Every finding on record at Pruitthealth - Monroe

Based on observations, staff interviews, and review of the facility policy titled, Pot/Pan Washing and Sanitation and review of the Sanitizing Solution Product Specification document, the facility failed to ensure dishware was air dried before usage to prevent the potential for cross contamination and bacteria contamination. The deficient practice had the potential to affect 62 of 63 residents receiving an oral diet. Findings include: Review of the facility policy titled Pot/Pan Washing and Sanitation revealed Air dry pots and pans on the drain board. Never use a dish towel. Review of the [name of company/product] Sanitizer Product Specification Document revealed Allow equipment to drain thoroughly and air dry. Observation on 5/4/2024 at 10:45 am of Dietary Cook CC taking the food processor bowl, lid, and blade out of the sanitizing solution from the three-compartment sink revealed she placed them on the drying rack for 10 seconds. Dietary cook CC was observed drying the food processor lid and the food processor bowl with a white paper towel. Dietary Cook CC did not allow the dishware to completely air dry. Further observation of the three-compartment sink revealed that the facility was using a quaternary (potent disinfectant solution) sanitizing solution. Interview on 5/4/2024 at 10:45 am, dietary cook CC revealed that the Health Department told them that they could use paper towel to dry dishware if needed after the items have been in the sanitizing solution. Dietary Cook CC revealed that the Dietary Manager (DM) would like dietary staff to air dry dishware when washed in the three-compartment sink. Interview on 5/4/2024 at 10:45 am, the DM revealed that she prefers dietary staff to air dry dishware after washing in the three-compartment sink. The DM revealed that the Health Department told her that they could wipe dry wet dishware with paper towels. The DM confirmed that the facility was using a quaternary sanitizing solution for washing dishware in the three-compartment sink and the DM confirmed that the manufacturer's recommendation for using quaternary sanitizing solution was to air dry.

Based on observations and staff interview, the facility failed to properly maintain the walk-in freezer to prevent ice build-up on food storage shelves and food products. The deficient practice had the potential to affect 62 of 63 residents receiving an oral diet. Findings include: Observation on 5/3/2024 at 8:30am of the walk-in freezer revealed ice build-up on the food storage shelf under the air condenser. The food storage shelf had six mounds of ice, the mounds were two inches in height and two inches in diameter. Continued observation revealed ice build-up on the top of food item inside a clear, plastic, resealable bag. The ice build-up on the plastic bag had a mound of ice on the left side that was about three inches in height and two inches in diameter. Further observation revealed ice build-up on top of a food item that was inside a box. The food item had a small ice mound on top that was about one inch in height and half inch in diameter. Observation on 5/5/2024 at 9:00 am of the walk-in freezer revealed that the previous ice build-up on the food storage shelf and on the food products remained. Continued observation revealed an open box of hushpuppies with a thin layer of ice covering the top lid and ice noted near the open area to the inside of the box. Interview on 5/5/2024 at 9:00 am, the Dietary Manager (DM) confirmed that there was ice build-up on the food storage shelf under the air condenser. The DM confirmed that there was ice build-up on the food item in the clear, plastic, resealable bag, on top of the food item inside the box of food, and ice build-up on top of the open box of hushpuppies. The DM revealed that she had not noticed the ice build-up, this was the first time she noticed the ice.

Based on record review, staff interview, and review of facility policy titled, MDS Assessment Accuracy, the facility failed to accurately code an annual Minimum Data Set (MDS) assessment for Pre-Admission Screening and Resident Review (PASRR) Level II for one of 26 sampled residents (R) (R2) from a sample of 26 residents. The deficient practice had the potential to affect the accurate assessment of R2's care needs. Findings include: Review of the facility policy titled MDS Assessment Accuracy revealed it is the policy of this healthcare center that each Minimum Data Set (MDS) reflect the acuity and the medical status of each patient/resident in accordance with acceptable professional standards and practices. The assessment will be scheduled to accurately account for the acuity and complexity of the patient/resident. Each Assessment Reference Date (AFD) will be chosen to capture services rendered and reflect an accurate clinical profile of each patient/resident. Review of the electronic medical record (EMR) revealed a document from the Georgia Collaborative ASO (Administrative Services Organization) dated February 26, 2018, that a PASRR Level II assessment had been completed for R2. Review of a document provided by the facility titled, PASRR Level II, listed all residents in the facility that have had a PASRR Level II assessment. R2's name was listed. Review of R2's annual MDS assessment dated [DATE] revealed in section A-Identification Information that a PASRR Level II assessment had been completed but was not marked indicating that the assessment had been completed. Interview on 5/4/2024 at 1:45pm with the Senior Nurse Consultant DD revealed the facility's current MDS Coordinator is on a leave of absence, and they have part-time staff filling in to complete MDS assessments. The Senior Nurse Consultant confirmed that R2 had a PASRR Level II assessment in the EMR and stated that it should have been captured and reflected on the annual MDS assessment. The Senior Nurse Consultant revealed that she was not sure of the process the MDS Coordinator uses to identify residents with a PASRR Level II assessment and how that is coded on the MDS assessment. Interview on 5/4/2024 at 1:52pm with the Social Service Director (SSD) revealed that she provided the MDS Coordinator with a list of residents in the facility that have a PASRR Level II assessment completed. The SSD revealed if the PASRR list was updated, she provided a new document to the MDS Coordinator. The SSD revealed that the PASRR list was used by Social Services and MDS for care planning.

Based on observations, resident and staff interviews, and record review, the facility failed to follow the care plan for three of 26 sampled Residents (R) (R14, R24, and R30). Specifically, the facility failed to create a care plan for nutrition services for R14; failed to follow a physician's order for oxygen (O2) that was care planned for R24; and failed to add refusal of hand splint in the care plan for R30. The deficient practice had the potential for R14, R24, and R30 not to receive needed care services. Findings include: 1.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for R14 documented a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. Review of R14's Physician Orders revealed an order for a regular, no added salt (NAS) diet. Review of R14's care plans revealed no care plan created for nutrition. Review of a Registered Dietician Note/Nutrition assessment dated [DATE] documented etiology: poor appetite intake, with intervention large protein portions, and refer to provide to eval [evaluation] for potential benefit of a trial of an appetite stimulant given weight loss and low body weight, hyper metabolic condition. Interview on 5/5/2024 at 10:31 am with the Director of Health Services (DHS) and the Regional Consultant (RCC), both staff confirmed that there was no care plan for nutrition for R14. The DHS confirmed that the MDS Coordinator was out on leave and not available for interview. The RCC confirmed that a care plan was created for R14 after it was brought to her attention during the survey that R14's care plan was missing a nutrition care plan. She reported contacting her Regional MDS Coordinator to create the nutrition care plan. 2. Review of the annual MDS assessment for R24 dated 2/4/2024 documented a BIMS score of five, indicating severely impaired cognition. Review of R24's Physician Order dated 4/27/2024 revealed an order for oxygen 2 liters (liters per minute-LPM) by nasal cannula (NC) as needed (PRN). Review of R24's care plan dated 5/3/2024 revealed a plan of care for oxygen therapy with an intervention to administer oxygen at 2 liters per minute via nasal cannula as she will allow. Interview on 5/5/2024 at 11:29 am with the Director of Health Services (DHS) confirmed that O2 was set on the wrong liter flow and nursing staff had not followed the order. She reported that the MDS Coordinator was not available for an interview. She stated that her expectation was for staff to follow the physician's order. She confirmed that staff was not following the order and the care plan. 3. Review of the quarterly MDS assessment dated [DATE] for R30 documented a BIMS score of 5, indicating severely impaired cognition. Review of R30's care plan created 4/9/2024 documented a plan of care titled Activities Daily Living (ADLs) Functional Status/Rehabilitation Potential Resident requires splint/brace assistance to Right hand with intervention right hand orthotic 7am [7:00 am] to 7pm [7:00 pm]. Continued review of the care plan revealed no plan of care for refusal to wear hand splint. Interview on 5/5/2024 at 10:02 am with the DHS, the DHS reviewed the care plan with the Surveyor and confirmed that R30 had a care plan for a hand splint and staff was not following the care plan.

Based on observations, record review, resident and staff interviews, and review of the facility's policies titled, Restorative Nursing Program and Restorative Nursing Process, the facility failed to follow an Occupational Therapy (OT) Restorative Nursing Program (RNP) recommendation for orthotic application for two of 26 sampled residents (R) (R1 and R30) reviewed for ROM and mobility. This deficient practice had the potential of resulting in progression of contractures. Findings include: Review of the facility's policy titled Restorative Nursing Program revised 11/4/2021 revealed it is the policy of the healthcare center to provide restorative nursing which actively focuses on achieving and maintaining optimal physical, mental, and psychological functioning and wellbeing of the patient/resident. Documentation: 1. Restorative nursing care will be documented in the electronic health record (EHR) or paper form. 2. The nurse will evaluate patient's progress. Document in patient's care plan. Review of facility's undated policy titled Restorative Nursing Process revealed Restorative Team (any health personnel providing restorative nursing interventions) Documentation: Restorative team will document exact number of minutes provided for each restorative service in the electronic health record. Nursing Evaluation/Progress Notes: 1. License Nurse to complete evaluation of each service monthly in Restorative Nursing Care Plan. 1. Review of R1's EHR revealed that she was admitted to the facility with diagnoses including, but not limited to cerebrovascular disease, generalized muscle weakness, right hand contracture, stiffness of right-hand, left-hand contracture, and stiffness of left hand. Review of R1's annual Minimum Data Set (MDS) assessment dated [DATE] revealed she had functional limitation in range of motion on both sides of the upper and lower extremities and was dependent for activities of daily living (ADL). Review of R1's care plan revealed a problem related to resident having limited ability to use bilateral hands related to contractures. Review of R1's record revealed an Occupational Therapy Progress and Update Plan of Care dated 3/4/2024 which indicated prosthetic/orthotic use new goal resident will allow caregiver assistance to appropriately don (put on) and doff (remove) bilateral hand orthotics and tolerate wear of 1-2 hours in order to maintain skin/joint integrity. The patient does not consistently allow application of orthotic devices. Maximum assistance required to right hand orthotic. Review of R1's Occupational Therapy Progress and Discharge Summary for dates of service 1/16/2024 through 3/26/2024 revealed R1 and caregiver educated on proper splint wear/care/schedule. Resident from skilled therapy services where she would remain a long-term care (LTC) resident of the facility with 24/7 caregiver assistance for all needs. Recommendations for restorative program assistance to be provided following discharge to continue assisting resident in maintaining splint schedule/care/ management. Review of the EHR revealed there was not an order or any documentation in residents electronic record related to contracture management after resident was discharged from skilled therapy services on March 26, 2024. Verified by the Director of Health Services (DHS) and Regional Senior Nurse Consultant on 5/5/2024 at 10:01 a.m. Observation on 5/3/2024 at 8:54 a.m. revealed R1 lying in the bed with both eyes closed. Both of R1's hands were positioned in body alignment, fingers on both hands were clenched closed into a fist. Further observation revealed an orthotic device on R1's dresser. Observations on 5/4/2024 at 9:37 a.m. and 12:29 p.m. revealed R1 out of bed in an adjustable position wheelchair in her room. RR1's right hand was clenched closed, and the left hand was observed partially open during these observations. Observation on 5/4/2024 at 1:54 p.m. revealed resident lying in bed with right hand exposed and clenched closed. There was not anything in her hands for contracture management. The orthotic device remained on the dresser. Observation on 5/5/2024 at 8:39 a.m. revealed R1 lying in bed with both hands clenched closed. The orthotic device remained on the dresser. Interview on 8/5/2025 at 8:54 a.m. with the DHS revealed she was responsible for the Restorative Nursing Program. The DHS acknowledged R1 has had a restorative plan of care since discharge from skilled therapy sometime during the month of March. DHS also stated the Therapy Manager verbally informed her that R1 was being discharged from skilled care and started on the restorative program. She stated typically the Therapy Department was responsible for putting the restorative plan of care in the EHR. The DHS verified the restorative plan of care was not entered into the EHR. The DHS further stated she should have checked to make sure it was done, but she did not do so. The DHS stated there are two restorative aides in the facility, but for the past two months the restorative aides had been working as an assigned group rendering care to residents. She stated the Certified Nursing Assistants (CNAs) assigned to R1 were responsible for applying the splint. The DHS also stated she did not check to make sure splints were applied daily as it should be, she just trusts the CNAs to do it. She stated it should be done every day, but she was sure it was not being done every day. Additionally, the DHS stated she informed the Restorative Aides of R1 needing range of motion (ROM) and splinting. Interview on 5/5/2024 at 9:20 am with CNA/Restorative Nursing (RNA) EE revealed she had not worked directly with the restorative program for about two months. CNA/RNA EE further stated she was assigned to R1 today and on 5/3/2024 and did not apply the splint. She stated she was not aware the documentation was not in the EHR but was aware of the service, because the Therapy Manager informed her verbally. CNA/RNA EE further stated sometimes residents will resist and not allow the splint to be applied, but when she went back later, R1 allowed the splint to be applied and she usually wore it for about two to three hours. Interview on 5/5/2024 at 9:28 am with Licensed Practical Nurse (LPN) FF revealed she had seen R1 wearing the right-hand splint from time to time, but not consistently. She further stated refusals of care should be documented in the electronic record when they occur. LPN FF verified R1 had not had the hand splint on during the three-day survey. Post Survey telephone interview on 5/5/2024 at 12:22 pm with the Therapy Manager revealed that she was aware that R1 was recently discharged from skilled therapy services to the restorative program for passive range of motion (PROM) and splinting to the right hand. She further stated that it was the responsibility of the discharging therapist to write the restorative order and update the care plan at the time of discharge from skilled care. She further stated she does not always check the record to ensure the therapist had followed the process, some she does check but she did not check this one. The Therapy Manager also stated that she verbally informed the DHS and the caregiver of the restorative services needed for R1. 36377 2. Review of R30's EMR revealed the following diagnoses but not limited to dementia and contracture right hand. The Minimum Data Set (MDS) assessed a Brief Interview Mental Status score (BIMS) of 5, indicating severe cognitive impairment. Review of R30's care plan created 4/9/2024 documented a plan of care titled, Activities Daily Living (ADLs) Functional Status/Rehabilitation Potential resident requires splint/brace assistance to right hand with intervention right hand orthotic 7:00 am to 7:00 pm. Continue review of care plan revealed no plan of care for refusal to wear hand splint. Observation and interview on 5/3/2024 at 10:11 am, R30 revealed that staff were not applying her hand splint on a routine basis. Observation revealed R30's hand splint on her bedside nightstand. Observations on 5/3/3024 at 11:30 am and 3:30 pm revealed R30 in bed with no hand splint on. The splint was on the bedside nightstand. Observation on 5/4/2024 at 9:25 pm revealed no hand splint was on R30 and the hand splint was on the bedside nightstand. Review of the CNA Point of Care (POC) charting revealed gaps in staff documenting applying R30's hand splint. Interview on 5/5/2024 at 9:25 am, CNA EE reported being unaware that R30 had a hand splint to be applied daily. She reported that she was only aware of the leg brace. She stated that what she was documenting in the POC was the leg brace. She confirmed receiving in-service on the leg brace only. Interview on 5/5/2024 at 9:37 am, CNA KK confirmed applying the hand splint only one day during the survey, 5/4/2024, and applying the leg brace daily. She reported that she was aware of the hand splint and received in-services. She confirmed that she did not always document a refusal in the POC for R30 refusing to wear her hand splint. CNA KK confirmed receiving restorative training on the leg brace and hand splint. Interview on 5/5/2024 at 9:46 am, CNA GG reported being unaware that R30 had a hand splint. This was the first time that she had seen R30 with the hand splint on. She observed R30 wearing the hand splint yesterday, 5/4/2024, and had removed the hand splint from the resident hand. She confirmed receiving restorative training on the leg brace and range of motion on R30's hand, but not to apply a hand splint. Interview on 5/5/2024 at 9:48 am, LPN AA reported being aware of the hand splint and only documenting on the leg splint. She reported only being aware of what the CNAs had told her in the past, that R30 refused the hand splint. She stated one time she attempted to try to help the resident to understand. She reported that R30 seemed like she understood but at times will refuse. She confirmed not documenting and providing this information to restorative. Interview on 5/5/2024 at 10:02 am with the DHS confirmed being unaware of the missing gaps on CNA POC documentation. She confirmed that her staff was not following the care plan for R30 to wear the hand splint and apply the hand splint daily. She also stated that because the care plan was not triggered to run on the flow sheet for the leg brace to distinguish it from the hand brace, this caused the confusion on the CNA's POC documentation. She confirmed that this confusion was most likely why the CNA was thinking only to document for the leg brace, missing documentation on POC Restorative and ADL Sheets that the CNA's used to communicate and to document for hand brace application.

Based on observations, staff and resident interviews, record review, and review of the facility policy titled, Oxygen Administration, the facility failed to ensure oxygen (O2) was administered in accordance with the physician order for one of 20 residents (R) (R24) receiving oxygen therapy. The deficient practice had the potential for respiratory difficulty for R24. Findings include: Review of facility policy titled Policy titled Oxygen Administration revealed under category Policy Statement It is the policy of [NAME] Health Hospice and Healthcare Centers/Veteran Homes to provide oxygen safely and accurately to appropriate patients /residents. Oxygen will be administered by licensed personnel only when ordered by the physician, PA, or NP. The physician order may be written PRN [as needed] for comfort /dyspnea [shortness of breath] or may specify the number or liters, method of administration and length of time the oxygen is to be administered. Review of R24 's electronic medical record (EMR) revealed the following diagnoses of unspecified dementia, hypoxia, and anxiety disorder. The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview Mental Status (BIMS) score of 5, indicating severe cognitive impairment. Review of R24's care plan created 5/3/2024 revealed a plan of care of oxygen therapy with an intervention Administer oxygen at 2 LPM via NC [nasal cannula] as she will allow and explain the importance of keeping oxygen at the prescribed setting. Review of the Physician Order Form dated May 2024 revealed an order for oxygen at 2 LPM (liter per minute) via nasal cannula prn start date of 3/4/2024. Observations on 5/3/2024 at 8:48 am, 10:00 am, and 12:00 pm revealed R24 lying in bed receiving O2 by NC and the O2 concentrator (oxygen machine) set on four LPM. Observations on 5/3/2024 at 1:00 pm and 4:00 pm revealed R24 lying in bed receiving O2 by NC and the O2 concentrator was set on three LPM. Observation/Interview on 5/3/2024 at 2:24 pm, Unit Manager/Licensed Practical Nurse (LPN) confirmed that R24's O2 was set on three LPM instead of two LPM. She reported that she will notify the nurse to get the order changed to three LPM. She could not provide an explanation for R24 's O2 was set on three LPM and four LPM instead of two LPM. Interview on 5/5/2024 at 11:29 am, the Director of Health Services (DHS) reported being unaware that R24 O2 was set on the wrong liter flow. She confirmed that her licensed nursing staff was not following the physician order and the resident 's care plan. She reported that her expectation was for staff to follow the physician order. The DHS reported that her plan was to provide in-services to her nurses.

Based on observations, staff interviews, record review, review of the facility's policies titled, Medication Administration: Oral Medications and Medication Administration: Insulin Injections and review of the facility document titled, Oral Dosage Forms That Should Not Be Crushed 2016, the facility failed to ensure the medication error rate was less than 5%. There were two errors with 27 opportunities for two of five residents (R) (R38 and R56) for a medication error rate of 7.41%. These failures had the potential to result in medication not being given in accordance with the physician's orders or manufacturer's recommendations and the potential to adversely affect R38 and R56's clinical conditions. Findings include: 1. A review of the facility's policy titled Medication Administration: Oral Medications, revised 12/10/2021, revealed the Policy Statement of It is the policy of [facility name] Pharmacy that oral medications are administered in an organized and safe manner. The Special Considerations section included 1. Refer to Crush List prior to crushing any medication for assurance that it can be pulverized safely. The Procedure & Key Points: section included 9. Crush medication if indicated by Physician's order for this resident only after checking the Crush List. For tablets that appear on the Do Not Crush List check with Pharmacist regarding a suitable alternative and get new order from physician if appropriate. A review of the facility-provided document titled Oral Dosage Forms That Should Not Be Crushed 2016 revealed that metoprolol extended-release (ER) (a medication used to treat high blood pressure, heart failure, and chest pain) was on the list. A review of R38's electronic medical record (EMR) revealed diagnoses including, but not limited to, hypertensive heart, chronic kidney disease with heart failure, and paroxysmal atrial fibrillation. A review of the physician's orders included an order dated 9/18/2023 for metoprolol succinate 25 milligrams (mg) ER tablet, one tablet oral, once a day at 9:00 am. During a medication pass observation on 5/4/2024 at 9:00 am, Licensed Practical Nurse (LPN) AA was observed to crush R38's medications, including one metoprolol succinate 25 mg ER tablet, mix the medications with applesauce, and administer the medications to R38. In an interview on 5/4/2024 at 1:40 pm, LPN AA verified she had crushed the metoprolol succinate 25 mg ER tablet and administered it to R38. She stated she normally crushed the medications at R38's request, including the metoprolol succinate 25 mg ER tablet. LPN AA verified the instructions on the metoprolol succinate 25 mg ER tablet pharmacy packet included Do not crush. She stated she did not notice the instructions not to crush on the medication. Further interview revealed she was aware of the medication Do Not Crush list on the medication cart and verified she did not check to see if any of R38's medications were on the list before crushing them. She verified that administering the crushed metoprolol succinate 25 mg ER tablet could cause R38 to have adverse medical complications. In an interview on 5/4/2024 at 1:45 pm, the Director of Health Services (DHS) revealed her expectation was for the nurses to ensure medications were not on the facility's Do Not Crush list, which was located on each medication cart before crushing the medication. She stated all residents had a physician's order to allow medications to be crushed, but if the medication was on the Do Not Crush list or had instruction to not crush on the pharmacy label, the nurse should contact the pharmacy to ask for an alternative form of the medication or contact the physician to request an alternative medication and should not crush the medication. She confirmed administering a crushed medication that was on the Do Not Crush list placed residents at risk for adverse medical complications. She further stated she was unsure whether education had been provided about crushing medications, but the education would be provided immediately to the nurses. 2. A review of the facility's policy titled Medication Administration: Insulin Injections revised 10/27/2020 revealed the Policy Statement of It is the policy of [facility name] that the procedures outlined in this policy must be followed to aid oxidation and utilization of blood sugar by the tissues and to control the blood sugar levels in resident/patients with diabetes mellitus through the correct administration of insulin. The Procedures and Key Points: For Insulin Pens section included 2. Prime pen by dialing up 2 units on the pen and pressing the button on the end of the pen. Repeat priming procedure until insulin secretes from the needle. 3. Turn the knob on the end of the pen (or dial) to the number of units. A review of R56's EMR revealed diagnoses including, but not limited to, type 2 diabetes mellitus. A review of the physician's orders included an order dated 4/11/2024 for Novolog Flex Pen (a medication used to improve blood sugar control in people with diabetes mellitus) 100 unit/milliliter subcutaneous before meals and at bedtime, per sliding scale: If blood sugar is less than 70, call the Medical Doctor (MD). If blood sugar is 251 to 300, give 2 units. If blood sugar is 301 to 350, give 4 units. If blood sugar is 351 to 400, give 6 units. If blood sugar is 401 to 450, give 8 units. If blood sugar is greater than 450, call the MD. During a medication pass observation on 5/4/2024 at 11:30 am, LPN BB checked R56's blood sugar, with results of 411. The observation revealed her to prepare R56's Novolog Flex Pen insulin by dialing the pen's setting to 8 units, attaching the needle to the pen, and administering the insulin to R56. She did not dial the pen's setting to 2 units and prime the pen before dialing the dosage of 8 units. In an interview on 5/4/2024 at 11:35 am, LPN BB verified she did not prime the insulin pen with two units of insulin before dialing the ordered dosage on the pen and administering the insulin to R56. She stated she was unaware that she should prime the pen with two units of insulin before setting the dial to the ordered dose. She confirmed if the insulin pen was not primed before dialing the dosage amount, the resident could receive less than the ordered amount of insulin, which could result in adverse medical complications for the resident. In an interview on 5/4/2024 at 2:15 pm, the DHS stated her expectations were for the nurses to follow the manufacturer's guidelines and facility policy when administering insulin. She stated if the insulin pen was not primed as recommended, the resident could receive an inaccurate dose of insulin, which could cause medical complications. She further stated a pharmacy consultant provided education during monthly medication pass observations with the nurses, but she was unsure whether insulin pen or insulin administration education had been provided recently. She stated that education would be provided to the nurses immediately.

Based on record review, staff interviews, and review of the facility's policy Documentation of Skin and Wound Care, the facility failed to ensure wound assessments were completed weekly for one of three sampled residents (R2) and failed to accurately document skin assessments for one of three sampled residents (R2). Findings include: Review of facility policy Documentation of Skin and Wound Care revealed 'Policy Statement: It is the policy of the Healthcare center to complete documentation that reflects the current resident status as related to skin/wound care. Documentation will provide current and timely documentation on resident's condition related to skin/wound care, accurate information on resident's status as it pertains to skin/wound care, record care rendered and interventions in place and provide a detailed history of the wound assessments that have occurred in the healthcare center. Weekly Documentation: Weekly Documentation of Treatments will be completed on Wound Manager in the EHR (electronic health record) and Focus Observation to include Skin observation.' Record review of the Electronic Medical Record (EMR) for R2 revealed a diagnoses including but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Crohn's disease, and anoxic brain damage. Record review of Quarterly Minimum Data Set (MDS) for R2 dated 8/2/2023 revealed under section G-Function Abilities revealed extensive to dependent one-to-two-person assistance with activities of daily living (ADL) care. Review of progress notes for R2 revealed a note dated 7/7/2023 at 6:06 a.m. stated 'resident was noted to have open area on left buttocks. Tx nurse was made aware.' Record review of R2's physician orders revealed an order dated 7/9/2023 as follows 'Clean left buttocks with Normal Saline. Blot dry. Apply dry dressing daily. Once A Day.' Record review of Skin Observation Reports revealed on 7/12/2023 and 7/27/2023 nurse documented R2's skin was intact, no issues noted. R2 did not have 'Wound Management Detail Report' done until 7/25/2023, at which time the wound was declining. Interview on 11/2/2023 at 10:18 a.m. with Licensed Practical Nurse (LPN) AA revealed she was notified by a Certified Nursing Assistant (CNA) about an area on R2. LPN AA stated that she inspected R2's skin and found an open area on the left buttocks. She further revealed that she notified the Skin Integrity Coordinator (SIC) nurse but did not dress the area, notify the Physician, or the family of the area. This SIC nurse is no longer employed by the facility. Interview on 11/2/23 at 10:20 a.m. with the Director of Nursing (DON) revealed she was made aware of the area to R2 on 8/4/2023 by the previously employed SIC Nurse and the wound management company that comes in once per week. The DON stated that she started at the facility on 7/17/2023 and was not aware R2 had a wound prior to 8/4/2023. The DON further revealed her expectation is for the nurses to accurately document skin assessments and wound observations. Stated education was started on 8/4/2023 and every resident in the building had a skin observation done that day with no adverse findings.

Based on record review, staff interview, and review of the facility policy Weight Monitoring Program, the facility failed to ensure resident with significant weight loss was addressed in a timely manner for one of three sample residents (R2) with a significant weight loss. Findings include: Review of facility policy 'Weight Monitoring Program' last revised 6/2/2023 revealed 'Weight Team: 3. Weight Team Responsibilities: The Weight Team's responsibilities include evaluating weights for significant changes; recommending appropriate interventions; reviewing patient/resident meal, supplement, and snack intakes; revision of interventions, if necessary; attending weekly meetings; completing the Weight Loss/Gain Checklist and completing weekly documentation in the patient/resident's chart.' Record review of the most recent Quarterly Minimum Data Set (MDS) for R2 dated 8/2/2023 revealed under section K-Swallowing/Nutritional Status revealed resident had a 5% weight loss in one month or a 10% weight loss in six months and was not on physician prescribed weight loss regimen. Record review of the weight record revealed on 5/3/2023 R2 weighed 183.2 lbs (pounds). On 7/14/2023 R2 weighed 158 pounds, a 13.76% loss. There was no weight recorded for June 2023. There is no documentation the weight loss was addressed until 8/15/2023. A supplement was added and the responsible party, Physician, and Registered Dietician were notified. Interview on 11/2/2023 at 10:45 a.m. with Registered Nurse (RN) BB revealed she took over the weight program in July or August 2023. RN BB stated that she became aware of R2's weight loss when she took over the program and notified the Physician. Order was received to start supplement. Stated she also notified the Registered Dietician but did not get a response until September 2023. Interview on 11/8/2023 at 12:49 a.m. with Registered Dietician (RD) revealed weights are pulled once a month to see if any residents trigger for weight loss. The RD stated she prioritizes residents based on their needs. Further revealed she does not recall R2 showing up on the weight report for July as a significant weight loss but did address the weight loss in September. Interview on 11/13/2023 at 11:10 a.m. with Director of Nursing (DON) revealed residents with weight loss are discussed in weekly meetings. Stated the Physician should be notified as well as the Registered Dietician. Confirmed R2's weight loss was not addressed by the facility until August 2023 and by the Registered Dietician September 2023. Stated the weight loss should have been addressed sooner.

Based on observations, interviews, and policy review the facility failed to ensure opened food items in the walk-in refrigerator were dated; failed to discard food items after Best If Use By date; and failed to properly thaw food items to prevent food borne illness. This deficient practice had the potential to effect 49 of 51 residents receiving an oral diet. Findings include: Review of the facility policy titled Labeling, Dating, and Storage with a reviewed date of 1/8/21 revealed: Foods will be stored in their original containers or in an approved container or wrapped tightly with film, foil, etc and clearly labeled with the name of the item and the use by date. The policy also stated those items that require refrigeration and/or require refrigeration once they have been opened will be labeled with the use by date. Review of the facility policy titled Foodborne Illnesses with a reviewed date of 1/8/21 revealed: Foods will be used before the expiration date, use by date, best by date, and sell by date indicated on the food item. Food not used prior to the expiration date, use by date, best by date, or sell by date must be discarded. Continued review of the policy revealed meats will be thawed submerged in a solid bottom pan under cold running water. 1. Observation on 10/21/22 at 8:34 a.m. of the walk-in refrigerator revealed a one gallon container of sweet pickle relish that was opened with no date. The walk-in refrigerator also had two, five pound containers of cottage cheese with a Best If Use By date of 8/15/22. During an interview on 10/21/22 at 8:36 a.m. with the facility Dietary Manager (DM) she confirmed that the sweet pickle relish was opened with no date and expects staff to date food items after opening. The DM confirmed both containers of cottage cheese had a Best If Use By date of 8/15/22 and should have been discarded since it was past date, the DM did not why know it wasn't. Observation on 10/23/22 at 9:35 a.m. of the walk-in refrigerator revealed a one gallon container of Ranch Salad Dressing that was opened with no date. During an interview on 10/23/22 at 9:35 a.m. with the sister facility DM she confirmed that the Ranch Salad Dressing was opened with no date. The DM stated that she expects staff to label and date food items after opening. 2. Observation on 10/21/22 at 8:40 a.m. of the food preparation sink revealed inside was a large metal bowl that was filled white fish filets, the fish was covered with water. Continued observation revealed no running water going into the bowl. During an interview on 10/21/22 at 8:40 a.m. the facility DM confirmed that the fish filets were being thawed in the sink and confirmed that there was no running water going into the bowl. The DM stated that they should have had running water going into the bowl to thaw the fish.

Based on record review and staff interview, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) (Form CMS- ) to two residents (R) (R#18 and #43) who remained in the facility from a sample of five residents who were discharged from Medicare Part A services in the last six months. Findings include: 1. R#18 was discharged from Medicare Part A services on 8/19/22 and remained in the facility. However, the only notice that was provided to the resident was the Notice of Medicare Non-Coverage (NOMNC) (Form CMS- ). There was no evidence that the facility had issued an SNFABN (Form CMS- ) to R#18 or her responsible party, providing the opportunity to continue with skilled services, at her cost, if Medicare did not reimburse. 2. R#43 was discharged from Medicare Part A services on 6/3/22 and remained in the facility. However, the only notice provided to the resident was the NOMNC (Form CMS- ). There was no evidence that the facility had issued the SNFABN (Form CMS- ) to R#43 or his responsible party, providing the opportunity to continue with skilled services, at his cost, if Medicare did not reimburse. Interview with the Financial Controller on 10/23/22 at 10:40 a.m. revealed she did not provide the SNF-ABN form for R#18 or R#43. She thought that form was for Medicare Part B. She stated the Minimum Data Set (MDS) Coordinator provides her with the forms to get signed by the resident. MDS Coordinator entered the interview and was also unaware of the notice requirements. Further interview with the Financial Controller on 10/23/22 at 12:09 p.m. revealed she has not had any trainings on the specifics of providing the forms. She stated the MDS Coordinator has always given her the forms because she gets the information and updates the care plans. She stated she found some guidance in her emails and forwarded it to the MDS Coordinator. Review of the undated document provided by the facility titled Medicare Part A/ Medicare Replacement revealed for the following scenario, the facility will issue the NOMNC and SNF ABN notices: 1. Patient on Medicare A/ Medicare Replacement 2. Still has days available. 3. Part A/ Medicare Replacement being discontinued. 4. Remaining in the center following discharge from Part A/ Medicare Replacement.

Based on observations, interviews, and review of facility policy titled ''Medication Storage in the Healthcare Centers, the facility failed to ensure all medications carts were locked when out of view of the nurse for one of two medication carts and failed to ensure medications were properly secured inside of the medication cart when out of view of the nurse. Eight of 51 residents were wanderers. Findings include: Review of facility policy Medication Storage in the Healthcare Centers last revised 9/15/17 revealed: Procedure: 2. Only licensed nurses and the pharmacy personnel are allowed access to medications. Respiratory Therapists may access medications used in the provision of respiratory services. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. During observation of medication cart on 10/22/22 at 8:01 a.m. the medication cart was unlocked and unattended. The Administrator locked the cart and stated the nurse must have forgot to lock it. During observation of medication administration on 10/22/22 with RN AA revealed the medication cart was unlocked and unattended from 8:23 a.m. to 8:27 a.m., from 8:31 a.m. to 8:40 a.m., from 8:42 a.m. to 8:45 a.m., from 8:48 a.m. to 8:48 a.m., from 8:49 a.m. to 8:50 a.m., and from 8:53 a.m. to 8:55 a.m. During interview on 10/22/22 at 8:55 a.m. with Registered Nurse (RN) AA, revealed the cart is supposed to be locked when not in use or unattended. Confirmed medication cart has been unlocked and unattended during medication administration. During interview on 10/22/22 at 9:26 a.m. with Director of Health Services revealed the medication cart should be cleared of medications and the cart locked when nurses are away from the cart. Stated it is her expectation the nurses keep the cart locked when not in use and unattended. During interview on 10/22/22 at 9:27 a.m. with the Administrator revealed she had a conversation with the nurse after discovering the medication cart unlocked upon surveyor observation. Stated medication carts should be locked and secured when unattended.

Based on observation, interview, and recipe review the facility failed to properly prepare puree Salisbury steak to ensure adequate nutrient content. This deficient practice had the potential to effect 10 residents receiving a pureed diet from 49 residents that receive an oral diet. Findings include: Review of the cycle menu for lunch meal revealed residents ordered puree diet were to receive Baked Beef Steak. Review of the recipe for Puree Salisbury Steak revealed ingredients consist of prepared Salisbury steak, broth from base, and thickener. Observation on 10/22/22 at 10:30 a.m. of dietary cook BB puree Baked Beef Steak revealed dietary cook BB placed 12 cooked beef steaks in the food processor and purred, opened the lid and added 4 more beef steak to the food processor bowl and pureed. Dietary cook BB then poured about two cups of hot water into the food processor bowl using a gallon measuring pitcher and pureed. The cook opened the lid and added about another two cups of hot water and pureed. Dietary cook BB finished puree and placed in steam table pan. During an interview on 10/22/22 at 10:55 a.m. dietary cook BB stated that she does not use recipes when preparing pureed food items. The cook stated that she knows from past work experience how to puree food items.

Based on staff interviews, record review and review of the facility policy titled Care Plans, the facility failed to develop care plan interventions based on the assessed number of people required to provide care for one resident (R#4). The sample size was 10. On 9/27/22 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Senior Nurse Consultant were informed of the Immediate Jeopardy for F656 and F689 on 9/27/22 at 11:23 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 5/20/21. An Acceptable IJ Removal Plan was received on 10/2/2022 related to 483.21 (b) (1), Develop/Implement Comprehensive Care Plan (F656) and 483.25, Free of Accident Hazards/Supervision/Devices (F689). Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 6/5/21. Findings include: Review of the facility policy titled Care Plans with a revision date of 7/21/21, revealed the care plan approach serves as instructions for the patient/resident's care and provides continuity of care by all partners. Short and concise instructions, which can be understood by all partners, should be written and have a relationship to the problem and goal(s). When approaches that involve the Certified Nursing Assistant (CNA) have been added to the care plan, those approaches should also be included on the CNA Care Record or Resident Profile/Care Plan. R#4 was admitted to the facility on [DATE] and had the following but not limited to Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a 5/19/21 Quarterly Minimum Data Set which indicated the resident had severe impaired cognition, no behaviors, required total assistance of two staff for bed mobility, transfers and bathing, was nonambulatory, total dependence of one staff for dressing, toilet use, and hygiene. The resident had a care plan since 8/25/17 for being at risk for injury related to history of fall and related to [CONDITION(S)] accident with [CONDITION(S)] and dementia. There were interventions since 10/28/19 for fall mat at bed side, keep bed in lowest position with brakes locked and place resident in center of bed with positioning devices and use care when turning and repositioning. Although the resident was assessed as requiring total assistance of two staff for bed mobility, transfers and bathing, the care plan did not specify the number of staff needed to safely provide care. The ADL Care plan dated 10/28/19 only indicated to provide total assistance with bath/shower. Review of the Nurse's Note dated 5/20/21 at 6:14 p.m. revealed CNA AA notified the nurse that while providing resident care, the resident rolled out of the bed. It further noted the resident was non-verbal and blinked her eyes to indicate pain. The resident had a round circular shaped raised bump to the left lateral forehead. The resident was transported to the emergency room and the Nurse Practitioner and responsible party notified. The resident returned to the facility on [DATE] at 11:28 a.m. and continued to decline. On 5/20/21 at 7:45 p.m., the resident was pronounced dead. Interviews with multiple CNA's including, CNA DD on 9/13/22 at 11:55 a.m., CNA EE on 9/13/22 at 12:40 p.m., and CNA FF on 9/13/22 at 12:55 p.m. revealed that R#4 required two people to assist with repositioning in bed. During an interview with MDS Coordinator UU on 9/28/22 at 11:50 a.m., she stated the number of staff needed for assistance with care was not included in the resident's care plan and she had not been instructed to include that. Cross refer to F689. The facility implemented the following corrective action in response the deficient practice which occurred on 5/20/21: After the fall on 5/20/21, R#4's care plan was updated. Review of the employee timecard and employee personnel file revealed CNA AA (CNA present during the incident) was suspended on 6/1/21 and terminated per the separation notice on 6/4/21. On 6/03/21, the root cause analysis data review was completed by Senior Nurse Consultant (SNC). Review of the 6/3/21 Opportunity for Improvement- Root Cause Analysis form revealed contributing factors included resident was restless during care while one CNA performed care, resident was not positioned properly in bed, and CNA turned away to get items taking attention away/off the resident. Continued review of the 6/3/21 Opportunity for Improvement- Root Cause Analysis Form and interview with the Senior Nurse Consultant ZZ on 10/4/22 at 4:15 p.m. revealed the Care Plan policy was reviewed and no changes were needed. The facility ensured that CNA's and nurses were able to visualize the care plan interventions in the electronic medical record (EMR) regarding falls and Activities of Daily Living (ADL) care. Review of sampled resident's (R#3, R#9 and R#10) EMR containing falls and Activities of Daily Living care plans revealed easy visualization of care plan interventions. CNAs and nurses were knowledgeable on how to access care plan interventions in the EMR as evidenced by the following interviews conducted on 10/4/22 with the Minimum Data Set (MDS) Registered Nurse (RN) at 10:30 a.m., CNA FF at 11:00 a.m., CNA II at 11:15 a.m., CNA CC at 11:20 a.m., CNA EE at 11:30 a.m., CNA JJ at 11:40 a.m., RN LL at 12:50 p.m., LPN MM at 1:00 p.m., CNA BB at 1:10 p.m., LPN OO at 1:20 p.m., CNA PP at 1:30 p.m., LPN GGG at 1:35 p.m., CNA RR at 1:46 p.m., CNA SS at 1:58 p.m., LPN TT at 2:04 p.m., LPN VV at 2:11 p.m., LPN WW at 2:15 p.m., LPN XX at 2:20 p.m., RN GG at 2:28 p.m., LPN AAA at 3:00 p.m., CNA BBB at 3:26 p.m., CAN CCC at 3:35 p.m., CNAs DDD and QQ at 3:45 p.m., and CNAs EEE and FFF at 4:03 p.m. Review of the Quality Assessment and Assurance/QAPI Committee Meeting Attendance Sheet and minutes; and interview with the Administrator on 10/4/22 at 4:30 p.m. revealed a meeting was held on 6/4/22 with the Interdisciplinary Team (IDT) at which they reviewed the findings from the investigation and were educated on developing/ updating care plans. Staff were educated about following the resident's care plan as it pertains to proper resident positioning, requesting help if needed, having all materials and equipment ready when you enter room to provide ADL care, if an item is forgotten return resident to the center of bed, and place bed in lowest position, etc. Review of in-service sign in sheets dated 6/4/21 revealed 5 of 7 Registered Nurse, 12 of 15 Licensed Practical Nurse and 28 of 28 certified nursing assistants CNA's received the education. The education was verified as provided through staff interviews conducted 10/4/22 with the MDS RN at 10:30 a.m., Certified Nursing Assistant (CNA) FF at 11:00 a.m., CNA II at 11:15 a.m., CNA CC at 11:20 a.m., CNA EE at 11:30 a.m., CNA JJ at 11:40 a.m., RN LL at 12:50 p.m., LPN MM at 1:00 p.m., CNA BB at 1:10 p.m., LPN OO at 1:20 p.m., CNA PP at 1:30 p.m., LPN GGG at 1:35 p.m., CNA RR at 1:46 p.m., CNA SS at 1:58 p.m., LPN TT at 2:04 p.m., LPN VV at 2:11 p.m., LPN WW at 2:15 p.m., LPN XX at 2:20 p.m., RN GG at 2:28 p.m., LPN AAA at 3:00 p.m., CNA BBB at 3:26 p.m., CAN CCC at 3:35 p.m., CNAs DDD and QQ at 3:45 p.m., and CNAs EEE and FFF at 4:03 p.m. Review of 10 new hires since 6/4/21 revealed newly hired CNA's received ADL care planning competencies and safe techniques with bed mobility, positioning, and transfers (fall prevention) upon hire as part of their New Partner Orientation Checklist. Review of facility documentation revealed the Morse Fall Scale was completed and fall and ADL care plans were reviewed and updated on 6/4/21 for 50 active residents. This was confirmed through record review of sampled residents (R#3, R#9 and R#10) who were assessed as high risk for falls, The resident's banners were flagged as high risk for falls and care plans had appropriate interventions. The facility created a falls program review tool. Review of the Falls Program Review tool that was completed by the DHS on all falls from 3/8/21 to 6/2/21 revealed 17 falls within that timeframe. The Senior Nurse Consultant reviewed and signed the tool on 6/3/21. This was also verified via interview with DHS NN on 10/4/22 at 3:15 p.m. and the Senior Nurse Consultant ZZ on 10/4/22 at 4:15 p.m. The audit included reviewing all falls, fall documentation, updating/reviewing fall and ADL care plan interventions, Morse Fall Scale, banner for high risk, and identification of significant injuries. Review of Contagious Disease Monitoring Tool forms dated 5/20/21 through 6/4/21 revealed 56 CNAs were observed by the Clinical Competency Coordinator (RN KK) for appropriate care through the entire delivery of ADL care. This was confirmed as completed by interview with RN KK on 10/4/22 at 11:55 a.m. Interviews with 8 of 12 CNAs who were employed at the time of the incident and still working at the facility were conducted on 10/4/22 at 11:00 a.m. with CNA FF, CNA CC at 11:20 a.m., CNA EE at 11:30 a.m., CNA JJ at 11:40 a.m., CNA RR at 1:46 p.m., CNAs QQ and CNA DDD at 3:45 p.m. and CNA EEE at 4:03 p.m. who confirmed RN KK observed them providing care.

Based on interviews, record review, and review of facility policy titled Occurrences, the facility failed to ensure one resident (R) (#4) who was totally dependent on staff was properly positioned in bed when the Certified Nursing Assistant (CNA) turned to get supplies from the nightstand while providing care for the resident. The resident subsequently fell to the floor, sustained a hematoma to the forehead and died later that same evening from [CONDITION(S)]. The sample size was 10. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Senior Nurse Consultant were informed of the Immediate Jeopardy for F656 and F689 on [DATE] at 11:23 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. An Acceptable IJ Removal Plan was received on [DATE] related to 483.21 (b) (1), Develop/Implement Comprehensive Care Plan (F656) and 483.25, Free of Accident Hazards/Supervision/Devices (F689). Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. Findings include: The facility had an Occurrences policy with a revision date of [DATE]. The policy statement included in an effort to prevent occurrences, each patient/resident will be observed and assessed for risks. It also documented that appropriate, realistic interventions will be implemented in accordance to their plan of care. The policy documented the following for Investigation and Follow-up: 1. Occurrence investigation and follow-up is a joint responsibility within the healthcare facility. 2. Communication between all parties is essential for identifying the events and circumstances that resulted in the occurrence and the identifying interventions that limit the risk of the occurrence being repeated. 3. Director of Health Services will be responsible to review each occurrence for thorough investigation, documenting the investigation in the patient/resident care software occurrence report and appropriate care plan interventions are put in place to decrease risk for repeated occurrences. 4. The Administrator or designee will complete the supervisor investigation on all occurrences, and report to the appropriate state agency and/or other external agencies according to law. This documentation is to be typed on the patient/resident care software occurrence report follow up section. The Administrator's findings will include, but not limited to: Interview findings, was abuse ruled out, if abuse was noted list in detail type of abuse and who was involved, date of when report was completed, date external agencies were notified, when the physician and responsible party was notified and list any education and/or corrective action related to the occurrence. R#4 was admitted to the facility on [DATE] and had the following but not limited to diagnoses: cerebral infarct, [CONDITION(S)] without behavioral disturbance, [CONDITION(S)], functional [CONDITION(S)], and [CONDITION(S)] and [CONDITION(S)] following cerebral infarct affecting the right dominant side. The resident had a [DATE] Quarterly Minimum Data Set which indicated the resident had severe impaired cognition, no behaviors, required total assistance of two staff for bed mobility, transfers and bathing, was nonambulatory, total dependence of one staff for dressing, toilet use, and hygiene. The resident had a care plan since [DATE] for being at risk for injury related to history of fall and related to [CONDITION(S)] accident with [CONDITION(S)] and dementia. There were interventions since [DATE] for fall mat at bed side, keep bed in lowest position with brakes locked and place resident in center of bed with positioning devices and use care when turning and repositioning. Although the resident was assessed as requiring total assistance of two staff for bed mobility, transfers and bathing, the care plan did not specify the number of staff needed to safely provide care. Review of the Nurse's Note dated [DATE] at 6:14 p.m. revealed CNA AA notified the nurse that while providing resident care, the resident rolled out of the bed. It further noted the resident was non-verbal and blinked her eyes to indicate pain. The resident had a round circular shaped raised bump to the left lateral forehead. The resident was transported to the emergency room and the Nurse Practitioner and responsible party notified. The resident returned to the facility on [DATE] at 11:28 a.m. and continued to decline. On [DATE] at 7:45 p.m., the resident was pronounced dead. Review of the [DATE] emergency room (ER) record revealed while the resident was in the ER, she had a decline in her condition requiring oxygen and the resident's code status was changed from a full code to a Do Not Resuscitate. The ER record also indicated the resident had a Glasgow Coma Scale score of nine indicating moderate [CONDITION(S)]. The ER physician's assessment noted the resident had a closed head injury. Review of the resident's Death Certificate noted the date and time of death as [DATE] at 7:45 p.m. with the immediate cause of death as [CONDITION(S)] with the approximate interval between onset and death as 12 hours. Despite the incident occurring on [DATE] and resulting in death, the facility did not report the incident to the State Survey Agency (SSA) until [DATE] and CNA AA continued to work in the facility from [DATE] through [DATE] when she was suspended pending investigation. Review of the facility's investigation that was sent to the SSA on [DATE] revealed the following: On [DATE] at approximately 6:00 a.m., CNA AA, went to resident to provide hygiene care. Per her statement, when she arrived to the resident's room, she was noted in bed, lying on her left side with a wedge positioning cushion to her right side. The quarter side rails were up on both sides of the bed. The CNA placed her linen on the nightstand which was located next to the right side of the resident's bed. The CNA proceeded to reposition the resident in order to provide hygienic care. She reported the resident was agitated, but that was her normal. When asked to explain, she stated the resident would hit at staff and grab anything she can grasp, such as their clothes, linen, etc. The CNA stated she let the head and the foot of bed down, removed the wedge cushion from the resident's right side, and utilized a bed/draw sheet to move her closer to the right side of the bed in which she was standing. The CNA stated she turned to her left side to get more supplies from the nightstand. As she was facing the nightstand, she heard a sound and felt the resident on the floor by her right foot. The CNA stated there was no warning sign or sound to alert her of resident's impending fall. The CNA called for the nurse who arrived to assess the resident. The resident was noted on the floor mostly on her left side with her left arm underneath her body. She sustained a hematoma to her left frontal temporal area. Initial neurological observation was unremarkable, with no significant changes in her vital signs. At approximately. 6:14 a.m., the resident was sent to the hospital for evaluation of the head injury. The resident returned to the facility at 11:28 a.m. She was assessed by the Nurse Practitioner shortly after her return and hospital discharge paperwork was reviewed. While at the hospital, the resident had a decline in her overall condition with drops in her blood pressure and oxygen saturation. A chest Xray was completed due to low oxygen saturation; results were lungs clear. A CT (computerized tomography scan) without contrast was completed which noted No acute intracranial abnormality. Physician services consulted with the resident's family. A Physician's Orders for Life-Sustaining Treatment (POLST) form was completed to indicate the family wanted no resuscitation attempts. The resident's condition continued to decline throughout the course of the day. Due to her oxygen saturation dropping to 81%, she was placed on non-rebreather mask. There were changes noted in her vital signs with [CONDITION(S)] and [CONDITION(S)] noted. The Nurse Practitioner assessed the resident upon her return to the facility. New parameters to hold blood pressure medications were added to profile. At approximately 7:31 p.m., the resident was noted to be unresponsive with no respirations, pulse or blood pressure noted. She was pronounced deceased by the on call Registered Nurse (RN). Based on all the information, the resident expired due to a series of unfortunate events following a fall out of her bed. The facility received the signed death certificate on [DATE]. During an interview with the Administrator on [DATE] at 1:45 p.m., she stated she did not know if the fall mat was in place when the resident fell as indicated in the resident's care plan. She also confirmed the incident was not reported to the State Survey Agency until [DATE] after the incident was discussed in a MDS conference call. That same day they looked at the death certificate and determined the incident was something that had to be reported. They also conducted an investigation on [DATE] and determined the Director of Health Services (DHS) did not report the incident to the Senior Nurse Consultant per policy. During an interview with Senior Nurse Consultant ZZ on [DATE] at 2:15 p.m., she stated she could not remember the exact date she was notified of the resident's death but thought it was around [DATE] during a call discussing quality measures. She stated a full investigation should have done immediately. The previous DHS NN told her she had talked to CNA AA the next day ([DATE]) and she felt comfortable with what the CNA told her. Therefore, DHS did not proceed further. She stated DHS NN did not write any statements down and she thought the investigation was incomplete. She stated ideally the Administrator would have been notified the next day during the clinical meeting and she did not know if DHS NN told the Administrator all the details of the resident falling and dying later that evening. When asked if the MDS coding indicated a resident was a two person assist with care would she expect staff to use two people, she stated the MDS captures what the staff put in the ADL's during the assessment reference date. She stated most of the staff were able to take care of the resident by themselves without any problems except CNA AA. She stated the care plan would be specific if a resident required a specified number of staff. She stated they terminated CNA AA because they felt like something else happened and felt the resident was not positioned correctly in the bed and the CNA became distracted. During an interview with CNA DD on [DATE] at 11:55 a.m., she stated that the resident was able to hold on to the rail after she was turned in the bed, but the resident was not able to turn herself. She stated the resident did not have any behaviors and would not fight or grab you when providing care for her. She stated she only needed one person to provide care but needed two people to pull the resident up in the bed. During an interview with CNA EE on [DATE] at 12:40 p.m., she stated one person was able to work with the resident but had to have two people to pull her up in the bed or to transfer her with a mechanical lift. She also stated the resident was able to hold the rail with a tight grip. During an interview with CNA FF on [DATE] at 12:55 p.m., she stated one person was able to work with the resident except to pull the resident up in the bed or transfer her with a mechanical lift. She stated the left side of the bed was pushed up next to the wall and the nightstand was next to the right side of the bed. She stated if staff had to get something off the nightstand, you would still be facing the resident and be right next to the bed. The facility implemented the following corrective action in response the deficient practice which occurred on [DATE]: Review of ER Note dated [DATE] revealed R#4 had closed head injury, no acute intracranial abnormality, and chronic debility. Resident #4 was discharged back to the facility and expired. Review of the Death Certificate revealed R#4 had a cause of death listed as [CONDITION(S)]. Review of the employee timecard and employee personnel file revealed CNA AA (CNA present during the incident) was suspended on [DATE] and terminated per the separation notice on [DATE]. On [DATE], the root cause analysis data review was completed by Senior Nurse Consultant (SNC). Review of the [DATE] Opportunity for Improvement- Root Cause Analysis form revealed contributing factors included resident was restless during care while one CNA performed care, resident was not positioned properly in bed, and CNA turned away to get items taking attention away/off the resident. Review of the written statements from CNA AA and RN HHH, the [DATE] Facility Incident Report Form and the [DATE] investigation summary that was sent to the State Survey Agency revealed the administrator and DHS completed a thorough investigation with the CNA including drawing a pictogram to show the R #4's position after the fall. Review of an Immediate Notification Requirements form that was signed by the Administrator and the DHS NN revealed they received education from the Senior Nurse Consultant on [DATE]. Also verified by interview with the Senior Nurse Consultant ZZ on [DATE] at 4:15 p.m., the Administrator at 4:30 p.m. and DHS NN at 3:15 p.m. Review of the Quality Assessment and Assurance/QAPI Committee Meeting Attendance Sheet and minutes; and interview with the Administrator on [DATE] at 4:30 p.m. revealed a meeting was held on [DATE] with the Interdisciplinary Team (IDT) at which they reviewed the findings from the investigation. Verified via interviews with staff who attended the [DATE] QAPI meeting on [DATE] at 2:40 p.m. with the Social Services Director, CNA JJ at 2:50 p.m., the Senior Nurse Consultant ZZ at 2:30 p.m., LPN TT at 2:45 p.m. and RN KK at 11:55 a.m. Staff were educated about following the resident's care as it pertains to proper resident positioning, requesting help if needed, having all materials and equipment ready when you enter room to provide ADL care, if an item is forgotten return resident to the center of bed, and place bed in lowest position, etc. Review of in-service sign in sheets dated [DATE] revealed 5 of 7 Registered Nurse, 12 of 15 Licensed Practical Nurse and 28 of 28 certified nursing assistants CNA's received the education. The education was verified as provided through staff interviews conducted [DATE] with the Minimum Data Set (MDS) Registered Nurse (RN) at 10:30 a.m., Certified Nursing Assistant (CNA) FF at 11:00 a.m., CNA II at 11:15 a.m., CNA CC at 11:20 a.m., CNA EE at 11:30 a.m., CNA JJ at 11:40 a.m., RN LL at 12:50 p.m., Licensed Practical Nurse (LPN) MM at 1:00 p.m., CNA BB at 1:10 p.m., LPN OO at 1:20 p.m., CNA PP at 1:30 p.m., LPN GGG at 1:35 p.m., CNA RR at 1:46 p.m., CNA SS at 1:58 p.m., LPN TT at 2:04 p.m., LPN VV at 2:11 p.m., LPN WW at 2:15 p.m., LPN XX at 2:20 p.m., RN GG at 2:28 p.m., LPN AAA at 3:00 p.m., CNA BBB at 3:26 p.m., CAN CCC at 3:35 p.m., CNAs DDD and QQ at 3:45 p.m., and CNAs EEE and FFF at 4:03 p.m. Review of 10 new hires since [DATE] revealed newly hired CNA's received ADL care planning competencies and safe techniques with bed mobility, positioning, and transfers (fall prevention) upon hire as part of their New Partner Orientation Checklist. Annual Skills training are held for the RNs, LPNs, and CNAs including competencies and safe techniques with bed mobility, positioning, and transfers (fall prevention). Verified through review of the CNA, RN and LPN Annual Skills Fair for ,d+[DATE]. During an interview with the Administrator on [DATE] at 4:30 p.m., she stated the Annual Skills Fair for 2022 is scheduled for [DATE]. Also verified through interviews conducted on [DATE] with the MDS Registered Nurse (RN) at 10:30 a.m., CNA FF at 11:00 a.m., CNA II at 11:15 a.m., CNA CC at 11:20 a.m., CNA EE at 11:30 a.m., CNA JJ at 11:40 a.m., RN LL at 12:50 p.m., LPN MM at 1:00 p.m., CNA BB at 1:10 p.m., LPN OO at 1:20 p.m., CNA PP at 1:30 p.m., LPN GGG at 1:35 p.m., CNA RR at 1:46 p.m., CNA SS at 1:58 p.m., LPN TT at 2:04 p.m., LPN VV at 2:11 p.m., LPN WW at 2:15 p.m., LPN XX at 2:20 p.m., RN GG at 2:28 p.m., LPN AAA at 3:00 p.m., CNA BBB at 3:26 p.m., CNA CCC at 3:35 p.m., CNAs DDD and QQ at 3:45 p.m., and CNAs EEE and FFF at 4:03 p.m. Review of facility documentation revealed the Morse Fall Scale was completed and fall and ADL care plans were reviewed and updated on [DATE] for 50 active residents. This was confirmed through record review of sampled residents (R#3, R#9 and R#10) who were assessed as high risk for falls, The resident's banners were flagged as high risk for falls. The facility created a falls program review tool. Review of the Falls Program Review tool that was completed by the DHS on all falls from [DATE] to [DATE] revealed 17 falls within that timeframe. The Senior Nurse Consultant reviewed and signed the tool on [DATE]. This was also verified via interview with DHS NN on [DATE] at 3:15 p.m. and the Senior Nurse Consultant ZZ on [DATE] at 4:15 p.m. The audit included reviewing all falls, fall documentation, updating/reviewing fall and ADL care plan interventions, Morse Fall Scale, banner for high risk, and identification of significant injuries. Review of Contagious Disease Monitoring Tool forms dated [DATE] through [DATE] revealed 56 CNAs were observed for hand hygiene and personal protection equipment usage through the entire delivery of ADL care by the Clinical Competency Coordinator (RN KK). Also verified through interview with RN KK on [DATE] at 11:55 a.m. Interviews with 8 of 12 CNAs who were employed at the time of the incident and still working at the facility were conducted on [DATE] at 11:00 a.m. with CNA FF, CNA CC at 11:20 a.m., CNA EE at 11:30 a.m., CNA JJ at 11:40 a.m., CNA RR at 1:46 p.m., CNAs QQ and CNA DDD at 3:45 p.m. and CNA EEE at 4:03 p.m. who confirmed RN KK observed them providing care.

Based on observation, record review and staff and resident interviews, the facility failed to ensure two residents (R A and R B) were given showers as scheduled from a sample of 10 residents. Findings include: 1. Resident A was admitted to the facility on [DATE] with the following but not limited to Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/19/22 Quarterly Minimum Data Set indicated the resident had a Brief Interview for Mental Status (BIMS) of 15 indicating the resident had intact cognition, no behaviors, required limited assistance with one person physical assistance for dressing, one person physical assist for hygiene with activity occurring only once or twice, and was coded as activity did not occur for bathing. During an interview with the resident on 9/7/22 at 10:30 a.m., he stated he has only had three showers since his admission to the facility and that he needed one. He also stated he did not know what days his showers were scheduled but would like a shower at least three times a week. Review of the Bath Sheets revealed the resident received a shower on 7/28/22 and 8/20/22. Review of the July 2022 Point of Care History Sheets revealed the resident received a partial bed bath on 7/11/22, 7/13/22 and a complete bed bath on 7/25/22. Review of the August 2022 Point of Care History Sheets revealed the resident received a partial bed bath on 8/3/22, 8/8/22, 8/27/22, 8/28/22, 8/31/22 and a complete bed bath on 8/4/22. The September Point of Care History Sheet indicated the resident received a partial bed bath on 9/1/22. During an interview with Certified Nursing Assistant BB on 9/7/22 at 11:30 a.m., she stated the resident was assigned to get showers on the 3-11 shift on Monday, Wednesday and Friday. 2. Resident B was admitted to the facility on [DATE] with the following but not limited to Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/17/22 Quarterly Minimum Data Set indicated the resident had a Brief Interview for Mental Status (BIMS) of 15 indicating the resident had intact cognition, no behaviors, limited assistance with transfers and hygiene and limited assistance with one person physical assistance with bathing. During an interview with the resident on 9/7/22 at 10:15 a.m., she stated that her last shower was on 8/10/22 and 8/24/22. The resident showed the surveyor her calendar where she had documented her showers which confirmed those dates. She stated she was scheduled for showers on the 3-11 shift on Monday, Wednesday and Friday. She has even told them that once a week would be enough. The resident stated that her hair need washing and she was going to try and wash it in her bathroom sink but her [CONDITION(S)] was too bad today. An observation of the resident's hair at that time confirmed the resident's hair was greasy and needed to be washed. During an interview with Certified Nursing Assistant CC on 9/7/22 at 10:50 a.m., she stated the resident was scheduled to get a shower on the 3-11 shift on Monday, Wednesday and Friday.

Based on record review and staff interview, the facility failed to have a valid Do Not Resuscitate (DNR) in place and obtain a concurring physician signature on a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: 1. R#4 was admitted to the facility on [DATE] with the following but not limited to Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the POLST form dated [DATE], revealed it was signed by the resident's daughter who was not the Durable Power of Attorney for the resident and the form contained only one Physician's signature. The POLST indicated the resident's code status as Allow Natural Death- Do Not Attempt Resuscitation. Per the POLST section CPR, for Allow Natural Death- Do Not Attempt Resuscitation contained the following, **Signature of a concurring Physician is needed for this section to be valid if this form is signed by an Authorized Person who is not the Health Care Agent. Therefore, the resident did not have a valid DNR. Review of the Nurse's Note dated [DATE] at 6:14 p.m., CNA AA notified the nurse that while providing resident care, the resident rolled out of the bed. It further noted the resident was non-verbal and blinked her eyes to indicate pain. The resident had a round circular shaped raised bump to the left lateral forehead. The resident was transported to the emergency room and the Nurse Practitioner and responsible party notified. Review of the [DATE] emergency room (ER) record revealed while the resident was in the emergency room she had a decline in her condition requiring oxygen and the resident's code status was changed from a full code to a Do Not Resuscitate. Review of the Nurse's Notes dated [DATE] 7:31 p.m. revealed the resident was noted to be lying in bed with white frothy secretions noted in resident's mouth. Skin warm to touch. No respirations noted. Resident lying in bed eyes closed. Resident unresponsive to verbal stimuli. Resident unarousable. Director of Nursing (DON) notified of change in condition. DON notified Registered Nurse (RN) to assess resident. The [DATE] 8:21 p.m. Nurse's Note indicated the RN pronounced resident's death at 7:45 p.m. on this date. During an interview with the Administrator on [DATE] at 11:45 a.m., she confirmed the resident did not have a Durable Power of Attorney and there was not a second Physician's signature on the form as required. 2. R#7 was admitted to the facility on [DATE] with the following but not limited to Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the POLST form dated [DATE], revealed it was signed by the resident's daughter who was not the Durable Power of Attorney for the resident and the form contained only one Physician's signature. The POLST indicated the resident's code status as Allow Natural Death- Do Not Attempt Resuscitation. Per the POLST section CPR, for Allow Natural Death- Do Not Attempt Resuscitation contained the following, **Signature of a concurring Physician is needed for this section to be valid if this form is signed by an Authorized Person who is not the Health Care Agent. Therefore, the resident did not have a valid DNR. Review of the [DATE] at 12:50 a.m. Nurse's Note revealed the resident was not breathing, no pulse palpated or auscultated. At 2:20 a.m. hospice arrived at facility to pronounce death. During an interview with the Administrator on [DATE] at 11:45 a.m., she stated the resident's daughter who signed the POLST did not have POA and was not the healthcare agent for the resident. She also confirmed there was not a second Physician's signature on the form as required. She stated she called Hospice who told her they sent the form to the second Physician to be signed but never got the form back. During an interview with the Social Services Director on [DATE] at 1:05 p.m., She stated it would be Hospice's responsibility to ensure the DNR/POLST forms and complete. She was not sure if anybody in the facility reviews the forms from Hospice or the hospital. She stated Hospice would upload the forms into the system and if Hospice did not upload the forms, then medical records would review the forms for accuracy. She stated if she initiates the forms, she makes sure all the signatures are present on the forms. If it is incomplete, the person would still be a full code. If she is not here, then nursing would be responsible.

Based on observation, interview with staff, and review of policies and procedures, the facility failed to ensure supplies were available in critical high risk infection areas; housekeeping used proper disinfectant; and the staff followed established screening procedures upon entry to the building. These failed practices had the potential to spread infection, including COVID-19, to 32 of 55 residents in the facility. Findings include: 1. On 12/28/20 at 10:15 a.m., a mop bucket complete with a mop and green mop water was observed in the center of the A-Hall COVID-19 level one area where 15 resident's positive for COVID-19 were housed. Upon interview with housekeeper (HSK) BB and demonstration, HSK BB indicated she used a green product labeled, QC 35 Maxx Dual Action Floor Cleaner, with recommended use as a floor cleaner, from the central product dispenser to her mop bucket. Review of the Ecolab data sheet supplied by the Housekeeping Supervisor (HSKS) indicated the product had no disinfecting qualities. Interview with the HSKS on 12/28/20 at 10:50 a.m. indicated all housekeepers should be using Peroxide Multi-Surface and Disinfectant with recommended use as a disinfectant according to the Ecolab data sheet. HSKS asked HSK BB, Were you using the green floor cleaner? HSK BB indicated, Yes. HSKS stated, They all should know this and know better; they should be using the peroxide disinfectant on all floors throughout the building. HSK BB was dedicated to the A-Hall COVID-19 level one area. 2. On 12/28/20 at 10:25 a.m., the surveyor and Infection Control Nurse (ICN) left the A-Hall COVID-19 level one area, doffing PPE in the decontamination area to find no alcohol-based hand rub (ABHR) available in the bottle on top of the cart. At this time, the ICN searched the drawers of the cart containing supplies for a back-up bottle of ABHR. No back up bottle was found. The ICN opened the sealed temporary door to call out for assistance in obtaining an ABHR bottle. Interview with the ICN nurse indicated HSK BB was in charge of supplying the carts with all PPE. Review of the facility policy titled, COVID-19 Pandemic Isolation and Cohorting Process for Health Care Centers dated 11/11/20, item #7, .equipment will be maintained on level 1 units to prevent contamination. 3. On 12/28/20 at 2:45 p.m., the employee daily list, provided by the Administrator, which included all employees working on the current shift and in the building, and the screening records for 12/28/20 for the 7:00 a.m. to 3:00 p.m. shift, provided by Certified Nursing Assistant (CNA) BB were reviewed with CNA BB. CNA BB revealed 10 of the 29 staff on duty (Registered Nurse (RN) AA, RN BB, the Minimum Data Set (MDS) Nurse DD, the Administrator, maintenance worker (MW), the housekeeping supervisor (HSKS), Licensed Practical Nurse (LPN) BB, CNA CC, HSK BB, and dietary worker (DW) EE) did not sign in and were not screened in accordance with the facility policy. Interview with CNA BB on 12/28/20 at 2:50 p.m. revealed all staff were to check in at the front. She stated she was stationed at the desk Monday through Friday, 7:00 a.m. to 3:00 p.m., to screen staff upon entrance to the building. She stated at all other time frames when she was not on duty, staff used the thermometer to check themselves, sign in, and answer questions. Interview with the Administrator on 12/28/20 at 3:00 p.m., revealed all exit doors are accessible from the outside by staff if they used the key punch code to open the door. The front door to the building and check point area was locked and required someone to unlock it for access in and out of the building. No concerns were identified for prior days related to screening staff. On 12/28/20 at 2:50 p.m., a maintenance worker (MW) was observed filling out a screening questionnaire and took his own temperature. He stated he had reported to work at 11:00 a.m. Review of the facility policy titled, Contagious Disease Screening Tool-COVID-19 dated 03/11/20, indicated when entering for work, partners will be screened for symptoms. Partners will be asked to use alcohol sanitizer on hands, ask partner if they are experiencing symptoms such as fever, chills, sweats . the partner is denied if symptoms are present, partners are asked if they have left the country or been exposed to a person with COVID-19. The facility policy was lacking a reference to taking the partners temperature as part of monitoring for symptoms. Upon entrance to the facility on [DATE], the facility Administrator identified the facility currently had 23 of 55 residents who were positive for COVID-19.

Based on record review and staff interview, the facility failed to provide evidence that infection data was analyzed and appropriate follow-up done to address any increase in infections. This had the potential to affect the 70 residents in the facility. Findings include: Review of the facility's 2019 Infection Monitoring Logs revealed that they captured information monthly that included the resident's name; room number; date of S/S (signs and symptoms); I/C (infection control) Cat. (category); ABT Tx (antibiotic treatment); Report; Keyed; Resolved; Care Plan; CP (care plan) resolved. Further review revealed that the only information recorded were the columns from name to ABT Tx. Further review of the facility's infection surveillance information revealed that infections were plotted on a copy of the facility's floor plan, which was color-coded to designate whether the resident was admitted with the infection, acquired it in the facility, or was being treated [MEDICATION NAME], but did not specify what the infection was. Review of the 2019 Monthly Healthcare Associated Infection Summary Reports revealed that the numbers of specified types of infections were recorded. Further review of these forms revealed that the total number of infections were recorded, but no overall infection rates were calculated, and there was no evidence of analysis of the gathered data, nor comments of what was done to address any increase in infections. During interview with the Registered Nurse (RN) Infection Control Nurse on 10/10/19 at 11:43 a.m., she stated that she pulled an antibiotic usage report from the computer weekly, and logged this information on the Infection Monitoring Log. She further stated that she tracked for any trends of infections by plotting them on the floor plan, and did any education that may be needed if she saw any trends of facility-acquired infections. She stated that she used the Monthly Healthcare Associated Infection Summary Report to track infections per type of infection and unit. The Infection Control Nurse further stated that she brought infection control data to every QAPI (Quality Assurance Performance Improvement) meeting so that any trends could be discussed. She stated that she had been told about the use of the McGeer criteria and that it was available in the computer, but that she hadn't used it yet. She stated during continued interview that the nurses and physician looked at signs and symptoms the resident was exhibiting, vital signs, lab reports and chest x-rays to ensure an antibiotic was appropriate, and that when she got the antibiotic report she ensured this was done. Review of the Antibiotic Medication Report at this time revealed that it listed the start and end date of an antibiotic; the order description; the ordering practitioner; the diagnosis; category; and days used. Further review of this report and all of the infection surveillance data revealed that none of the data captured whether or not a culture was done, and if done what the organism was and whether it was susceptible to the antibiotic prescribed. Review of the 2019 Monthly Healthcare Associated Infection Summary Reports at this time revealed that none of them summarized any trend or concern, nor plan to address any increase in infection rates. This was verified by the RN Infection Control Nurse. January: Six UTIs (urinary tract infections) with a catheter, one UTI without a catheter, one lower respiratory infection, one other skin and one pneumonia. (note: proof of peri-care check-offs in (MONTH) were later provided). February: Three UTIs with a catheter, one UTI without a catheter, three upper and three lower respiratory infections, and one other skin infection. Review of the facility floor plan associated with this data revealed that ten of these infections were facility-acquired, but does not specify which ones. March: One UTI with a catheter, two UTIs without a catheter, four lower respiratory, one surgical wound, one shingles, one flu, one [MEDICATION NAME] flu, one candidal esophagitis, and one possible pneumonia. There was no notation if the flu and shingles residents were isolated to prevent the spread of infection. Review of the facility floor plan revealed that seven of these infections were facility-acquired, but does not specify which ones. April: Four UTIs with a catheter; two lower respiratory; two surgical wound; two other skin; one gastroenteritis; one acute vaginitis; and one yeast. Seven of these were plotted on the floor plan as being facility-acquired, but does not specify which ones. May: Two UTIs with a catheter, one UTI without a catheter, three lower respiratory, and two other skin infections. Eight of these infections were listed on the floor plan as being facility-acquired, but does not specify which ones. June: Three UTIs with a catheter, two UTIs without a catheter, two other skin, and one [MEDICATION NAME] Resistant [MEDICATION NAME] (VRE) infection. Seven of these were listed as facility-acquired infections, but does not specify which ones. July: Two UTIs with a catheter; three upper and two lower respiratory infections; one surgical and one other skin infection. Seven of these infections were listed on the floor plan as being facility-acquired, but does not specify which ones. August: One UTI with a catheter, three lower respiratory infections, and five other skin infections. Review of the Infection Monthly Log revealed that vulvar candidiasis and acute vaginitis were counted as skin infections. Eight of the infections were listed on the floor plan as being facility-acquired, but does not specify which ones. September: One UTI with a catheter, two UTIs without a catheter; four lower respiratory; and two other skin. Eight of the infections were listed on the floor plan as being facility-acquired, but does not specify which ones. Review of any in-services done related to infection control since (MONTH) of (YEAR) revealed that one was given on 1/31/19 for cleaning i-Pads (the staff's point-of-care tablet computers), and one on 10/4/18 for removing trash and soiled linens from resident rooms. The only other infection control education given was the Infection Control and Prevention course required annually for all employees, and Skills Checklists dated 1/31/19 that included hand hygiene and perineal care check-offs for the Certified Nursing Assistants (CNA). During interview with the Administrator on 10/10/19 at 1:42 p.m., she stated that infection control information was not always brought to QAPI, only if they saw that something was trending up, so that they could determine what the source was. During interview with the Director of Health Services (DHS) on 10/10/19 at 2:33 p.m., she verified that there were concerns related to the analysis of infection control data collected, and documentation of any follow-up done to address any increase of infections. Review of the facility's Infection Prevention and Control Plan, revised on 9/23/19, revealed the following: 2. Reporting: a. The Infection Prevention and Control Program/Infection Prevention and Control Oversight Committee will provide a monthly report to the QAPI Committee. 3. Surveillance Activities: c. Surveillance is conducted to ensure quality of resident care concerning infection control issues and is maintained on an ongoing basis. In addition to the infection types specified in the targeted surveillance plan, non-targeted infections, single occurrences, and/or outbreaks of HAIs (healthcare-associated infections) related to any unusual or virulent pathogenic organism are evaluated.

Based on record review and staff interview, the facility failed to provide evidence of a process for periodic review of antibiotic prescribing practices, and to document follow-up measures in response to the data for nine of nine months of 2019 infection control data reviewed (January 2019 through (MONTH) 2019). This had the potential to affect any resident who was prescribed an antibiotic. The facility census was 70 residents. Findings include: Review of the facility's 2019 Infection Monitoring Logs revealed that they captured information monthly that included the resident's name; room number; date of S/S (signs and symptoms); I/C (infection control) Cat. (category); and ABT Tx (antibiotic treatment). Further review of these monthly line listings revealed that they did not contain information such as the resident's signs and symptoms; if a culture or x-ray was done; and if the organism was sensitive to the ordered antibiotic. During interview with the Registered Nurse (RN) Infection Control Nurse on 10/10/19 at 11:43 a.m., she stated that she did not use any infection assessment tools to assess the minimum criteria for initiation of antibiotics. She further stated that she had been told about the McGeer criteria and it was available in the computer, but that she had never used it before. She further stated that the Physician and nurses would look at the resident's signs and symptoms, vital signs, lab reports, etc. before ordering an antibiotic, and that she ensured this was done but had no documentation of this. She stated that she would call the Physician if she had a concern about the appropriateness of an ordered antibiotic, and that he would sometimes change it. The Infection Control Nurse stated during continued interview that the pharmacist did a monthly report that included antibiotic usage which was giving to the DHS (Director of Health Services), but that the pharmacist did not come to QAPI meetings. During interview with the Administrator on 10/10/19 at 1:42 p.m., she stated that the Infection Control Nurse was responsible for the antibiotic stewardship program. She further stated that they discussed which residents were on antibiotics in morning meetings, but only to the extent of who was on an antibiotic, and not the [DIAGNOSES REDACTED]. The Administrator stated during continued interview that infection control information was not always brought to QAPI (Quality Assurance Performance Improvement), only if they saw something was trending up so that they could determine what the source was. She further stated that the pharmacist sometimes came to the QAPI meetings, but had not been to any meetings this quarter. During interview with the Administrator on 10/10/19 at 2:20 p.m., she stated that she just found out that the pharmacist had been sending ASP (Antibiotic Stewardship Program) reports monthly to the DHS, but that they did not have a DHS from (MONTH) until this month, so that nobody was looking at these reports. Review of Antibiotic Stewardship Reports provided by the facility's pharmacy services revealed that it was meant as a resource to monitor antibiotic prescribing and to help maintain an awareness of trends in infections and antibiotics at the facility. Review of these reports revealed that it contained a line listing with the resident's name; original fill date; cutoff date; drug label name; total days on antibiotic(s); order; Rx (prescription) type; and provider. Further review of this report revealed that it did not capture the organism if a culture was done, and the organism's susceptibility to the ordered antibiotic. During interview with the DHS on 10/10/19 at 2:33 p.m., she stated that before now, no assessments had been done to determine if antibiotic usage was appropriate, such as checking the resident's signs and symptoms, vital signs, lab cultures for the organism and the organism's susceptibility to an ordered antibiotic. Review of the facility's Antibiotic Stewardship Program policy revised 9/26/19 revealed: 1. Accountability: c. The ASP Team will monitor and review the following data: i. Infections and antibiotic usage patterns on a regular basis. ii. Antibiogram reports for trends of antibiotic resistance. iii. Antibiotic resistance patterns for multidrug resistant organisms (e.g,[MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus), VRE ([MEDICATION NAME]-resistant [MEDICATION NAME]), ESBL (extended spectrum beta- lactamase), CRE (carbapenem-resistent [MEDICATION NAME]), etc., and [MEDICAL CONDITION] infections. iv. Number of antibiotics prescribed (e.g., days of therapy) and the number of residents treated each month. v. Include a separate report for the number of residents on antibiotics that did not meet criteria for active infection. d. Prescribing practitioner's orders must include documentation of the indication, dosage, and duration of use for all antibiotic prescriptions. 5. Tracking: a. The IP (Infection Preventionist) will be responsible for infection surveillance and multi-drug resistance organism (MDRO) tracking. b. The IP, along with the DHS, will collect and review the following data such as: i. Documentation of completion of antibiotic choice, dosage, duration, indication, and route of administration. ii. Whether appropriate tests, such as labs and/or cultures, were obtained before ordering antibiotic. iii. Whether the antibiotic was changed during the course of treatment. 6. Reporting: a. Each month data tracked by the IP and/or other members of the ASP team will be presented and analyzed for issues and trends from the previous month at the Quality Assurance and Performance Improvement (QAPI) meeting. b. IP and/or other members of the ASP team will review and report findings to QAPI committee, who will then provide feedback to facility partners. c. Each quarter a Prescriber Practitioner Summary will be presented to the QAPI committee for review and provided for feedback to the prescribing practitioner(s) on their antibiotic prescribing patterns as indicated. Review of the facility's Infection Prevention and Control Plan revised 9/23/19 revealed: Program Objectives: 13. Monitoring antibiotic susceptibility results from cultures to detect clinically significant antibiotic-resistant bacteria, (i.e.,[MEDICAL CONDITION] or VRE). Use of this data will be used for planning and implementing interventions, (e.g., education and antibiotic restrictions), for improvement. Facility Activities: 6. Antibiotic Stewardship a. Monitor antibiotic susceptibility results to detect clinically significant antibiotic resistant bacteria. b. Monitor appropriate and inappropriate antibiotic utilization in the facility. c. Implement antibiotic stewardship policy, guidelines, and algorithms to improve antibiotic utilization. d. Continuous education to all partners/providers regarding antibiotic stewardship policy and program expectations. Cross-refer to F 880.