Every finding on record at Presbyterian Village

Based on observations, staff interviews, and review of facility policies titled, Mechanically Altered Diets and Thickened Liquids and How to Puree Foods, the facility failed to ensure dietary staff followed standardized pureed food recipes for nine of nine residents receiving pureed diets. This deficient practice had the potential to result in inconsistent nutritional intake and unsafe food consistency. Findings include:Review of the facility policy titled Mechanically Altered Diets and Thickened Liquids, issued on 05/01/2019, under the section titled Procedure, revealed, Mechanically altered diets are planned, prepared, and served with supervision or consultation from a registered dietitian.Review of the facility policy titled How to Puree Foods under the section titled Preparation Steps revealed, Depending on the resident's dietary restrictions, follow the proper recipes.Observation and interview on 01/26/2026 at 11:03 AM revealed [NAME] CC preparing pureed green beans for approximately 10 residents. The cook stated the consistency he was looking for was medium and that each resident received eight ounces. The cook was observed scooping the pureed green beans during preparation. During the observation, the cook was observed adding vegetable broth twice. When asked how the amount of vegetable broth was measured, the cook stated that half of the scoop equals one cup and that he used vegetable base to make the broth. The cook stated he added one cup of broth but was not observed using a measuring device. When asked if he was following a recipe for the pureed green beans, the cook stated there was no recipe he followed for pureed foods. He stated the facility had recipes for regular diets but no recipes for pureed diets. He further stated he was trained verbally by the Executive Chef and was told each resident received eight ounces. [NAME] CC stated he had never followed a pureed recipe and was typically the staff member who prepared pureed foods, stating he was just winging it based on what they tell me. The cook further stated that if the puree was not the consistency he wanted, he added two teaspoons of thickener. During the observation, he proceeded to add thickener, stating the puree was not the consistency he wanted. [NAME] CC stated he received verbal training only and never provided written pureed food recipes.Interview on 01/26/2026 at 11:08 AM with the Dietary Director revealed the facility did not currently have standardized recipes for pureed foods and that the facility planned to work with a company to develop pureed diet recipes. She stated a potential negative outcome of not having standardized pureed recipes was that residents may not receive adequate nutrients.Interview on 01/26/2026 at 11:08 AM with the Regional Director of Operations confirmed there were no puree diets available. She stated a potential negative outcome was that pureed foods not prepared to the correct consistency could present a choking hazard, degrade nutritional value, and affect calorie intake. She stated pureed meals should resemble what residents on regular diets received and stated a company will be assisting with providing pureed diet recipes.Interview on 01/26/2026 at 12:12 PM with the Dietary Kitchen Manager revealed she stated she, the dietitian, and dietary staf fwere familiar with residents' food preferences and used production sheets to identify residents on pureed, mechanical soft, regular, and cardiac diets. She stated the facility had approximately seven to eight residents on pureed diets, some on thin liquids and others on nectar-thick liquids. She stated she verified the diet by reviewing the meal ticket and visually confirming the plate. When informed of the observation indicating pureed recipes were not being followed, the Dietary Kitchen Manager stated she was not aware recipes were not being used and stated staff were expected to follow recipes. She stated the corporate dietitian was responsible for providing pureed recipes and that following recipes was important to ensure nutritional value and consistency. The Dietary Kitchen Manager provided a copy of a pureed green bean recipe during the interview.Interview on 01/29/2026 at 9:58 AM with the Dietary Director revealed she was able to locate the pureed food recipes and acknowledged that she had recently learned where and how to access them. The Dietary Director stated her expectations were to be in compliance, ensure proper staff training, and provide dietary staff with the knowledge and tools needed to follow standardized pureed recipes. Her expectation was that this issue did not occur again. She stated staff must be trained appropriately and consistently follow recipes to ensure resident safety and nutritional adequacy. She further stated the goal was to ensure pureed foods were prepared correctly and served according to residents' prescribed diets. The Dietary Director stated potential negative outcomes of not following pureed recipes included residents getting sick, receiving food with incorrect consistency, difficulty swallowing, and possible medical complications related to improper food preparation. She emphasized the importance of ensuring pureed meals were prepared correctly for the well-being of residents and to ensure meals are consistent with prescribed therapeutic diets.Interview on 01/29/2026 at 11:58 AM with the [NAME] President of Operations (VPO) revealed expectations were for staff to follow standardized recipes and have the resources available to locate them. He stated potential negative outcomes include inconsistent food quality, meals not matching therapeutic diet orders, and residents receiving food not consistent with prescribed diets.

Based on observations, record review, staff interviews, and review of the facility's policies titled, Labeling Food Product and Food Storage, the facility failed to ensure food items were properly labeled, dated, sealed, and discarded when expired in the pantry, freezer, cooler, and resident refrigerator. This deficient practice had the potential to affect all 62 residents who receive food orally and increased the risk of foodborne illness.Findings include:Review of the facility policy titled Labeling Food Product, reviewed on 01/02/2023, revealed under Policy: All prepared foods, leftovers and opened products stored for later use will be labeled according to food safety standards. Under Procedures: .3. a. All labels will contain the complete name of the product, the date the product was prepared or opened, the date the product must be utilized by, and the name of the individual creating the label.Review of the facility policy titled Food Storage revealed under Procedure: All products shall be dated upon receipt or when they are prepared. Under Dry Storage revealed: .Any opened products shall be placed in seamless plastic or glass containers with tight-fitting lids. Label and date all storage containers with the received date, date opened, and expiration date. Rotate stock.Observations on 01/26/2026 at 11:51 AM in the freezer revealed the following items in the freezer not properly sealed, labeled, or dated:One bag of tilapia not properly sealed and without an expiration date.One bag of hot dogs with no date.One package of pancakes with no expiration date.Observations on 01/26/2026 at 11:31 AM in the cooler revealed multiple food items stored without expiration or use-by dates, including:Orange segments in plastic containers with only a received-by date of 01/19/2026 and no expiration date.Bag of spinach with no expiration date.Bag of jalapenos with no expiration date.Bag of mint with only a received-by date of 01/26/2026.Bag of thyme with no dates.Bucket of cut potatoes with a shelf-life date of 01/25/2026 (expired at time of observation).Gluten-free bread slices with a shelf life of 01/20/2026 (expired).Six cups of greek nonfat yogurt with an expiration date of 01/05/2026 (expired).One loaf of sourdough bread dated 10/15/2025 with no expiration date.Observations on 01/26/2026 at 11:14 AM in the pantry revealed:Opened enriched elbow pasta not labeled or dated.Opened gluten-free spaghetti not labeled or dated.Expired light molasses.Expired one-gallon container of shrimp and crab boil concentrate.Five boxes of orange pekoe and pekoe cut black tea with best-by date of 12/14/2025 (expired).A bag containing two melons that were visibly spoiled.Observations and interview on 01/26/2026 at 10:20 AM in the resident refrigerator on the first floor revealed a container of half and half with a use-by date of 01/23/2026 (expired).Interview on 01/26/2026 at 12:12 PM with the Dietary Kitchen Manager (DKM) revealed the facility checks refrigerators daily and follows first-in, first-out (FIFO) practices. She stated staff assigned to refrigerator monitoring were responsible for checking expiration dates and discarding expired items. She stated a potential negative outcome of not discarding expired items was that food may appear acceptable externally while being unsafe internally.A follow-up interview on 01/29/2026 at 12:57 PM with the DKM revealed she had removed an expired item earlier that day but later observed the same item had been placed back into the refrigerator.Interview on 01/29/2026 at 9:58 AM with the Director of Dining revealed all kitchen staff shared responsibility for ensuring food items were properly labeled, dated, and discarded when expired. She stated expectations include routine walkthroughs, adherence to labeling requirements, and following food safety regulations. She stated a potential negative outcome of failing to discard expired food items is that residents become ill.Interview on 01/29/2026 at 11:58 AM with the [NAME] President of Operations revealed it was the facility's responsibility to ensure expired and exposed food items were discarded. He stated there should be a system in place with clear accountability and backup coverage. He stated a potential negative outcome of expired food items include foodborne pathogens and failure to meet quality and safety standards expected for residents.

Based on observations, staff interviews, and review of the facility policy titled, Environmental Services Policy - Cleanliness and Homelike Environment, the facility failed to maintain a clean and homelike environment related to a stained wall surface in one of eight rooms (Room F8) located on F Hall. This deficient practice had the potential to negatively impact the residents' right to reside in a safe, clean, and homelike environment. Findings include:A review of the facility policy titled Environmental Services Policy - Cleanliness and Homelike Environment reviewed on 08/28/2025, under the section titled Procedure, stated, Residents' rooms, bathrooms, and common areas will be cleaned and sanitized regularly per facility schedule and infection control practices. The policy further stated, Routine inspections of residents' rooms and common areas will be conducted to ensure compliance with cleanliness and homelike standards. The policy additionally stated, All staff are responsible for maintaining a clean and dignified environment. Spills, trash, or hazards should be reported immediately-regardless of department.Observations on 01/27/2026 at 1:38 PM, 01/28/2026 at 10:35 AM, and 01/28/2026 at 3:41 PM of Room F8, located on F Hall, revealed the wall surface directly adjacent to a resident bed had multiple visible brown and yellowish stains, splatter marks, and streaking. The stains varied in size and were observed at multiple heights along the wall. Some stains appeared dried and layered.Interview and observation conducted on 01/29/2026 at 10:16 AM with Housekeeping BB, stated the process for cleaning resident rooms, wiping down anything that needed to be wiped down-anything residents touched, among other duties. She stated it was also her responsibility to clean the floors and any splatter on the walls. She stated that rooms received a deep cleaning whenever a resident left the facility. During observation she pointed to the wall and stated she saw splatters, possibly food or something else. She stated she did not see that 01/28/2026 and did not see it on 01/27/2026. She stated that it looked like it had been there for a while. Housekeeping BB stated she knew he spit, and that it looked like spit, feces and food. She stated this was the first time she had seen it. Housekeeping BB confirmed it was not a homelike environment to have that on the wall.Interview on 01/29/2026 at 10:29 AM with the Assistant Director of Nursing (ADON)/ Infection Preventionist (IP) revealed a picture of the brown stains on the resident's wall was shown to the ADON. She stated that if it was food, it was likely molding, and that the resident could pick up an infection. She stated she would expect a nurse or Certified Nursing Assistant (CNA) to clean it up, and that housekeeping would then follow up.Interview on 01/29/2026 at 10:56 AM with the Housekeeping Supervisor revealed she saw the resident's wall and stated that it could be mucus because the resident spit a lot, and it could also be food. She stated her expectation was that if housekeeping saw the resident out of the room, housekeeping should give the room a deep cleaning. HS stated a potential negative outcome was the room not being homelike, and that she would not want to live like that with stains on the wall.Interview on 01/29/2026 at 11:58 AM with the [NAME] President of Operation (VPO) revealed his expectation was one hundred percent that anyone who sees something like that reports it to the supervisor and addresses it immediately and has it cleaned right away. The VPO stated a potential negative outcome could be an infection control issue, and beyond that, not meeting expectations for cleanliness of the building.

Based on observations, staff interviews, and review of the facility policy titled, Storage of Medications, the facility failed to ensure medications and biologicals were stored at proper temperatures to maintain their integrity. Specifically, one of two medication refrigerators in the first-floor medication room was not maintained within the required temperature range. Additionally, temperature monitoring was not completed daily in a second medication refrigerator located in the second-floor medication room. This deficient practice had the potential for residents to receive medications with compromised effectiveness.Findings include:Review of the undated facility policy titled Storage of Medications revealed the Policy states, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. The Policy Interpretation and Implementation section further indicated: 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls.7. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured locations.Review of the refrigerator temperature log from the first-floor medication room revealed the instructions state: Range: 36 degrees F (Fahrenheit)-46 degrees F. Adjust and comment if out of range.Review of the refrigerator temperature log from the second-floor medication room revealed the instructions state: If temperature is out of range-too warm (above 46 F) or too cold (below 36 F), act quickly and move everything to another refrigerator. Then report to maintenance.Observation on 01/28/2026 at 9:46 am of the medication storage refrigerator located in the first-floor medication room revealed a temperature of 50 F. Licensed Practical Nurse (LPN) AA confirmed the temperature reading of 50 F and stated that the night shift was responsible for checking and documenting refrigerator temperatures. Review of the temperature log for 01/28/2026 indicated the temperature had been documented as 41 F.Observation on 01/28/2026 at 9:53 AM of the medication storage refrigerator in the second-floor medication room in the presence of the Assistant Director of Nursing (ADON revealed that temperature checks had not been documented in the temperature log for 14 days in January 2025. The ADON revealed that the night shift was responsible for completing the log daily.Observation on 01/28/2026 At 10:02 AM, the surveyor and ADON returned to the first-floor medication room to recheck the refrigerator temperature. The temperature again read 50 F, which the ADON confirmed. The ADON stated the refrigerator temperature was too warm for medication storage and acknowledged that medications should have been relocated to another refrigerator and the issue reported to maintenance for corrective action.Interview on 01/29/2026 at 10:30 AM with the Director of Nursing (DON) revealed her expectation was for nursing staff to check and document medication refrigerator temperatures nightly and to take appropriate action based on the findings, as outlined in the refrigerator temperature log instructions, including adjusting the temperature and notifying maintenance as needed.

Based on observations, staff interviews, and review of facility policy titled, Medication Administration Policy, the facility failed to ensure infection prevention and control practices were maintained during medication administration when food was present on one of four medication carts.Findings include:Review of the facility policy titled Medication Administration Policy revised on 01/29/2026, documented under section titled, Medication Cart Cleanliness and Prohibited Items, the policy applies to all licensed nursing staff and is intended to ensure safe and sanitary medication administration practices. Medication carts shall be maintained in a clean, organized, and professional manner at all times. The policy further stated, Medication carts are to be used exclusively for medication storage and medication administration supplies. The presence of food or beverages on or within the medication cart is strictly prohibited. Under the section titled Medication Cart Cleanliness, the policy stated, Medication carts must be clean, uncluttered, and free from visible dirt, spills, or debris, and Any contamination identified during medication administration must be addressed immediately prior to continuing the medication pass. Under the section titled Staff Responsibility and Accountability, the policy stated, Licensed nursing staff are responsible for ensuring medication carts meet cleanliness and compliance standards before, during, and after medication passes.Observation and interview on 01/28/2026 at 3:18 PM of Licensed Practical Nurse (LPN) EE revealed LPN EE was eating popcorn from a red and white bag while leaning over a medication cart during medication administration activities. Upon noticing the surveyor, LPN EE immediately discarded the popcorn bag and apologized. LPN EE was observed picking up individual popcorn pieces that had fallen onto the medication cart and discarding them. During the interview, LPN EE stated her blood sugar had dropped, which was why she was eating, and further stated she knew she was not supposed to eat on the medication cart.Interview on 01/28/2026 at 3:26 PM and 3:38 PM, and on 01/29/2026 at 10:37 AM with the Director of Nursing (DON) revealed that staff were not permitted to eat at nurse stations or over medication carts. The DON stated she was aware of the incident involving a nurse eating on the medication cart, noted that the nurse was apologetic, and acknowledged she should not have been eating on the medication cart. The DON stated she would address the issue with the nurse and provide in-service education related to staff expectations. The DON further stated expectations include that medication carts were wiped down at the start of each shift, supplies were checked for expiration dates, insulin was stored appropriately, hand hygiene was performed between residents, and medication carts remained organized. The DON stated a potential negative outcome of eating at the medication cart included contamination of the medication cart and an increased risk of infection to residents.Interview on 01/29/2026 at 11:58 AM with the [NAME] President of Operations (VPO) revealed that staff were expected not to eat on medication carts due to infection prevention and control concerns. The VPO stated staff were expected to manage personal health needs away from medication carts, as eating on a medication cart created a potential infection control risk.

Based on observations, record review , staff interviews, and review of the facility policies/documents titled, Infection Prevention and Control Program, Infection Prevention and Control Committee, Surveillance Plan, Help Keep Our Residents Safe-Enhanced Barrier Precautions In Nursing Homes, Enhanced Barrier Precautions (EBP) Implementation-Observations Tool, and Wound Care, the facility failed to provide proper surveillance and monitoring for infections and communicable diseases for 71 of 71 residents (R) residing in the facility. In addition, the facility failed to ensure Enhanced Barrier Precautions signs were on residents' doors for 15 of 15 (R) on enhanced barrier precautions. Furthermore, the facility failed to provide wound care following appropriate technique to prevent spread of infection for one of eight sampled (R) (R19), and to ensure staff practiced infection prevention techniques relating to shared equipment use cleaning. These deficient practices had the potential to cause the spread of infection. The sample size was 26. Findings include: Review of the undated facility policy titled Infection Prevention and Control Program documented under the section titled Procedure: 1. It is the policy of this facility's Infection Prevention and Control Program to follow recommendations from the state, CDC recommendation through surveillance, auditing, and monitoring. The Infection Prevention and Control Program includes a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to regulatory requirements and following accepted nation standards. The following guidelines, standards, with policies and procedure will be followed. A. Written standards, policies, and procedures for the Infection Prevention and Control program include, but not limited to: 1. Surveillance: A system of surveillance designed to identify possible communicable diseases or infections before that can spread to another person in the facility. 2. Reporting: When and to whom possible incidents of communicable disease or infections should be reported. Review of the undated facility policy titled, Infection Prevention and Control Committee documented under the section titled Responsibility and Scope of Activities: 1. Surveillance of Infections - Review surveillance data looking for unusual epidemics, clusters of infections, infections due to unusual pathogens or any occurrence of healthcare associated infections; initiate isolation procedures as indicated. 3. Standard and transmission -based precautions to be followed to prevent spread of infections. 4. When and how isolation should be used for a resident; including but not limited to: a. The type and duration of isolation, b. Depending upon the infecting agent or organism involved. Review of the undated facility policy titled Surveillance Plan documented under the section titled Surveillance Process: The facility conducts surveillance daily by reviewing laboratory orders and results, antibiotic orders, admission/discharge/transfer records, and medical records. In addition, infection control designee attends morning update meetings to identify residents with a change in signs and symptoms to identify infections needing isolation as quickly as possible. Cases or persons meeting surveillance criteria for infection are identified using McGeer 2012 surveillance criteria for long-term care and/or National Healthcare Safety Network (NHSN) criteria for long-term care. Data is documented in files and stratified according to short-stay and long-stay residents and by unit as needed. Data is aggregated weekly, monthly, quarterly, and annually and compared on monthly, quarterly, and annual basis. Focus areas for surveillance include but are not limited to multi-drug-resistant organisms; influenza; pneumonia, C. difficile and other gastroenteritis infections; skin, wound, and soft tissue infections; urinary tract infections (with or without catheters). Surveillance goals and objectives are based on the results of the annual infection control risk assessment. Review of the undated facility document titled Enhanced Barrier Precautions (EBP) Implementation Observations Tool documented under 9. *Signs are intended to signal to individuals entering the room the specific actions they should take to protect themselves and the resident. To do this effectively, the sign must contain information about the type of Precautions and the recommended PPE to be worn when caring for the resident. The EBP sign should also include a list of the high-contact resident care activities for which PPE (gown and gloves) should be worn. Generic signs that instruct individuals to speak to the nurse are not adequate to ensure EBP are followed. Signs should not include information about a resident's diagnosis or the reason for the use of EBP (e.g., presence of a resistant germ, wound). Review of the facility policy titled Wound Care revised October 2010 revealed under Preparation: 3. Assemble the equipment (e.g., gowns, gloves, mask, etc., as needed). Revealed under Steps in the Procedure: 1. Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly. 3. Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. 4. Put on exam gloves. Loosen tape and remove dressing. 5. Pull glove off and discard into appropriate receptacle. Wash and dry your hands thoroughly. 6. Put on PPE. 13. Any items belonging to resident for multiple use should be wiped down with alcohol and placed in drawer with direction in next step stating only take disposable supplies that are needed into the room. 1. An observation on 11/12/2024 of the facility's Infection Control Book revealed the facility did not have evidence of infection control surveillance/ monitoring/ tracking for the last six months. An interview conducted on 11/13/2024 at 3:11 pm with the Infection Preventionist (IP) revealed that there had been no infection control tracking for the past six months. The IP explained that she had requested access to the records from the Director of Nursing (DON), but was informed that the DON did not have access to the records from the previous IP. The IP mentioned that she had only been able to track infection control data for the month of October, specifically focusing on residents who had been prescribed antibiotics or had experienced any type of infections. The IP acknowledged her responsibility to maintain infection control records but noted that due to insufficient time and incomplete training, she had been unable to fully carry out the required tracking and reporting duties. The IP further expressed several concerns about how infection control issues were currently being handled. The IP noted a lack of clarity around the reasons for certain tests and highlighted a breakdown in the chain of communication regarding testing, such as urinary tract infections (UTIs). The IP mentioned that when she first joined the facility, there were no existing policies or procedures in place for infection control, and she had to build the system from the ground up. Additionally, she reported that infection control issues, like UTIs, were not addressed in a timely manner. The IP also expressed frustrations with insufficient training for her role, a lack of assistance, and uncertainty about what was required in her position. An interview on 11/14/2024 at 2:41 pm with the Assistant Director of Nursing (ADON) revealed that infection surveillance had not been continuously monitored at the facility. The ADON further explained that the IP had not received full training in infection prevention when she was hired. It was included in her agreement that she would seek training; however, she had been utilized in other roles within the facility. The ADON stated the IP worked on infection control prevention duties on Mondays, Tuesdays, and Wednesdays, while on Thursdays and Fridays she was assigned to pass medications. An interview on 11/14/2024 at 02:46 pm with the DON revealed that the expectation was for the facility to implement proper infection control procedures to prevent the spread or transmission of disease. The DON stated she was aware that infection surveillance was not being conducted and mentioned that if needed, she would contact the sister company for additional support or guidance. When asked about the potential negative outcomes of inadequate infection control, the DON highlighted the risk of infections spreading. An interview conducted on 11/14/2024 with the Administrator revealed his expectations for infection control, which include identifying infection locations, tracking and trending infections throughout the building, notifying the clinical team, and leveraging their expertise to help mitigate infection-related issues. The Administrator emphasized the importance of educating staff on infection control practices, stating that this was an essential responsibility that must be carried out. He mentioned that infection control issues were discussed during their Quality Assurance and Performance Improvement (QAPI) meetings. When asked about the potential negative outcomes of inadequate infection control, the Administrator noted the risk of mass spread of infections, exposing other residents unnecessarily, and infections going untreated. An observation on 11/13/2024 at 3:40 pm revealed no EBP signs on residents' doors were observed on Halls A, B, C, D, E, or F, which were located on the first and second floors. Review on 11/14/2024 of a list provided by Clinical IT OO revealed 17 residents on EBP. An interview conducted on 11/14/2024 at 10:29 am with the IP revealed that EBP was required for residents with multi-drug-resistant organisms (MDROs) and those who had infections that were resistant to antibiotics. The IP stated in these cases, staff must use personal protective equipment (PPE) and that supply carts for infection control should be placed outside residents' rooms but did not elaborate on their current implementation. The IP noted that when she arrived at the facility, there were no EBP signs. The IP confirmed she was aware of the need for signage and had it available in her office, but because of her lack of time, she has not implemented EBP. The IP believed the training she received was insufficient and noted that infection control procedures had not been fully implemented at the facility. Additionally, the IP expressed concern that without proper signage and staff awareness of the need for PPE, there was a risk of infections spreading to both staff and other residents. An interview was conducted on 11/14/2024 at 10:20 am with Licensed Practical Nurse (LPN) JJ revealed having one patient with an indwelling catheter who occasionally experienced UTIs and was treated with antibiotics. LPN JJ stated that there was no signage for EBP on the patient's room (E5B) door. LPN JJ further explained that staff were not given PPE supply carts outside of rooms for patients requiring EBP unless there were concerns about contagions. LPN JJ mentioned that she informed other people about the patient's EBP status, when asked about how other staff or visitors know about the resident being on EBP. LPN JJ acknowledged having received an in-service on infection control about a week ago. An interview conducted on 11/14/2024 at 10:43 am with LPN EE indicated that the type of PPE required depended on whether the patient had a wound, was using a foley catheter, or had an airborne infection. When asked how visitors would know which PPE to use, LPN EE responded that signage was essential, and she confirmed that she hadn't seen any signs when she was hired. LPN EE recognized the importance of signage to prevent exposure to others. An interview conducted on 11/14/2024 at 11:20 am with Certified Nursing Assistant (CNA) KK revealed that she was aware of which residents were on EBP through her knowledge from working at the facility for an extended period. However, CNA KK confirmed that she had not seen any EBP signage recently, though she recalled seeing it during the COVID-19 pandemic. CNA KK stressed that the lack of signage could lead to exposure risks. An interview was conducted on 11/14/2024 at 11:25 am with Dining Server (DS) LL who reported that he delivered food trays to residents but was not so familiar with EBP. DS LL recalled seeing EBP signs during the COVID-19 pandemic but noted that he had not seen them in recent months. DS LL expressed concern about his safety now that he was aware of the importance of EBP signage, adding that he had never received in-service training on infection control. An interview was conducted on 11/14/2024 at 11:32 am with the Restorative Wellness Instructor (RWI) MM who stated that she was familiar with EBP. RWI MM confirmed seeing signage for EBP during COVID-19 but noted that she had not seen any signs recently. RWI MM added that shewas aware of which residents are on EBP through a list she received when conducting restorative therapy but had not seen any signage on residents' doors. An interview was conducted on 11/14/2024 at 11:39 am with the Maintenance Engineer NN, stated he was not familiar with EBP but speculated that it involved isolation procedures and the use of PPE. Maintenance Engineer NN stated that he had seen signs for EBP in the past but had not observed any in recent months. Although he did not personally feel concerned about non-contact infections, he understood the importance of having signs for everyone's safety. An interview was conducted on 11/14/2024 at 11:43 am with the Clinic Information Technology (CIT) OO revealed she was familiar with EBP. CIT OO mentioned that she would typically check the signs on residents' doors to determine the required PPE or would ask a nurse. While CIT OO didn't recall seeing any signs recently, she confirmed that residents with wounds, UTIs, and catheters were supposed to be on EBP, which required signage on their room doors. An interview conducted on 11/14/2024 at 2:41 pm with the ADON revealed that EBP should include signage indicating the proper PPE to use for residents with wounds, lines, drains, or those on antibiotics, as well as for any residents with conditions that were out of the ordinary. However, the ADON mentioned that EBP had not yet been fully implemented at the facility. The ADON recalled that when he arrived in July 2024, he did not see any signs related to EBP and noted that it was not a focal point for him at the time. The ADON further revealed that the IP voiced her concerns regarding their being no EBP signs since day one when she walked through the door. When asked about his concerns regarding infection control, the ADON mentioned that as a nurse, his primary concern included the risk of infections spreading. He noted that with fewer barriers in place and without proper precautions, there were more open pathways for infections to be transmitted and transported. An interview conducted on 11/14/2024 at 2:46 pm with the DON revealed that the negative outcome of not properly following EBP precautions could result in the spread of infection, potentially leading to widespread contamination. An interview conducted on 11/14/2024 at 3:21 pm with the Executive Director revealed that the expectation was that all residents on EBP must have signage displayed on their doors. The Executive Director noted that failing to follow this protocol could result in negative outcomes, including the potential risk of cross-contamination and the infection of other individuals within the facility. 50526 2. R19 was admitted to facility with diagnoses including but not limited to gastrostomy, dysphagia, oropharyngeal phase, unspecified dementia without behavioral disturbance. Diagnosis pressure ulcer stage four added 3/11/2024. Review of R19's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00, which indicates R19 identified to have severe cognitive impairment. Section GG, functional status, revealed R19 was dependent for all care. Section J, pain assessment, revealed R19 receives scheduled pain medication regimen as needed. Review of the care plan for R19 Focus of Care initiated on 11/17/2024 indicated a problem of R19 has a peg tube stoma and a healing stage four pressure ulcer to sacrum. She is at risk for additional alteration of skin integrity and pressure ulcers related to immobility, incontinence, and dementia. Goals included but not limited to sacral ulcer will show signs of healing. Interventions included but not limited to avoid positioning the provide pressure relief re-distribution to surface of bed. Follow up with wound care specialist. Hand splint and ROM with nursing restorative. Monitor and document sacral ulcer characteristics. Review of the Physician's Orders for R19 revealed the following order dated for 10/19/2024: wound care cleanse wound, pat dry, apply calcium alginate and Medihoney (wound and burn gel), to base of wound, house barrier cream to base of wound and cover with border island gauze. Observation on 11/14/2024 at 10:18 am revealed R19 lying down toward their left side with wedge pillow support. Registered Nurse (RN) AA was preparing for wound care. RN AA performed hand hygiene and was assisted by CNA BB. RN AA stated he medicated R19 for pain about an hour ago. No PPE or precaution signs were observed outside of the room. Staff put on exam gloves. RN AA gathered supplies as follows: Medihoney, tongue blade, adhesive, non-sterile gauze pads, Allevyn Life Foam Dressing, dermal cleanser, and calcium alginate dressing, and placed on top of the treatment cart. RN AA rolled the treatment cart into the resident's room and placed it at bedside. RN AA remained in the room for the duration of the procedure. RN AA placed the tube feeding pump on pause and lowered the head of the bed. CNA BB assisted to turn resident over, wedge pillow was removed and was noted to have a tear with exposed foam. Hand hygiene was performed by RN AA and CNA BB. At 10:27 am, RN AA used the tongue blade to get the supply of Medihoney for the wound, then removed the dressing. RN AA stated to CNA BB to pull her diaper down and then he changed gloves, no hand hygiene was performed. R19 was moaning and her hands were shaking, resident was nonverbal. CNA BB stated R19 did this when hurting. RN AA placed spray dermal cleanser, barrier cream, wipes, gauze, Allevyn Life dressing, and another spray bottle label not visible on the resident's bed. RN AA cleaned area with dermal spray cleanser and gauze, placed Medihoney on wound, placed calcium alginate, barrier cream, and removed gloves, no hand hygiene was performed. R19 was still moaning, reassured by CNA BB. RN AA applied Allevyn Life over wound and dated it for today. R19 was positioned, moaning stopped, and she appeared comfortable. Observation on 11/12/2024 at 10:49 am of R19 revealed her lying in bed, turned on her right side and was not responsive to calling her name. A pressure-relieving machine mattress was on the bed. Interview on 11/14/2024 at 10:37 am with the IP, they stated proper procedure for wound care was to prepare what was needed after verifying the order. Then create a clean surface with a barrier in the room, usually the over bed table, and take what was needed in the room and place it on that barrier, no shared items should be taken in the room and the treatment cart remained outside of the room, locked. RN DD also stated hand hygiene must be performed before starting. She verified photo showing wound care items on bed both and stated that shared and single use items should never be placed there. Interview on 11/14/2024 at 10:42 am with RN AA revealed he felt the wound care went well even though the cart was not well stocked. RN AA revealed he normally took the cart in the resident room, and it was cumbersome. He further confirmed this was an isolation room and he should get items and take them in the room, and he would have to wipe the cart, then stated he already wiped the cart. RN AA confirmed any trash that was bloody went in the red bag, otherwise he collected the trash and took it out of the room. RN AA verified that items in the photo (shared and single use items) should not have been placed on the resident's bed. Interview on 11/14/2024 at 2:55 pm with the DON revealed you don't need to wear a gown unless the wound was infected. On 11/14/2024 at 3:19 pm, the ADON agreed that no carts should be taken into the resident's room. If the resident was shaking and moaning, the resident was uncomfortable and you should stop and see what may be wrong. Observation on 11/13/2024 at 8:19 am of medication administration on Hall B, LPN EE was preparing for medication administration for R8 and walked down the hall and obtained a blood pressure machine from the hallway and returned, rolling directly into R8's room. R8's blood pressure was taken over her sweatshirt and then brought back out placing it in the hallway. Interview on 11/13/2024 at 8:30 am with LPN EE revealed awareness that blood pressure cuffs should be cleaned after each use and with wipes, adding she did not do it and generally did this before returning the BP machine to the charging station. Interview on 11/14/2024 at 10:37 am with the IP, they stated no shared equipment should be left uncleaned. Interview on 11/14/2024 at 3:22 pm with the ADON shared expectations that all shared equipment should be wiped down when staff obtain it and then expected they wipe them all down immediately when finished. When taking blood pressure with residents up in a chair, there should be no clothing underneath the blood pressure cuff to ensure you get a correct reading. Without proper technique, you won't know if something was going wrong with the resident.

Based on observations, record review, staff interviews, and review of the facility policy titled, Antibiotic Stewardship Policy, the facility failed to establish and maintain an antibiotic stewardship facility-wide monitoring system (line listing) for residents on antibiotics. The deficient practice had the potential to affect all 71 residents residing in the facility. Findings include: Review of the facility policy titled Antibiotic Stewardship Policy not dated, documented under section titled, Governance of Antimicrobial Stewardship, as part of the Infection Prevention and Control Program (IPCP), the facility has established a committee to oversee antimicrobial stewardship functions. The Infection Preventionist (IP), who is responsible for the overall IPCP, is an integral part of the committee. The Antibiotic Stewardship Committee will meet at least quarterly and review this policy annually and as needed. Under Composition: 1. An Antibiotic Stewardship Committee has been established and is composed of the following personnel: a. Infection Preventionist (IP), b. Director or Assistant Director of Nursing, c. Medical Director, d. Consulting and/or Dispensing Pharmacist, e. Administrator, f. Attending Physician or Nurse Practitioner, g. Nurse, h. CNA (Certified Nursing Assistant). 2. The IP will incorporate antibiotic stewardship into their current activities and will allocate dedicated time (10 hours/week) specifically for antimicrobial stewardship activities. The IP is required to complete the Nursing Home Infection Preventionist Training Course provided by The Centers for Disease and Control (CDC). 3. The Director of Nursing, Medical Director and Administrator for Presbyterian Village are responsible for ensuring that adequate staffing and resources are allocated to support the functions and efforts of the IP and the Antibiotic Stewardship committee. The determinations for adequate staffing and resources will be informed by the facility assessment used to establish and update the IPCP. Under Procedures, A. The Antibiotic Stewardship Committee will: 1. Support and promote antibiotic use protocols which will include: a. Assessment of residents for infection using standardized tools and criteria. The criteria used by this facility are adapted from the revised McGeer Criteria. b. Therapeutic decisions regarding antibiotic prescriptions based on evidence (e.g., guidelines and consensus statements from clinical and academic societies) that is appropriate for the care of long-term care facility residents. c. Specifying a dose, duration, and indication on all antibiotic prescriptions. d. Reassessment of empiric antibodies after 2-3 days for appropriateness and necessary, factoring in results of diagnostic tests, laboratory reports and/or changes in the clinical status of the resident. e. Whenever possible, choose narrow-spectrum antibiotics that are appropriate for the condition being treated. 2. Develop and maintain a system to monitor antibiotic use, which includes: a. Review antibiotics prescribed to residents upon their admission or transfers to the facility and those during the course of evaluation by a prescribing practitioner who is not part of the Facility's staff (e.g., emergency department provider, specialty provider). b. Periodically (quarterly) review a subset of antibiotics. prescriptions for inclusion of dose, duration and indication (or length of therapy, documentation of an antibiotic time-out, appropriateness based on antibiotic use protocols and written documentation of clinical justification for antibiotic use that does not comply with the facility antibiotic use protocols). Periodically review rates of prescriptions for any antibiotics or conditions identified by the committee as being of special interest. c. Annually review antibiotic use data by the facility and/or by individual providers to determine if there is excessive use of specific antimicrobial agents. The assessment will measure antibiotic starts (antibiotic days of therapy, defined daily doses of antibiotics) per 1000 resident days of care (and/or length of therapy). If excessive use or other conditions are identified, the facility will take action to address these problems. d. Provide feedback on the facility's antibiotic use data to the Quality Assessment and Assurance (QAA) Committee. 3. Develop and maintain a system to monitor resistance data, which will: a. At least annually, review surveillance data pertaining to microorganisms related to antibiotic use (e.g., methicillin resistant Staphylococcus aureus, Carbapenemase-Resistant Enterobacteriaceae spp. (CRE) or Clostridium difficile). An observation on 11/12/2024 of the facility's Infection Control Book revealed the facility did not have data of Antibiotic Stewardship line listing. An interview conducted on 11/14/2024 at 2:46 pm with the Infection Preventionist (IP) revealed she does not currently have a list of residents on antibiotics or a line listing. The IP explained that she started her infection prevention training on October 7, 2024, but due to staffing shortages, she had been primarily focused on passing medications. As a result, she was now working part-time as the IP and part-time as a Registered Nurse (RN). The IP noted that she had not yet completed her full training for the IP role, and while the Assistant Director of Nursing (ADON) was supposed to be training her, he had not had the opportunity to do so. As of now, she did not have a list of infections, and she felt that she had not been able to fully perform the duties she was hired for, despite having several meetings to discuss these concerns. An interview conducted on 11/14/2024 at 2:41 pm with the ADON revealed that the IP's role in antibiotic stewardship should involve running reports in the morning and ensuring that McGeer's criteria was being followed. However, he noted that the IP was not trained when she was hired and it was included in her agreement that she would seek training, but she had been assigned to other roles within the facility. The ADON mentioned being aware of clusters related to Urinary Tract Infection's (UTIs), which were discussed during Quality Assurance Performance Improvement (QAPI) meetings, but he observed that no actions were taken as a result. The ADON also mentioned that while he tracked antibiotic use in August and October 2024, the data for October 2024 was not yet complete. An interview conducted on 11/14/2024 at 2:46 pm with the Director of Nursing (DON) revealed she was aware that an antibiotic stewardship line listing was required, and that the antibiotic stewardship had not been adequately monitored. The DON stated her expectations were to ensure that antibiotics were properly tracked, and that the facility was consistently following antibiotic stewardship protocols. The DON emphasized that failing to meet these expectations could lead to the spread of infections, which could significantly impact the health and safety of residents. An interview conducted on 11/14/2024 at 3:21 pm with the Executive Director revealed that his expectations were for the facility to maintain an antibiotic stewardship line listing and to fully implement the antibiotic stewardship program. Furthermore, the Executive Director noted that failure to adhere to these expectations could lead to the overuse of antibiotics, potentially resulting in the development of antibiotic resistance.

Based on observations, record review, staff interview, and review of the facility policy titled, Antibiotic Stewardship Policy, the facility failed to employ a certified Infection Preventionist (IP) and experienced a lapse in infection prevention leadership. The deficient practice had the potential to affect all 71 residents residing in the facility. Findings include: Review of the undated facility policy titled Antibiotic Stewardship Policydocumented under section titled, Governance of Antimicrobial Stewardship, as part of the Infection Prevention and Control Program (IPCP), the facility has established a committee to oversee antimicrobial stewardship functions. The Infection Preventionist (IP), who is responsible for the overall IPCP, is an integral part of the committee. Under Composition revealed in 2. The IP will incorporate antibiotic stewardship into their current activities and will allocate dedicated time (10 hours/week) specifically for antimicrobial stewardship activities. The IP is required to complete the Nursing Home Infection Preventionist Training Course provided by The Centers for Disease and Control (CDC). Review of employee files on [DATE] revealed The Centers for Disease Control and Prevention (CDC) completion for Nursing Home Infection Preventionist Training Course Certificate for the IP revealed a completion date of [DATE], with 19.75 hours awarded. Interview on [DATE] revealed that the IP was hired on [DATE], but did not complete the required Infection Prevention training until [DATE], resulting in 19 days of employment without the proper training. Furthermore, according to the ADON, the former IP's last day was on [DATE]. The facility did not have a fully trained IP until the current IP was hired on [DATE]. However, the current IP did not complete the required Infection Prevention training until [DATE], resulting in a gap of approximately two months without a IP in place, and 19 days of employment without the proper training. An interview conducted on [DATE] at 3:11 pm with the IP revealed she started her IP training on [DATE], when she was hired. The IP acknowledged her responsibility to maintain infection control records, but noted that due to insufficient time and incomplete training, she had been unable to fully carry out the required tracking and reporting duties. The IP further expressed several concerns about how infection control issues were currently being handled. The IP noted a lack of clarity around the reasons for certain tests and highlighted a breakdown in the chain of communication regarding testing, such as Urinary Tract Infections (UTIs). The IP mentioned that when she first joined the facility, there were no existing policies or procedures in place for infection control, and she had to build the system from the ground up. Additionally, she reported that infection control issues, like UTIs, were not addressed in a timely manner. The IP also expressed frustrations with insufficient training for her role, a lack of assistance, and uncertainty about what was required in her position. An interview conducted on [DATE] at 2:41 pm with the Assistant Director of Nursing (ADON) revealed that he was training the IP when she first got hired. When asked if he had an Infection Prevention Certificate from the CDC, he stated he did the training about 5 years ago and didn't know it expired. The ADON further explained that the IP had not received full training in infection prevention when she was hired. It was included in her agreement that she would seek training; however, she had been utilized in other roles within the facility. The ADON stated the IP worked on Infection Control Prevention duties on Mondays, Tuesdays, and Wednesdays, while on Thursdays and Fridays she was assigned to pass medications. An interview conducted on [DATE] at 2:46 pm with the Director of Nursing (DON) revealed she did not have an Infection Control Training Certificate, and she was not aware that the IP needed to complete the training before she was hired. An interview conducted on [DATE] at 3:21 pm with the Executive Director revealed that his expectations were for at least one person in the building to have an active IP certification. The Executive Director noted that the negative outcome of not meeting this expectation would be missing out on crucial expertise to educate and counsel staff, thereby exposing individuals to unnecessary risk.

Based on observations, staff and resident interviews, record review, and review of the facility policy titled, Activities of Daily Living (ADLs) Policy, the facility failed to ensure activities of daily living relating to fingernail care and grooming were provided for five of 18 sampled residents (R) (R33, R42, R28, R55 and R31). The deficient practice had the potential to cause risk for unmet needs and a diminished quality of life. Findings include: Review of the policy titled Activities of Daily Living (ADLs) Policy revised October 2024 revealed under Policy Statement: Residents are provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. Under Policy Interpretation and Implementation: 1. Care will be provided unless clinically inappropriate. 2. Services that will be provided which include grooming, mobility, elimination during dining, and communication. 5. Residents are clinically assessed to determine the amount of assistance needed for tasks and any decline in abilities are noted in Minimum Data Set (MDS). 1. Review of the electronic medical record (EMR) revealed R33 was admitted to the facility with diagnoses including but not limited to major depressive disorder recurrent, severe with psychotic symptom, anxiety unspecified, and muscle weakness generalized. Review of R33's annual MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicates R33 was cognitively intact at time of assessment. Section GG, functional status, revealed R33 required substantial maximum assistance with activities of daily living (ADLs) with one/two or more-person assistance. R33 used a wheelchair for mobility. Review of R33's care plan dated 10/3/2024 indicated a problem of self-care deficits in part related to advanced age, arthritis, muscle weakness, and COPD. Goals included but not limited to needs will be met as evidenced by being clean, well-groomed and appropriately dressed. Interventions included but not limited to bathing/showering with moderate assist with bathing three times a week. Observation and interview on 11/12/2024 at 11:35 am with R33 revealed resident sitting up on the side of the bed, well-groomed with exception of long and dirty fingernails. R33 revealed the staff would cut her nails when they got around to it as weekend staffing was low as they don't come so quickly, not sure how long. Observation made on 11/13/2024 at 3:48 pm revealed R33 resting in bed on their left side. Fingernails remained long and less dirty. Observation on 11/14/2024 at 9:18 am of R33's fingernails revealed they had not been cleaned or trimmed. An interview on 11/4/2024 at 10:30 am with Certified Nursing Assistant (CNA) BB confirmed CNA's do fingernail care when providing baths or showers and in between as needed. CNA BB added she made sure they were clean as a lot of the residents eat with their hands. Interview on 11/14/2024 at 3:10 pm with the Assistant Director of Nursing (ADON), she stated resident nail care was either done by personal means otherwise CNAs should be monitored along with nurses, and toenails were taken care of by a podiatrist. The ADON stated if nails were unkept it was a lack of ADL care. Review of the EMR revealed R42 was admitted to the facility with primary diagnosis of fracture and other multiple trauma. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 13, which indicates R42 was cognitively intact at time of assessment. Section GG, functional status, confirmed R42 needs maximum assistance with ADLs. Observation and interview on 11/12/2024 at 12:10 pm of R42 revealed resident lying in bed with the head of the bed slightly elevated, awake, and watching television. She was dressed and her hair was combed. R42's fingernails on both hands were long and had dark material under them. R42 stated the staff here helped her when she needed it, and her fingernails were long and a bit dirty and they will cut them when they are ready. Observation on 11/13/2024 at 12:45 on revealed R42 sitting in wheelchair in the dining room finishing her lunch with no distress noted. Fingernails remained long and not cleaned. Review of the EMR revealed R28 was admitted to the facility with a primary diagnosis of non-traumatic brain injury. Review of R28's quarterly MDS dated [DATE] revealed a BIMS sccore of 11, indicating moderate cognitive impairment at time of assessment. Section GG, Functional Status, indicates R28 is dependent for lower body dressing and substantial maximum assistance with all other ADLs. Observation and interview on 11/12/2024 at 12:18 pm with R28 revealed an alert individual sitting in a wheelchair in the dining room, well-groomed except for the fingernails, which were long and dirty with dark, brownish-black material underneath them. R28 stated she was fine, but her fingernails needed to be taken care of. Observation on 11/14/2024 at 8:47 am revealed R28 at breakfast in the dining room, she shared no concerns, and her nails remained long. Review of the EMR revealed R55 was admitted to the facility with a primary diagnosis of metabolic encephalopathy. Review of R55's quarterly MDS assessment dated [DATE] revealed a BIMS score of 8, indicating R55 had moderate cognitive impairment at the time of assessment. Section GG, Functional Status, revealed R55 required extensive assistance for activities of daily living (ADLs) with one/two or more-person assistance. Observation and interview on 11/12/2024 with R55 revealed the bed in low position pushed up against wall on the right side, fall mat in place, with R55 lying in bed with the head of the bed elevated with two smaller side rails up. R55's hair was uncombed, and fingernails were long and dirty. R55 was pleasantly confused, had difficulty finding her words. Observation on 11/13/2024 at 4:00 pm revealed R55 up in a reclining geriatric chair in their room with the door closed, yelling out continuously. R55 did quiet when spoken to and made attempts to converse, however speech was very unclear at this time. R55's fingernails remained long and dirty. 50803 2. R31 was admitted to the facility on [DATE] with diagnoses that include but not limited to chronic obstructive pulmonary disease (COPD), muscle weakness, abnormalities of gait and mobility, and osteoarthritis. Review of R31's most recent quarterly MDS dated [DATE] documented that R31 had a BIMS score of 7, indicating R31 had severely impaired cognition. Section GG, Functional Status, documented that R31 requires substantial/maximal assistance with personal hygiene. Review of R31's care plan revised 10/17/2024 documented focus of self-care deficits related to advance age, impaired vision, muscle weakness, osteoarthritis, and COPD. Goals include needs will be met as evidenced by being clean, well groomed, and appropriately dressed. Interventions include but are not limited to extensive assist with toileting and incontinent care upon rising, after meals, at bedtime, and as needed. Observation on 11/12/2024 at 12:44 pm in the dining room revealed R31 eating independently. During this time, a black substance was observed underneath her fingernails. [NAME] hair was observed on her face. Observation on 11/12/2024 at 2:26 pm in the resident's room revealed fingernails to have a black substance underneath. [NAME] hair was observed on her face. Observation on 11/13/2024 at 12:17 pm in the dining room revealed R31 eating with her hands. A black substance was observed underneath her fingernails. [NAME] hair was observed on her face. Observation on 11/14/2024 at 10:26 am near the nurses' station revealed a black substance underneath R31's fingernails and chin hair on her face. Interview on 11/14/2024 at 2:24 pm with Certified Nursing Assistant (CNA) II confirmed R31's nails were dirty underneath and R31's face had noticeable chin hair. She stated that R31 received assistance with ADLs and did not refuse care. CNA II further stated that she cleaned the resident's nails in the morning when getting up, on shower day, during bed baths, when using the bathroom, and sanitized hands before and after meals. She stated that every day the care staff should be looking at facial hair and assisting residents.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Use of Psychotropic Medication, the facility failed to implement a stop date for a PRN (as needed) psychotropic medication for one of five Residents (R) (R53) reviewed for unnecessary medications. The deficient practice had the potential to affect the resident's highest practicable mental, physical, and psychosocial well-being. Findings include: Review of the facility's policy titled Use of Psychotropic Medication revised 7/2024 revealed under Policy: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Under Policy Explanation and Compliance Guidance: . 9. PRN [as needed] orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. 14 days). R53 was admitted to the facility with diagnoses that include but not limited to cognitive communication deficit, Alzheimer's disease, depression, and generalized anxiety disorder. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE] documented that R53 had a Brief Interview for Mental Status (BIMS) score of 99, indicating R53 had severely impaired cognition. Section GG (Functional Status) documented that R53 is dependent on physical assistance with eating, transfers, and personal hygiene. Review of R53's care plan revised 11/7/2024 documented no focus related to antipsychotics. Review of the Physician Orders for R53 dated 6/24/2024 documented lorazepam 0.5 milligrams (mg) every 4 hours as needed for agitation, anxiety, and restlessness, and staff should monitor every shift for aggressive-impulse behavior, fidgeting, agitation, restlessness, and change in sleep patterns. The stop date was defined as indefinite. There was no documented clinical rationale for the duration of the PRN lorazepam. Review of the monthly medication review (MRR) dated 10/10/2023 revealed that the consultant pharmacist sent a note to the attending physician regarding a previous PRN order for lorazepam, reminding the physician that CMS regulations state that a PRN psychotropic medication order should be limited to 14 days unless the attending physician or prescribing practitioner documents their clinical rationale in the medical record and indicates the duration for the PRN order. Review of the Medication Administration Record (MAR) dated 11/2024 revealed R53's most recent dose of PRN lorazepam was administered on 11/7/2024. Observation on 11/13/2024 at 12:34 pm in the dining room, R53 was noted to be sleepily hunched over but eating with assistance. Observation on 11/14/2024 at 10:49 am revealed R53 crying coming out of the shower room near the first-floor nurses' station with the care aides. The care aides rolled her chair near the activity but not facing the activity. R53 was then sitting facing an empty table, hunched over in her chair sleeping. Further observation at 11:33 pm revealed R53 still sitting with no engagement and falling asleep. Interview on 11/14/2024 at 11:14 pm with Certified Nursing Assistant (CNA) PP revealed that R53 was usually seen crying and sleepy. Interview on 11/12/2024 at 2:04 pm with Registered Nurse (RN) AA revealed that R53 was sleeping most of the time and awake for a few hours.

Based on observations, staff interviews, and review of the facility policy titled, Storage of Medications, the facility failed to ensure medications were secured for one of two medication carts on one of two Halls (Hall B). The deficient practice had the potential for residents, visitors, and staff to access medications that may cause illness or injury. The facility census was 71. Findings include: Review of the policy titled Storage of Medications dated 3/1/2024 revealed under Policy Statement: All drugs and biologicals will be stored in a safe secure and orderly manner. Under Policy Interpretation and Implementation: 1. Drugs are stored in locked compartments stored in their packaging as received from pharmacy. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. 9. Unlocked medication carts are not left unattended. Observation on 11/13/2402 at 8:19 am of medication administration on Hall B, Licensed Practical Nurse (LPN) EE was preparing for medication administration for R8 and walked down the hall leaving the medication cart unlocked with her back turned away from the medication cart. LPN EE obtained a blood pressure machine from the medication cart in the hallway and returned rolling the cart directly into R8's room with a cup of pills on top of the cart. While LPN EE was preparing medication, she left multiple medication cards on top of the cart, along with a medicine cup with three capsules in it. Medications left on cart: 1. senna plus 2 tablets 2. amiodarone 200 mg 1 pill 3. vitamin C 1 tablet 4. Caltrate 600 1 pill 5. Eliquis 5 mg 1 pill 6. gabapentin 100 mg 1 pill 7. Jardiance 10 mg 1 pill 8. Macrobid 1 pill 9. metoprolol 50 mg 1 pill 10. Areds2 1 capsule 11. vitamin D 2000 u 1 pill Interview on 11/13/2024 at 8:30 am with LPN EE revealed she was aware that a cup with capsules was left on the medication cart stating they were empty from giving medicine to another resident who had crushed medications and thought that was all right since they were empty capsules. LPN EE confirmed six medication cards and five bottles with over-the-counter medications were left on top of the medication cart stating she doesn't usually do that and thought the surveyor would need them again. LPN EE confirmed this was not appropriate practice and could be harmful to others. Interview on 11/14/2024 at 3:22 pm with the Assistant Director of Nursing (ADON) revealed their expectation was that no medications or empty capsules be left unattended. The ADON added this could lead to someone ingesting something that may cause them harm, even the capsules could have some medication remaining inside and the nurses know not to leave the medication cards unlocked.

Based on observation, record review, interviews and review of facility policies titled Activities and Social Services and Activities Attendance, the facility failed to provide an ongoing program of activities based on resident representative input and/or activity preference assessments for four of 24 sampled residents (R) (R#42, R#40, R#53, R#38) reviewed for the activities. Findings include: 1. During an observation and interview with R#42 on 7/12/22 at 10:15 a.m., she stated that she would like to participate in activities but there are no group activities being offered. She stated that she is extremely frustrated because she has obeyed all the rules, took all four of her COVID shots and boosters. She stated, I am sick and tired of the staff blaming COVID for everything Resident was observed coloring with markers in adult coloring books and had puzzles at her bedside. She stated, All I do is either color or do puzzles and I want to do something else. A review of Electronic Medical Records (EMR) for R#42 revealed the resident was admitted on [DATE]. A review of the most recent comprehensive Minimum Data Set (MDS) Assessment for R#42 dated 6/1/22, the resident presented with a Brief Interview for Mental Status (BIMS) score of 15, meaning the resident is cognitively intact. The assessment further indicated that the resident enjoys contact with others prefers to choose own activities, prefers small group settings and activities in the activity room. Comments included R#42 cannot attend group activities at this time due to COVID restrictions. She does express an interest in attending the morning group activities and goes outside on nice days. 2. During an interview and observation of R#40 on 7/12/22 at 10:00 a.m. R#42 was in her room seated in a wheelchair sorting and organizing her closet. She confirmed what her roommate R#40 had stated and added there is nothing to do, and we can't go out of our room to participate in activities because of COVID. Further revealed back in April they got to do a few activities but then it all stopped again. Continued interview revealed there is nothing to do except puzzles, books, and television. The resident expressed a desire to play bingo and do group exercises. A review of the most recent comprehensive MDS Assessment for R#40 dated 3/17/22, the resident presented with a BIMS score of 15, meaning the resident is cognitively intact. The assessment further indicated that the resident enjoys contact with others, prefers to choose own activities, and prefers small group settings and activities in the activity room. 3. An interview with R#53 on 7/12/22 at 11:48 a.m. regarding the level of activities that are being offered within the facility revealed that there is not much to do. However, he states he does color, work on jigsaw puzzles and sometimes exercises with programs on television when he remembers to tune in. Further stated he would like to have more activities to choose from including group activities with other residents. A review of the Annual MDS assessment, completed on 7/14/22, R#53 had a BIMS score of 15 out of 15 which indicated he is cognitively intact. A review of an assessment noted the resident enjoys contact with others, prefers to choose own activities, and prefers to be with people prefers both small and large group settings. 4. An interview with R#38 on 7/14/22 at 9:10 a.m. regarding the level of activities that are being offered within the facility revealed that, BINGO was finally offered on yesterday and that she really enjoyed it because there have not been many activities offered in a long time. She continues to state that BINGO was a great start because without activities it gets boring around here. Further interview revealed she is bored and wants to be with the other residents and participate in activities other than what she had been doing for months in her room. A review of the most recent comprehensive Minimum Data Set (MDS) Assessment for R#38 dated 5/24/22, the resident presented with a Brief Interview for Mental Status (BIMS) score of 15, meaning the resident is cognitively intact. The assessment further indicated the resident enjoys contact with others prefers to choose own activities, does not refuse to attend activities, prefers small group settings, activities in the activity room, and accepts invitations to most group activities. A review of R #38 care plan dated 3/2/22 revealed Problem: Resident leads a self-directed daily lifestyle of choice, inclusive of choice, inclusive of attending those structure activities of her interest, and engaging in her own chosen pursuits of interest in context with her health status at the time. Goal: Resident will engage in her own self-directed leisure pursuits for 1/3 to 2/3 of the time. Interventions: Invite, remind and escort to activities of this resident's interest. Provide with encouragement for leisure pursuits. Provide with leisure materials of this resident's interest. Provide with monthly activity calendars An interview 7/12/22 at 10:15 a. m. with the Activities Director revealed she is doing one to one activity with residents at this time. Continued interview revealed while in outbreak status she is not allowed to do group activities and she tries to spend quality time with each resident and provide word search, jigsaw puzzles, coloring sheets, books, magazines, snacks, and mail. Further revealed briefly during April some group activities had taken place but were stopped due to the most recent Covid outbreak. Further revealed she encourages the residents to tune in to the Presbyterian Village TV station on Channel 78 for yoga and exercise and provides an enlarged calendar each month for the resident's closet door. Stated the TV calendar was the only planned activities, and they are to watch the TV in their own rooms. Further revealed she tries to do social visits and tries to individualize to each resident's needs. Continued interview revealed she goes by the Administrators direction since he is her supervisor, and she confirmed the facility had no group activities since May. A review of the resident's medical records revealed no documentation of one-on-one visits with the Activities Director or staff. There were no activities recorded of any nature on four of four sampled residents. The Activity Director confirmed she has no documentation of any of the activities she provides the residents. An interview 7/12/22 at 10:35 a. m. with the Administrator revealed the facility follows The Centers for Disease Control and Prevention (CDC)recommendations and while in outbreak status the facility per his direction has not been allowing group activities. Further revealed the residents have been in their rooms except for some dining at individual tables six feet apart and it is his understanding no group activities should be occurring. Continued interview revealed to prevent the spread of COVID-19 residents should not be allowed to gather for activities. During an interview on 7/13/22 at 10:57 a. m., the Director of Nurses (DON) revealed that the facility is using the CDC Guidance that was released February 2022 regarding activities and social gatherings. She stated that she had a discussion last week on Thursday with the Activity Director regarding resuming group activities and told her residents could do activities as long as they were non-symptomatic, up to date with immunizations, wore mask and six feet apart to social distance. Further interview revealed residents are not restricted to their rooms and are allowed to come out while wearing masks and social distancing and some have been dining together in the communal dining areas. During an interview on 7/13/22 at 11:05 a.m., the DON, Activities Director and Administrator confirmed there has been no group activities since April except for a 4th of July parade outside. The Activity Director said she talked to the DON last week about group activities and was told the Activity Director could resume. She stated that she went to ask the Administrator before resuming and he had not gotten back to her. The Activities Director said she has only been doing one-on-one activities because she felt like she should not be doing groups while in outbreak that it would be wrong. The DON revealed she had gone over the CDC guidance with the Activities Director on Thursday of last week (7/14/22) discussing, social distancing of six feet, wearing masks, and non-symptomatic and there was no reason residents could not participate in group activities if those recommendations were followed. The Administrator revealed he was unaware activities were allowed during an outbreak and felt it was safer to avoid group activities. The DON and Administrator both confirmed the facility uses the CDC guidelines to make decisions for the facility. A review of the Centers for Disease Control and Prevention (CDC) document updated 2/2/22 was presented by the DON and she stated this is the guidance the facility uses for Covid recommendations. The DON referred to the section titled Manage Residents with Close Contact which stated in general residents who are up to date with all recommended COVID-19 vaccine doses do not need to be quarantined, restricted to their room unless they develop symptoms of COVID-19, are diagnosed with [CONDITION(S)]-Cov-2 infection, or the facility is directed to do so by public health. During an interview on 7/14/22 at 9:24 a.m., the Social Worker revealed she is aware the residents are bored and requesting to do activities. Continued interview revealed when she was hired three months ago residents were doing small group activities, but activities had shifted to one-on-one in the residents' rooms to minimize spread of COVID. Further interview revealed it has been discussed in the morning meetings and the Activity Director had asked occasionally about resuming gatherings, but the Administrator kept saying to keep activities on hold. Continued interview revealed the facility held a 4th of July parade outside which the residents loved. She revealed when she visits with the resident's, several of them has asked her when the outside room activities will resume because they miss interactions with other residents. During an interview on 7/14/22 at 10:30 a.m., Certified Nursing Assistant (CNA) BB revealed the residents are complaining about not having activities because of COVID and would like to start gathering again because they miss their friends. During an interview on 7/14/22 at 10:05 a.m., Licensed Practical Nurse (LPN) AA revealed the facility has not been allowing group activities and that the residents have been requesting gatherings. Review of the facility policy titled Activities and Social Services, (no date) revealed the Policy Statement: Residents shall have the right to choose the types of activities and social events in which they wish to participate as long as such activities do not interfere with the rights of other residents in the facility. Interpretation and Implementation Choosing Activities/Events Residents are encouraged to choose the types of recreational, cultural, and religious activities and social events in which they prefer to participate. Activity and Social Care Plan stated, when the Care Planning Team develops the resident's activity and social care plans the resident will be given an opportunity to choose when, where, and how he or she will participate in activities and social events. As much as possible the facility will provide activities, social events, and schedules that are compatible with the resident's interests, physical and mental assessment, and overall plan of care. A Review of the facility policy titled Activities Attendance (no date) revealed Policy Statement: The Activity Department records activities attendance and participation of all residents. Attendance Record Expectations: Attendance and participation is recorded for every resident in group and individual activities on a daily basis. Attendance records are filed for minimum of three years. Attendance records are used when completing residents' progress notes to determine their participation as it relates to their activity plan.

Based on observations, staff interviews, and record review the facility failed to ensure one of five sampled residents (Resident (R) #4), with a known exposure to COVID-19, was placed on transmission-based precautions to prevent the potential spread of COVID-19. This failure had the potential to allow spread of infections, including COVID-19, to 13 residents on C hall, out of a total census of 78. Findings include: Upon request for documentation related to resident testing for COVID-19, the facility provided a Log Book. Review of an untitled document in the Log Book, which listed the residents tested for COVID-19 and the test results, indicated R#2 was tested for COVID-19 on 12/8/20, and a positive result was received on 12/10/20. Review of the Nursing Notes located in the Progress Notes tab in the Electronic Medical Record (EMR), documented R#2 was transferred to the COVID-19 positive unit on 12/10/20. Review of the facility Census Sheet, provided by the facility, dated 12/16/20, revealed R#2 had shared a room with R#4 prior to the positive test results. Review of the facility's Log Book indicated R#4 was tested for COVID-19 on 12/8/20 and 12/15/20, both test results were negative. Review of R#4's Nursing Notes and Orders in the EMR, under the Progress Notes tab and the Orders tab, indicated no documentation R#4 was on transmission-based precautions. On 12/17/20 at 9:20 a.m., R#4's room was observed. There was no indication R#4 was on transmission-based precautions. On 12/17/20 at 3:27 p.m., the Administrator and Director of Nursing (DON) were interviewed. The DON was also the facility's Infection Preventionist. The Administrator, who was also a registered nurse, assisted with Infection Preventionist responsibilities. The Administrator stated if a resident tested positive for COVID-19 the Medical Director, responsible party, and admissions were notified so the resident could be placed in the isolation wing. The Administrator stated the roommate of a resident who tested positive would be placed on quarantine and monitored for COVID-19 like symptoms for three days. The DON clarified quarantine meant the resident was to stay in his/her room, it did not include placing the resident on transmission precautions. The Administrator stated R#2 was tested on [DATE] and her positive result was received on 12/10/20. The Administrator stated R#4 was also tested on [DATE] and her negative result was received on 12/10/20. The Administrator stated R#4 remained on quarantine in her room. The Administrator stated staff wore a face shield and mask when working with R#4 but not a gown and gloves. (Note: At the time of survey, the standard of care in the facility was for staff to wear a facemask and face shield at all times in the facility.) During interview on 12/17/20 at 4:06 p.m., Licensed Practical Nurse (LPN) AA stated vital signs were taken every shift and recorded in the EMR. LPN AA stated R#4 had not had any signs or symptoms of COVID-19. LPN AA stated after R#2 tested positive for COVID-19 they sanitized the resident room and monitored R#4 for temperature changes, cough changes, and vital signs every shift. LPN AA stated there were no other precautions in place for R#4. During interview on 12/17/20 at 4:33 p.m., the Administrator stated she spoke with the DON who stated staff probably should have been wearing gowns with R#4. On 12/17/20 at 4:44 p.m., R#4's room was observed. There was now signage outside the door which indicated contact precautions were in place and gloves and gown were to be donned prior to entering the room. During interview on 12/17/20 at 4:48 p.m., the Medical Director stated typically once one roommate tested positive for COVID-19 the other roommate would turn out positive. The Medical Director was unsure if the roommate would also need to be on precautions and stated that precautions (face shield and mask) were used on all residents right now, except wearing a gown. The Medical Director stated it was probably a good idea (to wear a gown) and that they had just been monitoring (the residents). During interview on 12/17/20 at 7:07 p.m., Certified Nursing Assistant (CNA) AA stated R#4 was able to perform most activities of daily living on her own with only standby assistance. CNA AA stated R#4 required physical assistance in the shower to reach her back and legs. CNA AA stated she wore gloves in addition to her face shield and mask when providing direct care to R#4; however, the resident was not on any isolation precautions. The facility's policies did not address procedures for resident's following a known exposure to a roommate who tested positive for COVID-19.

Based on observation, interviews and policy review, the facility failed to discard expired medications in the storage room and one of four medication carts. The sample size was 32. Findings include: During medication storage observation on 2/25/18 at 11:20 a. m., with Registered Nurse (RN) BB, the facility has two medication storage rooms on each floor, four medication carts and one central supply room. Second floor medication room was observed with RN BB, she revealed that one bottle of unopened natural force slow release iron 50 milligrams (mg) tablet with code number 4, expired on 04/17, and one box of [MEDICATION NAME] 2 milligrams (mg), anti-diarrheal tablet lot: number 23 expired on 10/2018. It was found stored with house stock medications not discarded according to their medication storage policy. Observed two medication carts; first floor medication cart on east hall revealed one unopened bottle Vitamin B Complex with Vitamin B-12 tablet with code number , expired on 10/18. It was found in the medication cart together with administering medications not discarded according to facility's medication storage policy. Review of the facility policy titled, Medication Storage Policy, revised 2019, indicate that the facility should ensure that medications and biologicals have an expiration date on the label and have not been retained longer than recommended by the manufacturer or supplier. The policy revealed on number D Nurses will check for expiration dates of medications and medical supplies in the medication room weekly (11-7 Shift) and document checks on a log. All expired medications and supplies will be properly disposed of. Medications should be reordered as needed. E revealed that nurses will be responsible for checking expiration dates of all medications and supplies before removing them from the medication room and storing them on the medication cart. F revealed that nurses are responsible for checking their assigned medication cart daily for expired prescription medications and over the counter (OTC) medications. Expired medications should be properly disposed of. G revealed All Over the Counter (OTC) medications and supplies delivered to each medication room by the Central Supply Director should be checked for expiration dates, before storage in the medication rooms. H reveals The Central Supply Director will check expiration of all Over the Counter (OTC) Medications and supplies stored in the medication rooms twice a month. An interview was conducted on 2/26/19 at 11:48 a.m., with Registered Nurse (RN) BB, stated the policy for opened or unopened medications storage and medication cart was that all nurses should check for expired medications daily and dispose it per facility policy; there is no reason for leaving expired medications since 4/17 and 10/2018 in the medication storage room or medication cart. RN BB, stated that it was a human error. Interviewed Licensed Practical Nurse (LPN) AA, on 2/26/19 at 12:00 p.m., he stated that the facility policy for opened and unopened medications in the medication cart was for the assigned nurse to check daily for expiration dates of medications before the administering them to residents. He verified that he was not aware that the unopened bottle Vitamin B Complex with Vitamin B-12 tablet with code number , expired on 10/18. LPN AA stated he did not check his medication cart that day and he did not know how the medication got in his medication cart. An interview was conducted with RN CC, on 2/26/19 at 12:10 p.m.; stated she could not explain how the expired medications in the medication room and medication cart had remained stored for so long; the only reason she could offer was human error.

Based on staff interview and record review, the facility failed to develop and implement a Comprehensive Care Plan that included specific treatment goals and care interventions for a leg immobilizer for one (1) resident (R#56) . This failure resulted in harm when the resident developed a pressure ulcer under the leg immobilizer. The facility census was 94 residents. Findings include: Record review indicated that R#56 had a fall on 12/9/17 and 12/10/17 which resulted in injury and hospitalization on [DATE]. The resident was readmitted to the facility on [DATE]. The transfer orders indicated the resident was readmitted with a Foley catheter and a left leg immobilizer and a [DIAGNOSES REDACTED]. Review of the facility nursing assessment note upon re-entry from the hospital on [DATE] at 8:05 p.m. reflects the resident was admitted with an immobilizer in place to left leg. No specific interventions or instructions for the use of the left leg immobilizer were ordered upon the resident's admission on 12/13/17, nor was a clarification of the physician's orders. Review of the Care Plan: dated 12/14/17, noted a significant change on 12/21/17 for the immobilizer. The care plan intervention for 12/21/17 documented left leg immobilizer to be worn. The care plan did not include interventions specifically for the risks related the knee immobilizer use. The care plan noted; recent left femoral fracture/no surgical intervention; discomfort/pain related to (r/t ) femoral neck fracture/no surgical intervention; history of multiple falls risk (r/t) lack of safety awareness, memory problems, Dementia, impaired balance, gait disturbance, fracture left femoral fracture and use of [MEDICAL CONDITION] and pain medications; risk for pressure ulcers r/t [DIAGNOSES REDACTED]. Received care plan from the Director of Nursing (DON) who stated the 2/1/18 care plan was the most recent updated version. The care plan did not reflect specific goals and treatments such as who will monitor the skin, whether the immobilizer could be removed, or how often, and who should remove the immobilizer to clean and check the skin. The physician orders [REDACTED].

Based on observation, staff interviews, record review, and review of the Nursing Restorative/Splinting and Skin Assessments policies, the facility failed to ensure that services were provided to prevent the development of pressure ulcers for one (1) resident (R#56). The resident did not have interventions such as how the skin would be monitored during the application of a leg immobilizer which resulted in harm when the resident developed a pressure area under the left leg immobilizer. The facility census was 94 residents. Findings include: Resident #56 fell on [DATE] and 12/10/17 and sustained injury to the left leg. The resident was hosptalized on [DATE], with re-entry to the facility on [DATE]. The readmission [DIAGNOSES REDACTED]. Review of the facility nursing assessment note upon re-entry from the hospital on [DATE] at 8:05 p.m. reflects the resident was admitted with an immobilizer in place to left leg. Although there was a physicians order for the immobilizer the facility failed to get clarification indicating how the skin would be assessed under the immobilizer. Review of the nursing re-admission assessment note of 12/13/17 revealed fading bruises behind the left knee , underneath the immobilizer. Review of subsequent nursing notes and nursing skin assessments revealed no indication the skin under the immobilizer was inspected until 1/30/18 during the physicians visit. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] and the Significant Change assessment dated [DATE] section M skin condition coded the resident at risk for pressure ulcer development, with no pressure ulcers at the time of the assessments. A review of the resident's care plan dated 12/21/17 reflects that the resident was not care planned specifically for the risks associated with the immobilizer and the care plan did not reflect specific goals and treatments such as who will monitor the skin, whether the immobilizer could be removed, or how often, and who should remove the immobilizer to clean and check the skin. Review of nursing notes dated 1/30/18 at 7:00 a.m. the Assistant Director of Nursing (ADON) documented the removal of the left leg immobilizer and finding an open area. A nursing note dated 1/30/18 at 9:55 a.m written by the Treatment Nurse documented an open area (5.0 cm (centimeter) x 1.5 cm x 0.1 cm) wound bed noted with yellow slough, peri-wound pinkish/red color. Swelling around wound noted. Wound cleaned with normal saline, Santyl (enzymatic [MEDICATION NAME] ointment) applied and covered with [MEDICATION NAME] and wrapped with Kerlix. The current physician orders [REDACTED]. On 1/31/18 at 10:10 a.m. R#56 was observed asleep in his bed wearing soft protective boots on his feet and a bulky dressing in place on the left leg. On 1/31/18 at 3:55 p.m. an interview was conducted with the facility's Treatment Nurse. When asked who is responsible for the weekly skin assessments she confirmed that the nursing staff on the units are responsible for weekly skin assessments, mainly the Licensed Practical Nurses (LPNs) who do the weekly skin assessments. She further stated the Certified Nurse Assistants (CNAs) are to report any resident skin changes or issues they notice during resident bathing on a bath ticket, which they give to the unit nurse for further evaluation. When asked where these bath tickets are recorded and kept she stated they are given to the nurses but not kept. When asked if a physician order [REDACTED]. Continued interview with the treatment nurse when asked if she had done a skin assessment on R#56, she stated she had done one yesterday (1/30/18) when the physician removed the immobilizer and left an order to treat a new pressure area caused by the immobilizer. She confirmed that the physician had just ordered the resident's Foley catheter and the immobilizer to be removed. When asked about missing skin assessments; not found in the computer's two electronic systems, she stated we have been having problems with the nurses not doing them, and further stated, I am not surprised you didn't find all of them. On 2/1/18 at 12:45 p.m. during an interview with the ADON, when asked who first noticed the resident had a pressure area, she confirmed that she and the facility's physician noted the pressure wound on the resident's left calf, after the physician removed the immobilizer on 1/30/18. A printed copy of the transfer order from the hospital physician dated 12/13/17 was provided by the Director of Nursing, the transfer order for an immobilizer was not specific regarding use or limitations of the immobilizer. The order included weight bearing as tolerated left knee immobilizer intact the rest of the hand-written note and signature is not clear and unreadable. On 1/31/18 at 2:30 p.m. the surveyor called the physician to discuss their expectations of care necessary with an immobilizer, the physician did not return the call. Review of current medications for R#56 included [MEDICATION NAME] 75 mg daily (medication to prevent blood clots), aspirin 81 mg daily (blood thinner medication), [MEDICATION NAME] (anticoagulant medication) 30 mg via injection daily x 30 days, [MEDICATION NAME]/[MEDICATION NAME] 10/325mg (narcotic pain medication) every 4 hrs. as needed for pain, immobilizer to left leg. Review of the nursing notes from 12/13/17 to 1/30/18 the notes stated only that the immobilizer in place left leg. Further review revealed no evidence of documentation of the immobilizer on; 12/19/17, 12/24/17, 12/27/17, 1/3-1/7/18, 1/9/18, 1/11-1/14/18, 1/16-1/20/18, 1/23-1/29/18. Review of the weekly skin assessments, completed by the nursing staff, for the period 12/14/17 to 1/30/18. Seven (7) of ten (10) skin assessments conducted did not assess the skin condition of the affected left leg. Review of the facility's undated policy titled Nursing Restorative/Splinting reflects that nursing staff will immediately notify therapist if splint no longer appears to fit properly, or splint is causing swelling, reddened areas or other problems. Review of the facility's undated policy titled Skin Assessments reflects that a skin assessment should be completed on admission, weekly or PRN (as needed). This procedure is in addition to the responsibility of each employee to notify the Charge Nurse at any time an area of altered skin is identified. CNAs will assess skin during each shower/bath and notify the Charge Nurse of any findings. The procedure is to inspect the skin thoroughly, document on the resident's skin assessment sheet or nurse's notes. Notify the MD and Resident Representative of any abnormal findings and treatment plan.

Based on observation, staff interviews and documentation review the facility failed to ensure that an infection control policy was in place for guidance to prevent the spread of a Gastrointestinal virus (GI) on four (4) of six (6) units for 23 residents (eight residents on the A Hall, seven residents on the B Hall, seven residents on the C Hall and one resident on the D Hall, as of [DATE]) with symptoms of a GI illness. The Census was 99 and the sample size is 34. A determination was made that the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. Immediate Jeopardy was identified to exist on [DATE] and at the time of exit on [DATE], remains on-going. On [DATE] at 4:32 p.m., the Administrator and Director of Nursing (DON) were informed of an Immediate Jeopardy. The non-compliance related to the Immediate Jeopardy was identified to exist on [DATE], the date the facility had a Gastroenteritis Outbreak beginning on [DATE] with three residents having symptoms of vomiting and diarrhea. The DON and the Administrator were not notified, by staff, of the outbreak until [DATE], by which time included 20 additional residents. Upon entrance to the facility, by the State Survey Agency (SSA), on [DATE] the survey team observed a notice on the door restricting visitors due to a GI Virus. The facility did not implement isolation precautions, or have a policy to address an infectious outbreak, to prevent the spread of infection. The facility did not contact the Public Health Department, or the State Survey Agency (SSA) and did not have a policy in place related to a GI virus outbreak until [DATE]. Findings include: Review of a document produced by the facility titled Recommendations for Controlling an Outbreak of Viral Gastroenteritis in a Long Term Care Facility, supplied by the Health Department on [DATE], recommended the following actions: 1. Immediately call a Board of Health epidemiologist when two or more residents or staff begin experiencing vomiting or diarrhea within a three day period. This might indicate the start of an outbreak. (Georgia Law requires the reporting of all outbreaks to the local health department.) Remain in close contact with the epidemiologist throughout the outbreak. 2. Promptly isolate residents with gastrointestinal symptoms (vomiting, diarrhea, fever and/or abdominal Pain.) Keep residents in their rooms for 72 hours after vomiting or diarrhea cease. 3. Have staff report all fecal and vomiting accidents to their supervisor. Log all such events, including date, time, locations (including room number), people affected and clean up personnel. 4. Restrict visitation and post a sign at the main entrance advising family and friends not to visit. 5. Ensure that resident and staff wash their hands more often than usual. Wash hands with soap and water for at least 20 seconds. Do not rely on alcohol based hand sanitizers during an outbreak as they are not effective against the Norovirus and similar viruses. Food Service Recommendations: Consider closing the dining room and serve meals in resident ' s rooms. Patient Care and Employee Health Recommendations: 1. Ensure staff are using precautions when caring for a patient with an active gastrointestinal illness, including wearing gowns, gloves, and a mask. 2. Minimize movement of staff between affected and unaffected areas. 3. Require that all staff with nausea, vomiting or diarrhea notify their supervisor and remain off duty for at least 72 hours after their symptoms end. If due to staffing shortage, ill members can return before 72 hours after symptoms end, they should be restricted to affected wards and be vigilant about good hygiene. Disinfectant Recommendations: Chlorine bleach solution is the recommended disinfectant. Prepare a fresh dilution of bleach daily. Use an Environmental Protection Agency ' s website for a list of other disinfectants that are effective against Norovirus. Observation, by the survey team, on [DATE] at 10:30 a.m. upon entering the facility revealed posted signs on the front doors informing family members and visitors that the facility is experiencing an outbreak of the Gastrointestinal Virus (GI). As the initial tour of the facility continued, it was observed, by the surveyors, that no resident's room had signs on their doors and there were no observed personal protective equipment (PPE) carts on the hallways or in resident's rooms. Interview on [DATE] at 10:30 a.m. with the Infection Control Nurse revealed the residents on A, B and C units are having complaints of nausea, vomiting and loose stools and these units are upstairs but the downstairs residents on D, E and F units are not affected with this virus. She continued to reveal that there are no signs on the resident's door to their rooms because this is each resident's home and that would be a dignity concern. She stated that the gowns for the staff to use are in the closets on the hallway and gloves are out at all times in each resident's room, on the unit and the nursing station. She revealed she was not aware of this virus until the morning of [DATE] and at this time she had not informed the State Survey Agency nor the Health Department because she was waiting for guidance from the Director of Nursing (DON). Continued interview and review at this same time of the Facility's Infection Control Policy and Procedures with the Infection Control Nurse revealed there was no policy or guidelines for an outbreak or cluster of a GI virus. The Infection Control nurse, revealed that the Physician, ZZ was notified this weekend and has written a protocol to follow which consisted of giving [MEDICATION NAME], Immodium and [MEDICATION NAME] for active symptoms and to keep residents in their rooms until they no longer have active symptoms, such as vomiting and loose stools. She continued to state that the supervisor that was working over the weekend and on Monday ([DATE]), which was a holiday, is part time and she informed the physician and received orders for residents that was affected. She also revealed that staff education on universal precaution and good handwashing have started today for all staff. Interview on [DATE] at 4:00 p.m. with Licensed Practical Nurse (LPN) HH revealed she was the supervisor over the week end and on Monday, [DATE]. LPN HH revealed that she notified the physician of each resident with symptoms and confirmed that she did not inform the Director of Nursing (DON) or the Infection Control Nurse at that time. Continued interview with LPN HH revealed that the Administrator came to the facility on Monday ([DATE]) and that she informed the physicians and received order to restrict visitors and placed signs on the front doors of the facility and the doors to the unit and notified the families. Interview on [DATE] at 4:15 p.m. with the Administrator revealed the Health Department actually contacted her, on [DATE], due to residents at the local Hospital and other surrounding facilities are having the Norovirus and wanted to know if this facility was having symptoms and she informed the Health Department of the cases at the facility. She stated the Health Department was bringing in kits to test three (3) residents for the Norovirus. The Administrator continued to reveal that she has not reported this GI virus to the State because she was not aware that she should of report this incident nor was she aware that the Health Department should be notified. An interview with Certified Nursing Assistant (CNA) PP on [DATE] at 5:00 p.m. revealed that she assist residents as needed and only uses gloves when assisting resident to the toilet. She would only wear a gown if the resident was actively vomiting and that gowns are available in the supply room closet. An interview with the Assistant Director of the Property AA on [DATE] at 11:30 a.m. revealed that all laundry, except resident ' s personal items, are sent to the hospital laundry. Continued interview revealed that all dirty laundry was placed in the dirty laundry room in individual bags and isolation items were placed in melt-away bags. The laundry bags were taken to a downstairs area to be picked up by the hospital. An interview on [DATE] at 8:20 a.m. with Housekeeper LL revealed that she uses a cleaner (Geneon) that is sprayed on all items in each room, bed rails, door knobs, counter tops, over bed trays, bedside table and in the bathroom sink and toilet. Further interview revealed that the facility had been using this cleaner for about a year or longer and stated this is a cleaner and disinfectant. She revealed that if a resident has had been vomiting or had diarrhea then she would wear a gown to clean the room. Interview on [DATE] at 2:46 p.m. with the DON and the Infection Control Nurse revealed they received five (5) kits from the Health Department to test five (5) residents for the Norovirus but at this time no sample had been collected due to the use of the Immodium for residents. They also stated, at this same time, that they received recommendations from the Health Department for the facility to follow in order to prevent further spread of this virus. They stated the first outbreak was on Friday ([DATE] on the 3:00 p.m. to 11:00 p.m. shift) and there were no breakouts on Saturday or Sunday but Monday was a great increase. The Infection Control Nurse stated she had verified all the information on the residents with symptoms in order to report to the Health Department. Further interview revealed that the Administrator notified the families on Monday ([DATE]) of the virus and the signs were put up for all visitors and family. A telephone interview on [DATE] at 3:45 p.m. with Physician YY revealed that he was notified of the residents on his caseload, with symptoms of nausea /vomiting and loose stools. He stated this started on Friday ([DATE]) and had a great increase in residents with these symptoms by Monday ([DATE]) which was a concern and he wrote a protocol for the nurses to follow. Physician YY revealed that the protocol was to keep the residents with active symptoms in their room which is a big challenge due to some of the resident's decreased cognitive level, and to not have visitors if possible to prevent spread of the virus. He further stated that some residents were sent to the hospital due to being fragile and the need for closer monitoring. A telephone interview on [DATE] at 3:55 p.m. with Physician ZZ revealed that he was notified of the residents on his case load over the weekend and revealed he gave orders to keep resident with active symptoms in their rooms and in bed until they are better and it is ok for the residents to leave their room if they are symptom free. Continued interview with Physician ZZ revealed that he did not think things were that bad at the time to report this to the State. Review of the Protocol that Physician YY labeled as Standing Orders for Viral GI Symptoms per Physician YY, which was not dated, but included the following: Clear Liquids to advance as tolerated, contact precaution, monitor temperature, keep isolated in room for 24 hours, Immodium 4 milligrams (mg) two every four hours prn (as needed) for diarrhea, [MEDICATION NAME] (for nausea) 4 mgs, one every eight hours prn, If Immodium does not help, [MEDICATION NAME] 625 mg tablet every four hours prn for diarrhea, if [MEDICATION NAME] does not help, [MEDICATION NAME] 12.5 mg by mouth (p.o.) or 25 mg rectal suppository every six hours. Notify MD Physician if no resolution in 48 hours. An interview with the Administrator on [DATE] at 4:15 p.m. revealed that the Health Department had contacted the facility, on [DATE], and inquired if they had residents sick with the illness and further revealed that she was not aware that she was to contact the Health Department for an outbreak of illness. She also stated that R #11 had dementia, and that in order to confine her to her room they would have to restrain her. She stated other residents had refused to remain in their rooms after their symptoms had subsided. She revealed that the Health Department sent documents to the facility, including the document titled Recommendations for Controlling an Outbreak of Viral Gastroenteritis in a Long Term Care Facility. Additionally, the Administrator supplied a line listing (required by the Health Department) dated through [DATE] which revealed that four residents had an onset of symptoms on [DATE], including R#118 and R#56, five residents had an onset on [DATE], including R#107, R#109, and R#108, eight residents had an onset date of [DATE], including R#8, three residents had an onset date of [DATE], including R-FN (#37), and two resident with an onset date of [DATE]. Interview on [DATE] at 4:10 p.m. with the Administrator revealed she was not sure what time the Health Department contacted her on Wednesday ([DATE]) but the Health Department informed her that there was a GI problem going around and was contacting the facility to see if there were any concerns going on. The Administrator revealed the Health Department stated they would be sending kits to check residents for the Norovirus and recommendations to follow along with colored signs to post on the units. 1. Observation and interview with Resident (R) #108 on [DATE] at 5:20 p.m. revealed the resident in her room lying in bed. R#108 was alert and stated she felt a little better and just wanted to rest at this time. An interview with the DON at this same time revealed R#108 had returned from the hospital today and revealed the resident was transferred to the hospital due to having loose stools and vomiting. The DON revealed that the resident ' s daughter was notified of the resident ' s symptoms and wanted her mom transferred to the emergency room because she did not want her to get dehydrated. The Physician was notified and resident was transferred to the hospital for further monitoring. Record review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident is cognitively intact. Review of R#108 Nurses Progress notes dated [DATE] revealed resident complained of a stomach ache and nausea and when staff entered the resident's room, she was observed in the bathroom on the toilet leaning over complaining of feeling sick and started to vomit and every time resident started to talk she would vomit and also had watery loose stools. The Physician and responsible party were notified. The resident's daughter wanted her mom to be sent to the hospital for evaluation due to the vomiting and having loose stools because she did not want her mother to become dehydrated. Resident was admitted to the hospital on [DATE] and returned to the facility of [DATE]. Post survey Quality Assurance Review: Review of the facility records revealed that R#108 was [AGE] years old with multiple [DIAGNOSES REDACTED]. Review of the facility line listing dated [DATE] revealed the resident had onset of GI symptoms on [DATE] ending on [DATE]. Review of the facility interdisciplinary notes dated [DATE] at 2018 (military time) revealed the resident was complaining of stomach ache, nausea, vomiting and diarrhea and the resident ' s temperature was 99.9. The family was contacted and ask that the resident be sent to the hospital for evaluation out of concern the resident may become dehydrated. The physician was notified and the resident was transported to the hospital. Review of the hospital records revealed the resident was admitted for vomiting, diarrhea and a compression fracture of the lumbar spine at L1. The resident was re-admitted to the facility on [DATE] with a discharge [DIAGNOSES REDACTED]. 2. An interview was conducted with Licensed Practical Nurse (LPN) HH on [DATE] at 5:02 p.m. revealed that she had cared for Resident (R) #107 while the resident had active symptoms and used universal precautions and gloves. Further interviewed revealed that she did not use a gown when caring for the resident per the Health Department Recommendations for Controlling and Outbreak of Viral Gastroenteritis in a Long Term Facility , Patient Care and Employee Health Recommendations. 3. An interview with Certified Nursing Assistant II on [DATE] at 5:48 p.m. revealed that R#11 had diarrhea today and that she used gloves when providing incontinent care for the resident, and washes her hands, but did not wear a gown or mask. Review of the Interdisciplinary Note dated [DATE] at 3:19 p.m. by LPN KK revealed that R#11 had no nausea, vomiting or diarrhea, and came out of her room to the nurse's station at approximately 2:00 p.m. on [DATE] before the Health Department recommendation of 72 hours symptom free. Observations, by the surveyor, on [DATE] at 10:42 a.m. and 3:30 p.m. revealed R#11 was in the common area close to the nursing station and sitting with several residents before the Health Department recommendations of 72 hours symptom free. 4. Interview on [DATE] at 5:00 p.m. with R#17 revealed she started feeling sick today and was waiting for staff to come in her room because she was feeling nauseated but had not vomited at this time. Stated she has not seen any staff in a gown but they do have the gloves on. Review of R#17 MDS assessment dated [DATE] revealed a BIMS score of 10 indicating the resident is cognitively intact. Observation, by the surveyor, on [DATE] at 5:00 p.m. revealed Certified Nursing Assistant (CNA) PP taking a bath basin in resident's room and sitting it by the resident's bed. CNA PP had on gloves but not a gown. Per the Health Department Recommendations for Controlling and Outbreak of Viral Gastroenteritis in a Long Term Care Facility staff should wear gowns, mask and gloves when caring for residents with an active GI illness. An interview on [DATE] at 5:00 p.m. with CNA PP revealed she was educated to use the gown if a resident was actively vomiting. CNA PP revealed that she knew to wear gloves and that the gowns were in the storage rooms on the units (in the store room closet). She further revealed that she attended an in-serviced on Tuesday, [DATE], on Universal Precaution due to the resident's symptoms. Review of the facility line listing of residents with symptoms of the GI illness includes R#17 beginning on [DATE]. A telephone interview with the Public Health surveillance employee AAA on [DATE] at 4:06 p.m. confirmed that R#17 tested positive for the Norovirus. 5. Observation and interview, by the surveyor, on [DATE] at 5:00 p.m. revealed the R#35 lying in bed. The resident stated that she too (in the same room as R#17) was not feeling well today. Review of R#35 ' s Annual MDS dated [DATE] revealed a BIMS score of 11 indicating the resident is cognitively intact. 6. Review of an Interdisciplinary Note by LPN FF dated [DATE] at 3:16 p.m. revealed documentation that R#8 was alert and oriented, unable to stop diarrhea. Immodium was given twice with no result and the resident ' s colostomy bag was emptied five times with watery stool. Physician YY was notified and the R#8 was sent to the Emergency Department on [DATE]. The resident remained hospitalized as of [DATE]. 7. A review of an Interdisciplinary Note by LPN QQ dated [DATE] at 5:33 p.m. documents revealed that R#56 complained of a severe headache and stated she had vomited several times. R#56 had a temperature of 102.3 at this time. The resident requested to be sent to the local hospital and the Physician was notified and ordered the resident to be sent to the hospital for evaluation and treatment. Review of the facility records revealed that R#56 was [AGE] years old with multiple [DIAGNOSES REDACTED]. Review of the facility line listing dated [DATE] that the resident had GI symptoms beginning on [DATE]. Review of the facility interdisciplinary notes dated [DATE] at 1733 (military time) revealed the resident was complaining of a headache, vomiting several times today with a temperature of 102.3. The resident was transferred to the hospital on [DATE]. Review of the hospital admission notes revealed the resident was diagnosed with [REDACTED]. Diarrhea, rule out recurrent[DIAGNOSES REDACTED] colitis. The resident was re-admitted to the facility on [DATE]. Review of the facility interdisciplinary notes dated [DATE] at 1112 (military time) revealed the resident was not feeling good, complaining of feeling weak and having nausea. The resident was readmitted to the hospital on [DATE]. 8. Observation, by the surveyor, on [DATE] at 5:10 p.m. of R#51 revealed that the resident was sitting in the dayroom watching television which was before the Health Departments recommendation to keep resident ' s in their rooms for 72 hours after free of symptoms. Review of the facility line listing dated [DATE] revealed that R#51 began GI symptoms on [DATE] which ended on [DATE]. 9. Observation and interview, by the surveyor, on [DATE] at 5:25 p.m. revealed that R#113 is sitting in a chair in her room and stated that she was feeling a little better. She reveals that staff only use gloves when assisting her with care. Review of the facility line listing dated [DATE] revealed that R#113 began symptoms on [DATE] with no further symptoms by [DATE]. Review of the R#113 Minimum Data Set (MDS) Annual assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 and a five day assessment dated [DATE] with a BIMS score of 10 indicating cognitively intact to answer questions. A telephone interview during, Quality Assurance Review, on [DATE] at 1:31 p.m. with the Administrator revealed that the facility has had two deaths since the team exited on [DATE]. Requested the hospital records and facility records for the following residents who were hospitalized and the residents who expired in the facility including, R#8, R#56, R#109, R#37, R#108 and R#118. 10. Record review for R#118 revealed the resident was [AGE] years old with multiple [DIAGNOSES REDACTED]. Record review of the facility interdisciplinary notes revealed that R#118 began having vomiting on [DATE] at 2225 and then began having frequent loose stools, weakness and abdominal pain on [DATE] and was transferred to the hospital on the same day at 10:30 p.m. Review of the hospital admitting records reveal the resident was admitted for nausea, vomiting, diarrhea, hypotension, dehydration and [DIAGNOSES REDACTED]. Further review of the hospital records reveal that the family has decided they do not wish to have a feeding tube inserted, would like the resident started on hospice care and to be transferred back to facility were his wife is also a resident. The resident was re-admitted to the facility on [DATE] on hospice care and the resident expired on [DATE] at 11:25 a.m. 11. Record review for R#37 revealed the resident was [AGE] years old with multiple [DIAGNOSES REDACTED]. Review of the facility line listing dated [DATE] revealed that R#37 had an onset of loose stool on [DATE] ending on [DATE]. Review of the facility interdisciplinary notes revealed and entry dated [DATE] at 1258 the resident was very weak, lethargic, refusing to eat, coughing and congested. The Physician and the family were notified. An interdisciplinary note dated [DATE] at 0200 (military time) revealed the resident was hypotensive with a temperature of 101.1, with rapid respirations and Oxygen Saturation of 84%. The resident was placed on 4 liters of oxygen which increased the Oxygen Saturation to 94%. A note dated [DATE] at 0430 the resident was absent of vital signs and had expired. The Physician and family were notified. Observation on [DATE] at 5:27 p.m., by the surveyor, revealed the R#37 was in bed and confused. The resident was unable to answer questions from the surveyor at this time. 12. Review of the facility records revealed that R#109 was a [AGE] years old with multiple [DIAGNOSES REDACTED]. Review of the facility line listing dated [DATE] revealed that R#109 began having GI symptoms on [DATE] which ended on [DATE]. Review of the facility interdisciplinary notes dated [DATE] at 0110 (military time) revealed the resident was given medication for nausea but threw the medication back up and continued to have vomiting without diarrhea. The family was notified and asked that the resident be sent to the emergency room . R#109 ' s husband (R#118), and roommate had been sent to the hospital on [DATE]. Review of the hospital History and Physical dated [DATE] revealed the resident had a sudden onset of nausea and vomiting since yesterday, no diarrhea, no abdominal pain or fever. The resident ' s spouse is currently hospitalized since yesterday for nausea, vomiting and diarrhea. The resident was admitted to the hospital for Intractable Vomiting and plan for gentle hydration . The resident was re-admitted to the facility on [DATE]. 13. Review of the facility records revealed that R#8 is a [AGE] year old with multiple [DIAGNOSES REDACTED]. Review of the facility line listing dated [DATE] that R#8 began GI symptoms on [DATE] and was transferred to the hospital and remains in the hospital. Review of the facility interdisciplinary notes dated [DATE] at 1206 revealed the resident continues to have loose stools, the Physician and family were notified and antidiarrheal medication was given. The facility interdisciplinary notes dated [DATE] at 1516 revealed the resident is alert and oriented, unable to stop the diarrhea. Physician and family notified with a new order to send to hospital for evaluation. Review of the hospital History and Physical dated [DATE] at 3:39 p.m. revealed the resident had profuse watery diarrhea and has a colostomy. The family reports that several of the residents at the facility had profuse diarrhea. The resident ' s White Blood County is elevated at 12.9 (3XXX,[DATE].5). An assessment plan [DATE] at 9:27 p.m. revealed the resident was admitted to the hospital for Systemic Inflammatory Response Syndrome (SIRS) with probable infectious diarrhea. R#8 remains hospitalized as of [DATE]. A telephone interview with Public Health surveillance employee AAA on [DATE] at 9:20 a.m. revealed that the facility was to send a line listing of residents with symptoms to them daily and they have not received a list since [DATE]. Further interview revealed that the facility had been using a cleaner/disinfectant (Geneon) which is not on the Environmental Protection Agency (EPA) as an effective disinfectant for the Norovirus. She further explained that the facility was contacted on Wednesday, [DATE] after being alerted by the hospital of a potential outbreak of a GI virus at which time the facility confirmed they had an outbreak. The facility was then supplied with written recommendations (which are listed below) and that resident ' s with symptoms should be isolated for 72 hours after symptoms have ceased. She further revealed that the facility was supplied with five fecal test kits for the Norovirus at no charge. She revealed that once Public Health was notified of an outbreak and that Environmental Health is notified and they conduct a site visit of the facility kitchen, which had been completed. Public Health recommends to close the dining room during an outbreak to protect residents from exposure. A telephone interview on [DATE] at 1:31 p.m. with the Administrator revealed that she had attempted to contact the SSA Regional Director of the two deaths in the facility but did not have the correct number. She revealed that the facility did have two deaths since the SSA survey team exited on [DATE] (R#118 who was hospitalized with GI symptoms and R#37 who had only one episode of diarrhea). At this time additional records were requested from the facility and were received on [DATE] with two additional records received on [DATE]. The Administrator confirmed that the facility was now using the recommended bleach solution for disinfecting but additionally uses the Geneon mist (which is not on the EPA ' s list of disinfectants that are effective against the Norovirus) after the bleach solution is used. The Administrator confirmed at this time that they have never had an infectious outbreak and did not know who to contact. The Administrator further revealed that they have not closed their dining room to date as she did not feel this was a mandatory recommendation although she was aware, after receiving the Public Health recommendations on [DATE], that this is recommended. The facility is currently working on their Allegation of Compliance for the ongoing IJ situation. A telephone interview with the Public Health surveillance employee AAA on [DATE] at 4:06 p.m. revealed that there was a second facility outbreak in the area and has received the test results for both facilities. She reports that three fecal samples (R#17, R#61 and R#115) were collected from this facility and that all three were positive for the Norovirus. Only R#17 was listed on the facility line listing dated [DATE]. She reports that all five samples from the second facility were positive for the Norovirus including a Licensed Nurse BBB at the second facility, who also works, on an as needed basis, at this facility.

Based on observation, staff and resident interviews and record reviews the facility failed to ensure that an infection control policy was in place for guidance to prevent the spread of a [MEDICAL CONDITION] (GI) on four (4) of six (6) units for 23 residents (eight residents on the A Hall, seven residents on the B Hall, seven residents on the C Hall and one resident on the D Hall, as of 1/18/17) with symptoms of a GI illness. The facility census was 99 and the sample size is 34. A determination was made that the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. Immediate Jeopardy was identified to exist on 1/13/2017 and at the time of exit on 1/20/2017, remains on-going. On 1/18/17 at 4:32 p.m., the Administrator and Director of Nursing (DON) were informed of an Immediate Jeopardy. The non-compliance related to the Immediate Jeopardy was identified to exist on 1/13/2017, the date the facility had a Gastroenteritis Outbreak beginning on 1/13/2017 with three residents having symptoms of vomiting and diarrhea. The DON and the Administrator were not notified of the outbreak until 1/16/2017, which by then included 20 additional residents. Upon entrance to the facility, by the State Survey Agency (SSA), on 1/17/2017 the survey team observed a notice on the door restricting visitors due to a [MEDICAL CONDITION]. The facility did not implement isolation precautions, or have a policy to address an infectious outbreak, to prevent the spread of infection. The facility did not contact the Public Health Department, or the State Survey Agency (SSA) and did not have a policy in place related to a [MEDICAL CONDITION] outbreak until 1/19/2017. Findings include: During an interview with Administrator on 1/17/17 at 11:30 a.m., she communicated the facility had not notified the health department or the State Survey Agency (SAA) because she was not aware that this was requirement. An interview with the Administrator, Director of Nurses (DON), and the Infection Control Nurse on January 18, 2017at 2:05 p.m., they revealed that the facility was not aware that this type of infections needed to be reported to the SAA or the local Public Health Department. The interview further revealed that the Public Health Department had contacted the facility on 1/18/17, to inquire if the facility was experiencing any type of [MEDICAL CONDITION] outbreak. The Public Health Department further stated several facilities were having a large number of reported [MEDICAL CONDITION] outbreaks. Continued interview revealed that the Public Health Department had e-mail information to the facility, on 1/18/17, with recommendations on how to handle this type of outbreak. The Administrator further revealed that the facility had never experienced an infectious outbreak and were not aware of the reporting requirements and that she had dropped the ball . She confirmed the facility did not have a policy, at the time of the outbreak, to address an infectious outbreak.

Based on record reviews and staff interviews, the facility failed to ensure monthly drug regimen reviews were being done by a pharmacist for twenty-six (26) of twenty-six (26) sampled residents. The facility's census was ninety-five (95) residents. Findings include: Record reviews for twenty-six (26) sampled revealed that monthly Drug Regimen reviews had not been conducted by a consultant pharmacist since February 2014. During interview with the Administrator on 5/6/15 at 4:00 p.m., she revealed that the facility did not have a contract agreement for any pharmacy consultant to conduct resident drug regimen reviews from April 12, 2014 until May 01, 2015. She further indicated that it had been very difficult to obtain an appropriate pharmacy consultant contract agreement. However, she acknowledged that it is the facility's policy to maintain resident drug regimen review monthly by a pharmacy consultant. She indicated that for 13 months no resident in the facility was receiving drug regimen reviews. Interview conducted 5/7/15 at 3:07 p.m. with the pharmacy consultants "AA" and "BB" revealed that they had started drug regimen reviews for residents on 5/5/15. "AA" and "BB" revealed that they have completed reviews for all 95 residents in the facility. "AA" and "BB" revealed no gradual dose reductions for psychotropic medications were due; and no adverse reactions, irregularities, or negative outcomes were found.

Based on observation and staff interviews, the facility failed to ensure that garbage and refuse was properly disposed and contained to prevent leaks for one (1) of two (2) dumpsters. Findings include: An observation conducted on 5/4/15 at 10:05 AM with the Director of Dining Services revealed two (2) garbage dumpsters located alongside the loading dock. One (1) containing garbage and one (1) containing card board. There was approximately a two foot gap between the dumpsters and the concrete wall in which the ground was heavily covered with trash, rotting food, plastic bags, paper products and a black thick sludge type substance lining the entire length of the two dumpsters. Further observation revealed the dumpster containing garbage did not have a plug on the drain. An interview conducted on 5/4/15 at 10:08 AM with the Director of Dining Services revealed the engineering department is responsible for cleaning the dumpster area. She acknowledged the area is very dirty and that there is no plug on the dumpster containing garbage. Interview conducted on 5/4/15 at 10:19 AM with the Director of Property Management revealed the Property Management Department is responsible for keeping the dumpster area clean and acknowledged the area is very dirty and that there is no plug on the dumpster containing garbage.