all 35 residents in the facility. The findings include: The facility's Resident Census and Conditions of Residents form dated July 17, 2023, showed a resident census of 35. On July 17, 2023, at 9:00 AM, V4 Kitchen Aide was observed walking around the kitchen with no hairnet on. V4 walked over to the dishwasher and removed clean dishes from the dishwasher. V4 did not wash her hands or don gloves prior to removing the dishes from the dishwasher. V4 then began rinsing dirty dishes, not wearing any gloves. V4 placed the dirty dishes in the dishwasher. At 9:05 AM, V4 removed the clean dishes from the dishwasher, without washing her hands or donning gloves prior to handling the clean dishes. On July 17, 2023, at 9:10 AM, an open plastic bag of raisin bran cereal was noted on a prep table in the kitchen. On July 17, 2023, at 9:12 AM, pieces of fruit were frozen to the floor in the walk-in freezer. Multiple pieces of plastic and cardboard were also noted on the floor in the walk-in freezer. On July 17, 2023, at 12:04 PM, V6 Dietary Manager stated, Staff should always wear a hairnet in the kitchen, so hair doesn't get in the food. We should have two people washing dishes. If we only have one person running the dishwasher, they are to change gloves and wash their hands in between handling dirty to clean dishes. All floors are to be swept daily. The facility's Storage of Dry Goods/Foods policy dated 2021 showed, Dry foods and goods are handled so that the integrity of the packaging is maintained until ready to use . Opened products are labeled, dated with the use by date and tightly covered to protect against contamination from insects and rodents . Opened products that have not been properly sealed and dated are discarded . The facility's Cleaning Dishes/Dish Machine policy dated January 1, 2015, showed, The person loading dirty dishes should not handle the clean dishes unless they change their apron and wash their hands thoroughly before moving from dirty to clean dishes . The facility's Employee Sanitary Practices policy dated January 1, 2015, showed, All kitchen employees will practice standard sanitary procedures . All employee are restraint hair and wear clean uniforms .

Based on observation, interview, and record review the facility failed to separate Coronavirus 19 (COVID-19) positive residents and COVID-19 negative residents The facility failed to wear appropriate PPE (personal protective equipment) to prevent the spread of COVID-19 and the facility failed to ensure newly admitted residents to the facility were put on contact and droplet precautions. These failures had the potential to affect all 62 residents in the facility and resulted in Immediate Jeopardy to their health and safety. The Immediate Jeopardy began on 12/9/2020 when R7 was admitted the facility and not put on quarantine (contact/droplet isolation). The Immediate Jeopardy was identified on 12/16/2020. V1 (Administrator) was informed of the Immediate Jeopardy on 12/21/20 at 9:30 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 12/21/2020 however, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: 1.On 12/16/20 at 8:55 AM, V2 Director of Nursing (DON) said as of yesterday we had 40 positive COVID 19 residents in the facility. V2 said we have the second floor is our COVID 19 unit, and the first floor contains a PUI (person under investigation) unit and our non COVID 19 unit. V2 said all COVID 19 and PUI residents are separated from non COVID residents. V2 said if a resident tests positive for COVID 19 they are moved upstairs to the COVID unit. On 12/16/20 at 9:22 AM, on the non COVID 19 unit, V5 Respiratory Therapist stated there are residents that tested positive in this unit, I just don't know which ones. I just found out this morning. On 12/16/20 at 9:54 AM, on the non COVID 19 unit, V7 Occupational Therapist stated there are newly positive residents down here, I'm not sure their plan. On 12/16/20 at 10:00 AM on the non COVID 19 unit, V3 Registered Nurse (RN) stated there are four positive residents (R2 and R8-R10) on this unit, the results came in today. V3 said when residents test positive they are moved upstairs right away. We are waiting for rooms. On 12/16/20 at 10:12 AM, R2 and R8-R10's room (on the non COVID 19 unit) had signs on the door See nurse before entering and had carts with PPE outside the door. On 12/16/20 at 1:48 PM, V9 Licensed Practical Nurse said at 6:45 AM she saw the COVID 19 positive test results and emailed the department heads and the DON. On 12/16/20 at 12:30 PM, V2 (DON) said V9, around 6:00 AM, checked the COVID 19 lab results. V2 said V9 emailed her about the COVID 19 positive results for 4 residents. V2 said she called V10 Environmental Service Director and had V10 put the 4 positive residents on isolation and close their room doors. V2 said she arrived at the facility around 8:50 AM. On 12/16/20 at 12:55 PM, V10 said they were at the facility at 4:00 AM and found out about the COVID 19 positive residents from the night nurse. V10 said they had to wait for V2 to get the facility in order to come up with a plan to move the residents. V10 said he met with V2 when she got in and it was decided to open up another wing upstairs and install a divider to partition off the wing. V10 said he was finished opening the wing, the divider was up by 9:00 AM and it was ready for residents to be moved at that time. On 12/16/20 at 10:45 AM, V2 stated we have 10 COVID beds right now. We are going to move them right now. I found out this morning of the positive test results. On 12/16/20 at 12:49 PM, R10 was still in his room on the non COVID unit. On 12/16/20 at 12:59 PM, R10 was still in his room on the non COVID unit with the door to the room wide open. On 12/16/20 at 1:32 PM, R10's door to the room on the non COVID unit was wide open and unclean. R10 was not in the room. R2's COVID 19 lab result shows positive with a reported date: 12/16/20 12:25 AM. R8's COVID 19 lab result shows positive with a reported date: 12/16/20 12:25 AM. R9's COVID 19 lab result shows positive with a reported date: 12/16/20 12:25 AM. R10's COVID 19 lab result shows positive with a reported date: 12/16/20 12:25 AM. 2. On 12/16/20 at 10:14 AM, R10's room had a see nurse before entering sign on the door and a cart with personal protective equipment (PPE) next to the door. V4 Certified Nursing Assistant (CNA) went into R10's room with a vital sign machine wearing a cloth mask with an N95 mask over it, a face shield, and gloves. V4 did not have a gown on. V4 stated I'm taking care of 4 residents today, they are positive. I wear my own mask under the N95, a face shield, and gloves to do vitals. I did not wear a gown. I only wear a gown when I'm turning and repositioning or cleaning up a resident. On 12/16/20 at 10:26 AM, V4 went into R9's room (COVID 19 positive) without a gown. On 12/16/20 at 2:07 PM, V2 DON said PPE required to be worn for COVID 10 positive residents is: gown, N95 with a surgical mask over it, goggles or a face shield, and gloves. V2 said they also have hair coverings and booties if the staff want to wear them. V2 said staff should be wearing full PPE to go into the COVID 19 positive rooms on the non COVID 19 unit. On 12/16/20 at 12:56 PM, V4 (after going into 2 COVID 19 positive rooms without wearing a gown over her scrubs) went into R11's room (who is COVID 19 negative) without a gown, wearing the same potentially contaminated scrubs. The facility's Infection Control Policy dated 11/17/20 shows Strict isolation precautions should be initiated when a resident has an infectious disease or epidemiologically significant pathogen transmission by direct resident contact or by contact. 3. On 12/16/20 at 10:00 AM, V3 RN stated R2 is new she just came in 3 or 4 days ago. She was negative when she came in but she is positive today. R6 is a new admit about 2 or 3 days ago. R6 is not a PUI so she is not on isolation. R7 is also new and she just came back from a procedure at the hospital but she is not on isolation. On 12/16/20 at 9:30 AM, R7 was in a room on the non COVID unit with the room door open. On 12/16/20 at 12:10 PM, V2 said R2 was a new admit on the non COVID 19 unit and was just on standard precautions with symptom monitoring. On 12/16/20 at 12:54 PM, V3 RN said the new admits on the non COVID 19 unit are not on isolation, just standard precautions. On 12/16/20 at 2:07 PM, V2 said starting in December, all new admits are considered PUI (person under investigation) and staff should use full PPE when caring for them. R2's Face sheet shows R2 was admitted on [DATE] (to the non COVID 19 unit)with [DIAGNOSES REDACTED]. R6's Face sheet shows R6 was admitted on [DATE] to the non COVID 19 unit. R7's Face sheet shows R7 was admitted on [DATE] to the non COVID 19 unit. R2's COVID 19 lab result shows positive with a reported date: 12/16/20 12:25 AM. The facility's Infection Control Policy dated 11/17/20 shows enhanced droplet isolation is implemented for newly admitted asymptomatic and COVID 19 negative residents for 8-10 days since their admission. The Immediate Jeopardy that began on 12/9/2020 was removed on 12/21/2020 when the facility took the following actions to remove immediacy. Residents that were newly identified as Covid-19 positive were moved to Covid-19 positive floor. Newly admitted residents are currently being placed on PUI (Patient Under Investigation) Unit. PPE, according to the CDC guidelines, are provided to all staff. On 12/21/20 the Infection Control Preventionist is currently educating staff in the building to ensure that any resident who is Covid-19 positive is admitted to the Covid-19 unit and that any newly diagnosed resident is moved to the Covid-19 unit as soon as possible and ensure that proper PPE is being worn to prevent cross contamination. Strict isolation policy updated 12/21/20. On 12/23/20 a mandatory in-service will be held to educate all staff on update Strict Isolation policy which includes moving newly positive covid-19 patients to the covid-19 unit as soon as possible, admission of newly admitted patients will be placed on PUI until testing confirms negative or 8-10 days on quarantine without fever or signs and symptom, and proper wearing of PPE according to CDC guidelines. Administrator and/or designee will round daily to ensure that all residents are on the proper floor given [DIAGNOSES REDACTED]. Ensure that all employees are wearing appropriate PPE in compliance with CDC guidelines to prevent cross contamination to residents and other healthcare workers Result from daily rounds will be discussed every morning in morning stand up meeting as well as reviewed in our monthly Performance Improvement Committee x next 90 days to ensure compliance.

Based on interview and record review the facility failed to ensure all staff members were tested twice weekly as required by the county's positivity rate. Facility documents at the time of the survey show 44 residents currently have COVID-19 and 15 staff members had contracted COVID-19. These failures had the potential to affect all 62 residents in the facility and resulted in an Immediate Jeopardy to their health and safety. The Immediate Jeopardy began on 11/20/20 when V11 Registered Nurse did not receive testing for COVID-19. The Immediate Jeopardy was identified on 12/16/20. V1 Administrator was informed of the Immediate Jeopardy on 12/21/20 at 9:30 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 12/21/20, however, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: On 12/17/20 at 2:08 PM, V2 Director of Nursing (DON) confirmed the facility's Census for 12/16/20 was 62 residents. V2 stated 44 out of those 62 residents are positive for COVID-19 and 15 staff members have contracted COVID-19. On 12/16/20 at 8:55 AM, V2 DON said the facility has been doing twice weekly COVID 19 testing for staff since October when the county positivity rate was over 10%. V2 said staff testing is on Tuesdays and Fridays. The facility could not provide COVID-19 test results for V11 Registered Nurse (RN) from 11/20/20 to 12/4/20, V4 Certified Nursing Assistant from 11/24/20 to 12/1/20, and V12 from 11/24/20 to 12/4/20. V11 (according to twice weekly schedule) should have been tested on [DATE], 11/24/20, 11/27/20, 12/1/20, and 12/4/20. V11 tested positive for COVID 19 on 12/8/20. V4 should have been tested on [DATE], 11/27/20, and 12/1/20. V4 tested positive for COVID 19 on 12/4/20. V12 should have been tested on [DATE], 11/27/20, 12/1/20, and 12/4/20. V12 tested positive for COVID 19 on 12/8/20. The facility's resident testing list shows residents have tested positive on 11/22/20, 12/2/20, 12/3/20, and 12/7/20. The facility's Infection Control Policy dated 11/17/20 shows all staff, visitors, contractors will mandatorily be offered COVID testing. In accordance to IDPH guidelines will be determined per county positivity rate. The CDC's Interim Guidance on Testing Healthcare Personnel for [DIAGNOSES REDACTED]-CoV-2 updated on 7/17/20 shows, Testing asymptomatic HCP without known or suspected exposure to [DIAGNOSES REDACTED]-CoV-2 for early identification in special settings . Currently, testing asymptomatic HCP without known or suspected exposure to [DIAGNOSES REDACTED]-CoV-2 is recommended for HCP working in nursing homes is part of the recommended reopening process .In this situation, initial [MEDICAL CONDITION] testing of all HCP in nursing homes, along with weekly [MEDICAL CONDITION] testing thereafter is recommended. State and local officials may adjust the recommendation for weekly [MEDICAL CONDITION] testing of HCP based on the prevalence of [MEDICAL CONDITION] in their community; for example, performing weekly testing in areas with moderate-to-substantial community transmission and less frequent testing in areas with minimal-to-no community transmission .Healthcare personnel (HCP): HCP refers to all paid and unpaid persons serving in healthcare settings who have the potential for direct or indirect exposure to patients or infectious materials, including body substances (e.g., blood, tissue, and specific body fluids); contaminated medical supplies, devices, and equipment; contaminated environmental surfaces; or contaminated air. HCP include, but are not limited to, emergency medical service personnel, nurses, nursing assistants, physicians, technicians, therapists, phlebotomists, pharmacists, students and trainees, contractual staff not employed by the healthcare facility, and persons not directly involved in patient care, but who could be exposed to infectious agents that can be transmitted in the healthcare setting (e.g., clerical, dietary, environmental services, laundry, security, engineering and facilities management, administrative, billing, and volunteer personnel). The Immediate Jeopardy that began on 11/20/2020 was removed on 12/21/2020 when the facility took the following actions to remove immediacy: Employee roster generated from Human Resources to ensure 100% employees will be tested no later than 12/24/20 by either PCR testing or rapid testing via nasal swab according to the county positivity rate. All employees currently in the facility will received rapid testing as of 12/21/20. Employees will be required to get tested according to the county's positivity. Employees that that do not get tested will not be placed on the schedule to work until testing is complete. On 12/23/20 a mandatory in-service will be held to educate all staff on testing requirements according to the county ' s positivity rate. Employees will also be informed that any employee who is not tested will be removed off of the schedule until testing and results are received. Infection Preventionist will record on the employee roster all employees who has been tested in order ensure to ensure 100% compliance. Results from the employee roster will be reviewed bi-weekly in the morning meeting or according to the county ' s positivity rate to ensure 100% compliance. All results will be reviewed in our monthly Performance Improvement Committee to ensure 100% Compliance.