Every finding on record at Saint Simeons Episcopal Home

Based on record review and interview, the facility failed to ensure assistance with activities of daily living was provided for 1 (#4) of 4 residents who were reviewed for ADL assistance. The administrator identified 78 residents who resided in the facility. Findings: Resident #4 had diagnoses which included fracture of neck of left femur, fracture of left pubis and glaucoma. The five day assessment, dated 01/20/25, showed Resident #4 had a BIMS score of 13 and was cognitively intact for decision making. A care plan, revised 01/29/25, showed Resident #4 was dependent for toileting hygiene. On 02/27/25 at 2:34 p.m., Resident #4 stated an incident occurred when a CNA #1 had left them naked in bed. They stated they were pleased CNA #1 had been suspended and that it was unlikely CNA #1 would return. Resident #4 stated CNA #1 was not mean or hurt them, they felt CNA #1 did not like their job. They stated no other CNA had left them like that, just CNA #1. On 03/03/25 at 6:14 p.m., CNA #4 stated they had found Resident #4 at the start of their day shift on 02/26/25, sitting on the side of their bed that was raised too high. They stated Resident #4 stated they were waiting for CNA #1 to return. CNA #4 stated it was unusual because their bed should be in a low position. They stated they did not know what time CNA #1 had entered or left the room of Resident #4. CNA #4 stated Resident #4 was dressed and wearing a brief, was wet but not overly wet. On 03/03/25 at 6:20 p.m., Resident #4 was asked how they felt when the aide left them in bed. Resident #4 stated when CNA #1 left them in the bed, they did not know how it made them feel at that time. Resident #4 stated they did wonder where CNA #1 had gone. Resident #4 stated they guessed they felt abandoned by CNA #1 because they needed to be changed. On 03/04/25 at 12:19 p.m., CNA #2 stated the incident when Resident #4 was left without a brief by CNA #1 was a prior incident and could not remember the date. They stated they worked the evening shift before CNA #1 and their shifts overlapped by 30 minutes. CNA #2 stated during the 30 minute overlap, CNA #1 would take over the hall and answer the call lights so they could complete their charting for the evening shift. CNA #2 stated they observed CNA #1 was slow in answering the call lights. On 03/04/25 at 3:15 p.m., the CEO/president stated they expected requested care to be provided. They stated interrupted care that was left incomplete for 30 - 45 minutes did not meet their expectations.

Based on record review and interview, the facility failed to ensure residents were free from neglect for 1 (#4) of 4 residents who were sampled and reviewed for neglect. The administrator identified 78 residents who resided at the facility. Findings: Resident #4 had diagnoses which included mood disorder, PTSD, and anxiety. The five day assessment, dated 01/20/25, showed Resident #4 had a BIMS score of 13 and was cognitively intact for decision making The Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, revised April 2021, read in part, Develop and implement policies and protocols to prevent and identify: a. abuse or mistreatment of residents; b. neglect of residents. An Identifying Neglect policy, revised September 2022, read in part, Preventing resident neglect is a priority throughout all levels of this organization.Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical pain, mental anguish, or emotional distress.Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident requires but the facility fails to provide them and this has resulted in (or may result in) physical harm, pain mental anguish or emotional distress.Failure to provide supervision ad/or monitoring of the delivery and implementation of care. Review of the care plan, dated 01/31/25, for Resident #4, showed a focus of being dependent on staff for ADLs in toileting hygiene and transfers. Review of the ODH Form 283, dated 02/26/25, showed Resident #4 had alleged allegations of abuse/mistreatment by CNA #1. The form showed on 02/26/25 CNA #2 had reported Resident #4 told them they feared CNA #1 and did not want them to return to their room at night. The form documented Resident #4 stated CNA #1 came to their room to change their wet brief, removed their brief and left them naked to soil the bed and never returned. The form showed CNA#1 had been suspended pending the investigation. On 02/27/25 at 2:34 p.m., Resident #4 stated an incident occurred when a CNA #1 had left them naked in bed. They stated they were pleased CNA #1 had been suspended and that it was unlikely CNA #1 would return. Resident #4 stated CNA #1 was not mean or hurt them, they felt CNA #1 did not like their job. They stated no other CNA had left them like that, just CNA #1. On 02/27/25 at 3:25 p.m., the administrator stated they started the investigation 02/26/25 and CNA #1 had just come back from a suspension for a previous allegation that they had been unable to corroborate. They stated they provided CNA #1 with a teaching moment and the employee was allowed to return to work, but now there was another abuse allegation and the employee was again suspended. On 03/03/25 at 10:30 a.m., the administrator stated they completed the abuse investigation on 2/28/25. They stated CNA #1 was terminated. They stated the incident was brought before the IDT at the meeting this morning, and staff re-education had began. The administrator stated they would analyze the situation and determine if another process would be needed to monitoring. They stated they had notified the representative and updated them on the outcome of the investigation. The administrator stated there would be a weekly check in with residents for three months to ensure no further incidents of abuse and the social services person would be asking about abuse and quality of care during future care plan meetings. They stated any issues would be reported to them immediately. They stated all findings would be discussed during the daily IDT meetings Monday through Friday and addressed at the quality assurance meetings which were held quarterly. The administrator stated they were unable to get an interview with the staff, because once the staff member was suspended they no longer answered their phone. On 03/03/25 at 6:14 p.m., CNA #4 stated they had found Resident #4 at the start of their day shift on 02/26/25, sitting on the side of their bed that was raised too high. They stated Resident #4 stated they were waiting for CNA #1 to return. CNA #4 stated it was unusual because their bed should be in a low position. They stated they did not know what time CNA #1 had entered or left the room of Resident #4. CNA #4 stated Resident #4 was dressed and wearing a brief, was wet but not overly wet. On 03/03/25 at 6:20 p.m., Resident #4 was asked how they felt when the aide left them in bed. Resident #4 stated when CNA #1 left them in the bed, they did not know how it made them feel at that time. Resident #4 stated they did wonder where CNA #1 had gone. Resident #4 stated they guessed they felt abandoned by CNA #1 because they needed to be changed. On 03/04/25 at 12:19 p.m., CNA #2 stated the incident when Resident #4 was left without a brief by CNA #1 was a prior incident and could not remember the date. They stated they worked the evening shift before CNA #1 and their shifts overlapped by 30 minutes. CNA #2 stated during the 30 minute overlap, CNA #1 would take over the hall and answer the call lights so they could complete their charting for the evening shift. CNA #2 stated they observed CNA #1 was slow in answering the call lights. On 03/04/25 at 3:15 p.m., the CEO/president stated they expected requested care to be provided. They stated interrupted care that was left incomplete for 30 - 45 minutes did not meet their expectations. They stated a resident left soiled fell into neglect.

Based on record review and interview, the facility failed to ensure residents were treated with dignity and respect for 1 (#4) of 4 residents who were reviewed for dignity. The administrator identified 78 residents who resided at the facility. Findings: Resident #4 had diagnoses which included mood disorder, PTSD, and anxiety. The five day assessment, dated 01/20/25, showed Resident #4 had a BIMS score of 13 and was cognitively intact for decision making. Review of the care plan, dated 01/31/25, for Resident #4, showed a focus of being dependent on staff for ADLs in toileting hygiene and transfers. Review of the ODH Form 283, dated 02/26/25, showed Resident #4 had alleged allegations of abuse/mistreatment by CNA #1. The form showed on 02/26/25 CNA #2 had reported Resident #4 told them they feared CNA #1 and did not want them to return to their room at night. The form documented Resident #4 stated CNA #1 came to their room to change their wet brief, removed their brief and left them naked to soil the bed and never returned. The form showed CNA#1 had been suspended pending the investigation. On 02/27/25 at 2:34 p.m., Resident #4 stated an incident occurred when a CNA #1 had left them naked in bed. They stated they were pleased CNA #1 had been suspended and that it was unlikely CNA #1 would return. Resident #4 stated CNA #1 was not mean or hurt them, they felt CNA #1 did not like their job. They stated no other CNA had left them like that, just CNA #1. On 03/03/25 at 1:26 p.m., CNA #3 stated they made sure dignity was maintained by ensuring residents were dressed, knocked on their door before entering. On 03/03/25 at 1:53 p.m., LPN #1 stated they ensured residents were treated with dignity and respect by closing doors, taking residents to a private area, knocked on the door, called them by their name or whatever they wanted to be called. On 03/03/25 at 6:20 p.m., Resident #4 was asked how they felt when the aide left them in bed. Resident #4 stated when CNA #1 left them in the bed, they did not know how it made them feel at that time. Resident #4 stated they did wonder where CNA #1 had gone. Resident #4 stated they guessed they felt abandoned by CNA #1. On 03/04/25 at 3:15 p.m., the CEO/president stated they ensured residents were treated with dignity and respect during on-boarding and training, daily rounding by the director of nursing, assistant director of nursing, nurses, and administration. They stated the residents were provided opportunities to tell administration about their care. The CEO stated nurses were supposed to check on resident care throughout their shift. They stated it was not acceptable for a resident to be left soiled and it definitely did not leave the residents feeling dignified or respected.

Based on record review, and interview, the facility failed to ensure residents were free from abuse for two (#3 and #4) of three residents sampled for abuse. On 10/05/24 Res #3 was left soiled in bed and stuck between the bed and the wall. On 10/14/24 LPN #4 did not provide hydration, medication, or dressing changes for Res #4. The facility was in past noncompliance after having put the final measures in place to correct the deficiency on 12/13/24. The administrator identified 75 residents who resided in the facility. Findings: 1. Res #3 had diagnoses which included Parkinson's and immobility. A state reportable incident form, dated 10/05/24, documented on 10/05/24 CNA #4 left Resident #3 soiled and wedged in the bed while covering for another aide who was on break. The form documented CNA #4 was removed from patient care immediately and suspended. The form documented the administrator contacted the family, resident's legal representative, Adult Protective Services, and the appropriate licensing board. The form documented all residents residing in the facility were questioned on abuse and neglect by the administrator. Record review revealed CNA #4 was immediately removed from patient care and terminated after the incident was investigated. The record review documented CNA #4 was terminated and reported to the nurse aide registry. 2. Resident #4 had diagnoses which included Alzheimer's disease and osteoporosis. A state reportable incident form, dated 10/14/24, documented the facility discovered LPN #4 had inaccurately documented care for Resident #4. The care included hydration, dressing changes, and medication. Record review revealed LPN #4 was immediately suspended from the facility and terminated after the investigation was completed. The record review documented the LPN was terminated and reported to the appropriate licensing board. The in-service book documented multiple in-services on abuse and neglect. The initial in-service was conducted on 10/05/24 and another was conducted on 12/13/24 for all staff members. Staff members were interviewed and could voice information related to the inservice they attended. Residents were interviewed and denied abuse by staff. On 01/23/25 at 3:30 p.m., the administrator stated they reported the allegations of abuse to OSDH immediately. They stated they conducted a thorough investigation for both incidents by talking with all residents and staff members in the facility. The administrator stated to prevent recurrence they held abuse education services to educate all staff on abuse and neglect. The administrator stated CNA #4 and LPN #4 were terminated and reported to the appropriate registries. The administrator stated monitoring had been put into place to ensure these events did not reoccur and the QA committee had reviewed the incident and interventions.

Based on record review and interview, the facility failed to ensure discharge assessments were submitted to CMS within seven days of completion of the assessment for two (#64 and #66) of 18 sampled residents whose assessments were reviewed. The administrator reported 75 residents resided in the facility. Findings: Res #64 admitted to the facility with diagnoses which included hypertension, hyponatremia, and malnutrition. A discharge assessment, dated 08/29/24, was completed but not submitted to CMS. Res #66 admitted to the facility with diagnoses of chronic obstructive pulmonary disease, cerebrovascular accident, and hypertension. A discharge assessment, dated 08/31/24, was completed but not submitted to CMS. On 01/24/25 at 11:03 a.m., the MDS coordinator reported the assessments should have been submitted

Based on record review and interview, the facility failed to ensure assessments were coded accurately for one (#75) of 18 sampled residents whose assessments were reviewed. The administrator reported 75 residents resided in the facility. Findings: Res #75 admitted to the facility with diagnoses which included heart failure, hypertension, and diabetes. A discharge summary, dated 10/24/24, documented the resident went home. A discharge assessment, dated 10/28/24, documented the resident was discharged to the hospital. On 01/23/25 at 1:44 p.m., the MDS coordinator reported the assessment was not accurate.

Based on record review and interview, the facility failed to obtain an order for suprapubic catheter care for one (#46) of one resident reviewed for catheter care. The administrator identified 75 residents resided in the facility. Findings: Resident #46 had diagnoses which included benign prostatic hyperplasia with lower urinary tract symptoms. On 1/24/25 at 10:57 a.m., LPN #1 was preparing to perform suprapubic catheter care. When reviewing the resident's orders they noted there was not an order for catheter care. LPN #1 stated there should be an order for catheter care. On 1/24/25 at 11:29 a.m., the DON stated the resident went to the hospital and when they returned the order for catheter care was not put into the resident's orders.

Based on record review and interview, the facility failed to prevent abuse for one (#2) of three sampled residents who were sampled for abuse. Administrator #1 identified 71 residents resided in the facility. Findings: Resident #2 had diagnoses which included dementia and anxiety. An Incident Report Form, dated 10/12/23, documented the ADON overheard Resident #2 ask CNA #1 if the police were there yet because they were still scared. It was documented the ADON interviewed the resident and they stated they did not want to go back to their room because they were afraid of being hit again. It was documented Resident #2 stated CNA #2 took the buzzer so they could not call for help, turned of the lights and the TV, and would not help them all night. It was documented the resident stated they began to scream for the nurse when CNA #2 came back into the room and hit them. The facility's in-services records documented they had in-services with all staff on abuse dated 06/17/24. A review of the quality assurance records indicated abuse was being monitored with each quality assurance meeting and on going between meetings. On 10/8/24 and 10/9/24 all staff were interviewed regarding all types of abuse and were able to stated the different types of abuse. On 10/09/24 at 3:00 p.m., Administrator #1 stated the abuse of Resident #2 was investigated. They stated CNA #2 was suspended during the investigation and then terminated. They stated Resident #2 was moved to another room per resident request. They stated all staff were in-serviced regarding abuse.

Based on record review and interview, the facility failed to ensure a resident was not involuntarily discharged for one (#1) of three sampled residents reviewed for involuntary discharge. The Administrator identified 77 residents resided in the facility. Findings: A Transfer or Discharge, Facility-Initiated policy, revised 10/23, read in part, Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require residents/representative notification and orientation, and documentation as specified in this policy. 1. Each resident will be permitted to remain in the facility, and not be transferred or discharged unless: a .necessary for the resident's welfare . b . the resident no longer needs the services provided by this facility . c. the safety of individuals in the facility is endangered . d. the health of individuals in the facility would otherwise be endangered; e.nonpayment . f. the facility ceases to operate . Resident #1 had diagnoses which included Alzheimer's disease and sub-[NAME] hemorrhage. A progress note, dated 05/01/24, documented the resident's return to the facility from a hospital admission from a fall. An executive progress note, dated 05/02/24, documented the resident's spouse was upset on finding the resident was admitted back to their original room, and had concerns regarding receiving appropriate rehabilitation services. The spouse had originally agreed to a suggestion from the administrator to transfer the resident, but had now decided to have the resident remain in the facility. The spouse was told staying at the facility now was not an option. A progress note, dated 05/03/24, documented the resident was discharged from the facility at approximately 4:00 p.m. On 05/21/24 at 10:53 a.m., the Administrator stated the spouse of Resident #1 agreed to suggestion of a transfer and the process of finding Resident#1 new placement was begun immediately. The administrator stated the spouse did change their mind the next day but was told that staying at the facility was not an option. On 05/22/24 at 11:56 a.m., the Administrator stated Resident #1 was not allowed to remain in the facility because the transfer was already in process. The administrator stated a transfer could be stopped while the resident was still in the facility, but they had chosen not to stop it.

Based on interview and record review, the facility failed to track infection and analyze the data for trends in infection for three, (June, July, and August of 2022), of three months of tracking and trending data. The administrator identified 83 residents resided in the facility. Findings: On 08/17/22, the infection control tracking and trending reports were requested from the Infection Control Preventionist (ICP). The ICP was unable to provide these reports. On 08/18/22 the reports were again requested. The ICP stated she was working on them. On 08/18/22 at 1:05 p.m., the ICP stated, I was doing the tracking and trending, but then we got a lot of Covid19 and the tracking and trending just kind of fell off. Since mid June there has not been tracking and trending on the form. I was keeping up with the tracking and trending on a daily basis by looking at the individual lab sheets. We had not formally compiled the information. When asked if this was the proper way to do tracking and trending the ICP stated no. On 08/ 18/22 at 1:36 p.m. the administrator stated she was unaware the tracking and trending of infections was not up to date.

Based on record review, observation, and interview, the facility failed to ensure residents were free of significant medication errors for one (#69) of five residents whose medications were reviewed during an observation of the medication pass. The administrator identified 83 residents who received medications. Findings: The monthly physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/18/22 at 9:10 a.m., CMA #1 was observed to administer two [MEDICATION(S)] extended release 100mg capsules to resident #69 during the morning medication pass. The CMA placed two capsules in the souffle cup and handed the medication card to the surveyor. The medication card documented to give the resident two [MEDICATION(S)] extended release 100mg capsules in the morning, one in the afternoon, and one in the evening. On 08/18/22 at 3:05 p.m., the CMA was asked how many [MEDICATION(S)] extended release capsules they administered to resident #69. The CMA stated the medication card documented to give two capsules, so that was what they administered. The CMA was asked how they knew what the current order was for the medication. The CMA stated they usually looked at both the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The CMA was asked if there was more than one medication card. The CMA stated there were three medication cards for the medication. The CMA was asked if they all contained the same instructions for administration. The CMA stated yes. The CMA was asked if any of the cards were labeled with a change of order sticker. The CMA stated no. The CMA was asked if they administered two capsules to resident #69 every morning. The CMA stated they usually did not work as the CMA but held many positions in the facility and would help where ever it was needed. On 08/18/22 at 3:45 p.m., ADON #1 stated the resident had entered the facility for skilled services with their medications from assisted living. The ADON stated the resident's medications from assisted living would have been stored in one of the cabinets used for overstock of the residents' medications. The ADON stated when the resident entered the facility for skilled services, the physician wrote new orders and decreased the [MEDICATION(S)] 100mg extended release dosage. The ADON stated they thought when the resident was no longer on skilled services and their medications from their skilled stay had all been administered, the CMAs utilized the stored medications from the overstock cabinet. The ADON stated since the medications came from the same pharmacy, the medication cards would appear the same as what the facility used. The ADON stated it was the responsibility of the CMA to read the label on the medications and confirm it followed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on record review, observation, and interview, the facility failed to correctly label stored medications for one (#69) of five residents whose medications were reviewed during an observation of the medication pass. This resulted in a significant medication error for resident #69. The administrator identified 83 residents who received medications. Findings: The monthly physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/18/22 at 9:10 a.m., CMA #1 was observed to administer two [MEDICATION(S)] extended release 100mg capsules to resident #69 during the morning medication pass. The CMA placed two capsules in the souffle cup and handed the medication card to the surveyor. The medication card documented to give the resident two [MEDICATION(S)] extended release 100mg capsules in the morning, one in the afternoon, and one in the evening. There was no indicator to identify the medication dosage had been changed. On 08/18/22 at 3:05 p.m., the CMA was asked how many [MEDICATION(S)] extended release capsules they administered to resident #69. The CMA stated the medication card documented to give two capsules so they gave two capsules. The CMA was asked how they knew what the current order was for the medication. The CMA stated they usually looked at both the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The CMA was asked if there was more than one medication card. The CMA stated there were three cards for that medication. The CMA was asked if all the cards read with the same instructions for administration. The CMA stated yes. The CMA was asked if any of the cards were labeled with a change of order sticker. The CMA stated no. On 08/18/22 at 3:45 p.m., the ADON stated when a resident first entered the facility, the admitting nurse was responsible for confirming the medications they received matched the admitting orders. The ADON stated after admission, the CMA was responsible for ensuring any medications received were labeled with the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review and interview, the facility failed to ensure services related to [CONDITION(S)] were coordinated for one (#75) of one residents who were reviewed for [CONDITION(S)] services. The Resident Census and Conditions of Residents form documented one resident received [CONDITION(S)]. Findings: Resident #75 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 02/18/22, documented the resident was to be referred to [CONDITION(S)] for treatment. A quarterly assessment, dated 07/06/22, documented the resident received [CONDITION(S)]. A nurse's note, dated 07/27/22, documented the resident had returned from [CONDITION(S)] and had been seen by the nephrologist. The note documented the resident returned with a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record did not reveal documentation a follow up had occurred for the physician's progress note or that surgery had been planned. On 08/18/22 at 11:38 a.m., the social services director was asked if resident #75's surgery had been planned. They stated the nursing department scheduled clinical appointments for the residents. On 08/18/22 at 11:46 a.m., ADON #1 was asked what the facility's process was for consultations and orders for surgical appointments. ADON #1 stated when an order was received they notified the receptionist via email to schedule the appointment. ADON #1 was asked what the status was of the order for resident #75, dated 07/27/22, for fistula replacement. They stated they would need to check with the receptionist. They reviewed the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . They stated they would follow up with LPN #1 and the receptionist. A nurse's note, dated 08/18/22 at 12:29 p.m., documented the social worker had spoken to staff at the nephrologist office and had been informed the surgery had been set up for 09/15/22. On 08/18/22 at 1:15 p.m., LPN #1 was asked about the status of the physician's progress note for resident #75, dated 07/27/22, regarding fistula replacement. They stated they were not sure. They were asked what their role was to ensure follow through with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . They stated they communicated on [CONDITION(S)] forms with the [CONDITION(S)] center and communicated about appointments during shift change. LPN #1 was asked if they had informed anyone at the facility the nephrologist had written an order to plan for surgery to replace the failed fistula. They stated they had not reported to anyone and the [CONDITION(S)] center should keep them informed. On 08/18/22 at 2:58 p.m., ADON #1 stated the facility's receptionist had not been made aware of the need to follow up on the nephrologist's order. ADON #1 stated LPN #1 should have emailed the order to plan for surgical replacement of the fistula to the receptionist. ADON #1 stated they had spoken with LPN #1 and they had not notified anyone at the facility about the nephrologist's order. They stated LPN #1 informed them they had also not followed up with the [CONDITION(S)] center about the fistula replacement.

Based on observation and interview the facility failed to provide a sanitary kitchen environment in one (#5) of five kitchens observed for sanitation. The facility's Resident Roster identified 42 residents ate from the kitchen identified. On 03/18/22 at 12:29 p.m., the Executive Chef provided a tour of kitchen #5 (Cafe Chapman). Observations of gnats in the floor drain in the back of the kitchen, food particles on the floor throughout the kitchen, black and brown splatters on the walls, black areas of gout throughout the kitchen floor, and food particles in cupboards. At 1:00 p.m., the Executive Chef stated he would be responsible for ensuring the kitchens were cleaned and stocked with needed items when he completed his training. He stated the Dietary Manager currently was taking the responsibility, but he was not currently at the facility. He stated each kitchen's assigned staff were required to maintain a clean and sanitary environment. He was informed of the observations in kitchen #5. He stated the staff should be cleaning daily. He stated, They obviously were not, and he would address it today. On 03/28/22 at 10:19 a.m., observation of kitchen #5 was completed. The kitchen was not in use at that time. The floors were unswept and mopped, food particles were present on the floor throughout the kitchen. Food particles were observed to be around the burners on the stove top and the mini refrigerator under the counter top. Areas throughout the kitchen were observed to have dried liquid splatters on the walls and floors. While walking through the kitchen the floors were sticky. In the dining area under the counter to the kitchen, food particles were observed on the floor. No insects were observed in the kitchen during the observation. The Executive Chef was not present or available for interview.

Based on interview and record review the facility failed to provide and obtain an ordered medication for one (#4) of four residents reviewed for pharmacy services. The Administrator identified 88 residents reside at the facility. Resident #4 admitted to the facility on [DATE], with diagnoses that included acute kidney failure and left [CONDITION(S)] with a drain placed. Review of the Resident's discharge instructions from Ascension St. John Medical Center Emergency Department, dated 03/22/22, documented, . List of Medication to Take at Home acetaminophen-[MEDICATION(S)] ([MEDICATION(S)] 5 mg-325 mg oral tablet) 1 tab oral every 4 hours as needed Moderate to Severe Pain . The facility's, Nursing Admission Comprehensive Assessment, dated 03/22/22, documented the resident verbalized pain of six out ten on a pain scale. It documented the resident stated the pain was daily to her back. A Physician's Order, dated 03/23/22, documented the resident was to receive [MEDICATION(S)] 5/325 mg by mouth as needed every four hours. On 03/28/22 at 10:36 a.m., resident #4 stated her pain was a seven out of 10 on the pain scale. She stated she only received Tylenol for her pain, and it did not help much. The resident stated the pain was constant to the drain site in her lower back. She stated she was told she came from the hospital with an order for [MEDICATION(S)] but it had not arrived from the pharmacy. On 03/28/22 at 12:39 p.m., LPN #1 stated the resident did have an order for [MEDICATION(S)], but she did not know if it had been delivered from the pharmacy yet. On 03/28/22 at 12:39 p.m., CMA #1 stated the medication was not received from the pharmacy, and the resident had not taken the medication. On 03/28/22 at 12:50 p.m., the ADON was informed of the medication not being available to the resident. She stated she did not know why the medication had not been received and, Clearly there is a disconnect.

Based on observation, interview, and record review, it was determined the facility failed to implement their infection control program to prevent the potential spread of infection for five of s seven sampled residents who were reviewed for infection control. The facility failed to: ~ initiate transmission based precautions and quarantine for one (#7) of one residents who received [MEDICAL TREATMENT] outside of the facility and whose COVID status was unknown; ~ ensure residents who had possible exposure to COVID-19 were quarantined for 14 days for (#2 and #3) of two residents reviewed for potential exposure; ~ ensure residents who developed symptoms were quarantined for 14 days for two (#1 and #6) of two residents reviewed for the development symptoms; and ~ ensure staffs' proper use of face masks and hand hygiene/cough etiquette was performed. This had the potential to affect all 65 residents who resided in the facility. Findings: The Center for Disease Control guidance titled, Preparing for COVID-19 in Nursing Homes documented, .Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown. Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. The Centers for Disease Control guidance, regarding donning PPE, documented, .Respirator/facemask should be extended under chin. Both your mouth and nose should be protected. Do not wear respirator/facemask under your chin . The Core Infection Prevention and Control Practices for Safe Care Delivery in All Healthcare Settings recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) include the following strong recommendations for hand hygiene in healthcare settings: .Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient .Before performing an aseptic task .Before moving from work on a soiled body site to a clean body site .After touching a patient or the patient's immediate environment .After contact with blood, body fluids, or contaminated surfaces .Immediately after glove removal . 1. Resident #7 had [DIAGNOSES REDACTED]. A physician order, dated 01/19/18, documented the resident received outpatient [MEDICAL TREATMENT] three times a week. On 07/07/20 at 9:43 a.m., resident #7 was observed in her wheel chair coming out of home four into the main common area on the memory care unit. She was observed to wear a cloth mask which covered her mouth but was under her nose. The DON stated resident #7 received [MEDICAL TREATMENT]. The resident's room was observed in home four of the memory care unit. The room was not observed to have signage posted to indicate quarantine/isolation precautions or a bin with PPE. The room was observed to contain two beds. At 9:45 a.m., the DON was asked if resident #7 had a roommate. She stated yes. At 12:24 p.m., resident #7 was observed eating at a dining room table in home four. She was distanced from other residents. On 07/07/20 at 1:34 p.m., the infection preventionist was asked what precautions resident #7 was on. She stated the resident was screened every time she left the facility to go to [MEDICAL TREATMENT]. She was asked why resident #7 was not quarantined. She stated she was not aware the resident required quarantine. At 2:15 p.m., resident #7 was observed sitting in the common area eating a piece of pie. She was not six feet from the resident to her right. The activity director moved resident #7 but she was then not six feet from the resident to her left. On 07/07/20 at 2:43 p.m., the DON was asked why resident #7 was not quarantined upon return from [MEDICAL TREATMENT]. She stated the [MEDICAL TREATMENT] unit was protected and they took precautions. She stated the [MEDICAL TREATMENT] facility reported they did not provide services to residents who were COVID positive. She was asked why resident #7 had a roommate. She stated she has had the same roommate since before the pandemic. 2. Review of the respiratory surveillance line list documented resident #2 had possible exposure to COVID-19 on 06/23/20 and resident #3 had direct exposure to COVID-19 on 07/02/20. ~ Resident #2 had [DIAGNOSES REDACTED]. A nurse note, dated 06/23/20 at 12:31 a.m., documented a new order was received to obtain a COVID test due to possible exposure. A nurse note, dated 06/23/20 at 1:34 p.m., documented, .Spoke with (name withheld) (POA) regarding resident's new orders to be Covid tested today due to roommate having S&S. Resident continues to exhibit no S&S . A nurse note, dated 06/26/20 at 11:39 a.m., documented, .Resident removed from isolation d/t Negative Covid 19 results (received) by (name withheld) ADON, Resident showered and in Common area of Home #3 . ~ Resident #3 had [DIAGNOSES REDACTED]. A nurse note, dated 07/02/20 at 12:38 p.m., documented the resident had been moved to the isolation wing on the memory care unit for isolation protocol. A nurse note, dated 07/06/20 at 10:32 a.m., documented, .Resident's COVID test results came back notified (sic). Resident was given a shower and moved back to her original room . On 07/07/20 at 9:50 a.m., the isolation wing on the memory care unit was observed. Resident #2 and resident #3 were not observed to reside on the isolation unit. At 10:35 a.m., the isolation wing on the memory care unit was observed. Resident #3 was observed on the isolation wing. CNA #1 was asked why resident #3 was in isolation. She stated she was told the resident had to return to quarantine. At 10:37 a.m., LPN #1 was asked why resident #3 was in isolation. She stated the ADON instructed her to move the resident back to the isolation wing due to new guidelines. She stated the resident was removed from isolation to her previous room on 07/06/20 after receiving negative COVID-19 test results. A nurse note for resident #3, dated 07/07/20 at 10:38 a.m., documented, .Resident was moved back to Isolation Unit per facility protocol at 10:35 a.m. On 07/07/20 at 1:34 p.m., the infection preventionist was asked what criteria was met for a resident to be removed from isolation/quarantine. She stated they were to be in quarantine for 14 days and be symptom free. She was asked why resident #3 had been removed from quarantine before 14 days. She stated she did not know why. She was asked why resident #2 had been removed from quarantine before 14 days. She stated he tested negative for COVID-19. On 07/07/20 at 2:43 p.m., the DON was asked why resident #2 had been removed from isolation/quarantine before 14 days was completed. She stated resident #2 and his roommate, resident #1, tested negative for COVID-19. She stated resident #2 was a possible exposure from symptoms resident #1 had experienced. She stated resident #1 was diagnosed with [REDACTED]. She was asked why resident #3 was removed from the isolation wing on 07/06/20 after being placed in isolation for exposure on 07/02/20. She stated the resident's possible exposure was on 06/25/20. She stated once they were made aware of the possible exposure they placed the resident on the isolation wing and was tested on [DATE]. She stated they had received negative COVID results on 07/06/20 and removed the resident from isolation on that day. She was asked why resident #3 was on the isolation wing currently. She stated to complete a 14 day isolation. She stated, We prematurely took her out. 3. Review of the respiratory surveillance line list documented resident #1 had a cough and unspecified 'other' symptoms on 06/23/20. The respiratory line list documented resident #6 had a fever and shivering on 07/02/20. ~ Resident #1 had [DIAGNOSES REDACTED]. A nurse note, dated 06/23/20 at 11:51 a.m., documented the resident was observed coughing, his eyes were red, and had a temperature of 98.0. The note documented the physician ordered a chest x-ray a COVID-19 test, and [MEDICATION NAME] as needed. A nurse note, dated 06/23/20 at 2:59 p.m., documented a COVID-19 swab was completed by the ADON and the chest x-ray results revealed no acute abnormality. An x-ray report, dated 06/23/20, documented, .Reason for exam: Cough .EXAM: CHEST 1 VIEW .Impression: 1. No acute abnormality. 2. Mild cardiac enlargement with diffuse interstitial prominence which is thought to be chronic . A nurse note, dated 06/24/20 at 11:07 a.m., documented, .Resident cont on Isolation in room, alert x 1, coughing at times, eyes red, Temp 98.4 .pending Covid 19 results, no other S/S of discomfort observed or reported . A molecular lab report, dated 06/25/20, documented, H. influenzae was detected at a high level and S. epidermidis was detected at a low level. A nurse note, dated 06/25/20 at 4:55 p.m., documented, .Results from respiratory tested (sic) (received). H. Influenzae present .Still awaiting Covid test results. Resident remains afebrile . A nurse note, dated 06/25/20 at 10:48 p.m., documented, .Resident conts to be flushed in face and redness in eyes. Resident coughing during this shift, prn [MEDICATION NAME] given. Resident congested .Resident started [MEDICATION NAME] 500/125 this evening for H. influenza (sic). Still awaiting covid results. Afebrile . A nurse note, dated 06/26/20 at 1:00 p.m., documented, .Negative Covid 19 results per (name withheld) ADON .Resident removed from Isolation precautions, no cough observed while completing assessment, Cont on [MEDICATION NAME] 500mg d/t H Influenza (sic) . ~ Resident #6 had [DIAGNOSES REDACTED]. A nurse note, dated 07/02/20 at 9:59 p.m., documented, .CNA notified this nurse that (resident's name withheld) was shivering. This nurse went to check (resident's name withheld) temperature and noticed she had a runny nose and temp was 101.1. (Physician name withheld) has been notified via qliq, (Physician name withheld) responded 'Check for covid and isolate till back.' . A nurse note, dated 07/03/20 at 9:27 p.m., documented, .Resident is awaiting, covid results, no changes in symptoms, will continue to monitor . A nurse note, dated 07/07/20 at 4:44 a.m., documented, .Res cont on ISO, covid test pending, no runny nose, resp un labored, res shriving (sic) off an on throughout the night, right corona (sic) light pinkish colored .temp 97.7 . A nurse note, dated 07/07/20 at 9:19 a.m., documented, .Resident's COVID results were negative. Resident will shower and be moved back to her former room this shift . On 07/07/20 at 9:50 a.m., the isolation wing on the memory care unit was observed. The DON was asked how many residents resided on the isolation wing. She stated two. She stated resident #6 had mild symptoms but tested negative for COVID and was being moved back to her room today. She was asked how long resident #6 had been in isolation. She stated six days. At 9:58 a.m., LPN #1 was observed to enter the isolation wing and don PPE. She was observed to enter resident #6's room with CNA #1. At 10:04 a.m., LPN #1 was observed to doff PPE and push resident #6's broda style chair out of the isolation wing into the main common area of the memory care unit. She placed the resident more than six feet away from another resident who was across the room. At 10:35 a.m., resident #6 was observed to be on the isolation wing in memory care. CNA #1 was asked why resident #6 was back on the isolation wing. She stated she was told the resident had to return to isolation. At 10:37 a.m., LPN #1 was asked why resident #6 had returned to the isolation wing. She stated the ADON instructed her to return the resident to the isolation wing to complete 14 days of quarantine. She stated the resident had a fever and was tested for COVID last week. She stated they received negative results today which was why she had removed the resident from isolation. At 1:34 p.m., the infection preventionist was asked what criteria had been met to remove resident #1 and resident #6 from isolation before 14 days. She stated she did not know why they were taken out of isolation. A nurse note, dated 07/07/20 at 1:44 p.m., documented, Resident moved back into precautionary isolation unit due to new guidelines . On 07/07/20 at 2:43 p.m., the DON was asked why resident #1 was removed from quarantine on 06/26/20. She stated they had obtained a COVID test which was negative. She stated the resident had a respiratory illness. She was asked what symptoms resident #6 had experienced. She stated shivering but was afebrile. She was asked what criteria resident #6 met to be removed from the isolation wing on 07/07/20. She stated they had received negative COVID test results on 07/07/20 and the resident was asymptomatic. She was asked why resident #6 was returned to the isolation wing. She stated she would need to check. 4. On 07/07/20 at 9:37 a.m., the memory care unit was observed. CNA #4 was observed sitting across from a resident at a table. They were not six feet apart. CNA #4's facemask was observed below her chin and was not covering her nose or mouth. She was observed to obtain a cup of cranberry juice from the refrigerator and give it to the resident. She was observed to then place face mask over her nose and mouth and wash her hands. At 10:04 a.m., LPN #1 was observed to discard her surgical mask after she had dropped it on the floor in the isolation wing. She was observed to push a resident from the isolation wing into the main common area on the memory care unit. She was observed to walk through the common area to the nurse's station and sanitize her hands. She was then observed to walk around the nurse's station to the ADON's office and obtain/don a face mask. At 10:17 a.m., CNA #2 was observed to exit room [ROOM NUMBER]. Her face mask was observed to only cover her mouth with her nose exposed. She was observed to walk down the hallway, past the common areas to a hand washing sink, and wash her hands. At 10:19 a.m., CNA #2 was observed to walk back down the hall. Approximately mid-way down the hall, her mask was observed to cover her nose and mouth. At 10:43 a.m., CNA #4 was observed to sit across the table from a resident. They were not observed to be six feet apart. CNA #4's face mask was observed to be under her chin. She was observed to put something in her mouth and cough into her right fist. At 10:45 a.m., CNA #4 was observed to place her face mask over her nose and mouth. At 11:57 a.m., CMA #2 was observed assisting a resident with the noon meal. Her face mask was observed to only cover her mouth. At 12:01 p.m., CNA #1 was observed in resident #6's room on the isolation wing. She was observed to cover the resident with a blanket, place a fall mat by the bed, lower the bed, place the call light on the bed, push the mechanical lift out of the room, obtain sanitizing wipes, and sanitized the lift. She was observed to walk to resident #3 who was sitting at a table in the common area and throw her disposable lunch container into the trash. She was then observed to assist resident #3 in her wheel chair to her room. She obtained an incontinence pad, placed it on the bed, and shut the door. CNA #1 was not observed to perform hand hygiene or change her gloves between encounters with resident #6 and resident #3. At 12:21 p.m., CNA #1 was asked how often she changed her gloves. She stated she changed her gloves if she showered a resident or provided incontinent care. She was asked how often she performed hand hygiene. She stated, Every time I'm done touching anything. She was asked why she had not changed her gloves between encounters with resident #6 and resident #3. She stated, I forgot I needed to between them. She was asked when the last time she had performed hand hygiene and changed her gloves. She stated when she had returned from her break at approximately 11:30 a.m. At 12:21 p.m., CNA #1 was observed on the isolation wing. The bottom strap of her face mask was observed to hang freely below her chin. She was asked why her mask was not properly secured with both straps. She stated it was suffocating her. On 07/07/20 at 1:34 p.m., the infection preventionist was asked who monitored to ensure face masks were properly worn by staff. She stated anyone walking around doing rounds was to monitor. She stated if they observed masks not properly placed they inserviced that staff member. She was asked how hand hygiene and cough etiquette were monitored. She stated the staff were instructed to cough into their elbow, wash their hands with soap and water, and sanitize their hands after each resident encounter. She stated the nurses monitored the staff. At 2:25 p.m., CNA #1 was observed to ask a staff member for a urinal to empty resident #3's catheter bag. She was observed to wash her hands and don gloves before entering the resident's room. She was then observed to exit the room, open the door to the isolation wing, obtain the urinal from the CNA, reenter the resident's room, and empty the catheter bag into the urinal. She was not observed to wash her hands or change her gloves before the encounter. At 2:30 p.m., CNA #1 exited resident #3's room, removed her gloves, and washed her hands. She was observed to move her gown aside and obtain a pair of gloves from her pocket and don them. She was asked why she kept gloves in her pocket. She stated she wanted to make sure she had them available. At 2:49 p.m., the DON was asked how staff were monitored to ensure masks were properly worn and hand hygiene/cough etiquette were performed. She stated random rounds were conducted by the clinical educator and the infection control nurse.

Based on interview and record review, it was determined the facility failed to notify a resident's representative when a medication had been added to the resident's medication regimen for one (#4) of three sampled residents whose records were reviewed for notification of change. This had the potential to affect all 90 residents who resided in the facility. Findings: A policy titled, Change in a Resident's Condition or Status, dated (MONTH) (YEAR), documented, .Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status .Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status . Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. A physician order, dated 05/30/19, documented, [MEDICATION NAME] acid 250 mg capsule (1) Capsule oral .Restlessness and Agitation .Two times daily Starting 05/30/19 . No documentation was found that the daughter, resident representative, had been notified that the medication had been added to the resident's medication regimen. A discharge assessment, dated 06/10/19, documented the resident was severely impaired for daily decision making, had hallucinations and delusions, exhibited physical and verbal behaviors toward others. The assessment documented the resident required extensive assistance with personal hygiene, rejected care, was occasionally incontinent of bowel and bladder, and wandered the unit by self-propelling himself in a wheelchair. The assessment documented the resident had been administered an antipsychotic two days of the seven day look back period. On 10/02/19 at 4:43 p.m., the DON was asked what the facility procedure was when a resident had a change in their medication. She stated any change in the resident's orders were relayed to the family or representative. She was asked who was responsible to ensure the family/representative were notified with a change in a resident's medication. She stated the nurse accepting the order. She was asked where that notification would be documented. She stated the nurses' notes. She was asked if resident #4's daughter had been notified when the physician ordered that the resident be started on [MEDICATION NAME] Acid. She stated she would have to review the medical record. At 5:20 p.m., the DON stated she could not find any documentation that the daughter had been notified of the [MEDICATION NAME] Acid being added to the resident's medication regimen.

Based on interview and record review, it was determined the facility failed to develop a comprehensive care plan related to: ~The use of an anticonvulsant for restlessness and agitation; ~The use of a [MEDICAL CONDITION] medication; and ~Behaviors; for one (#4) of three sampled residents whose care plans were reviewed. This had the potential to affect all 90 residents who resided in the facility. Findings: A policy titled, Care Plans, Comprehensive Person-Centered, dated (MONTH) (YEAR), documented, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. A physician order, dated 05/30/19, documented, [MEDICATION NAME] Acid 250 mg capsule .two times daily .Restlessness and agitation . A review of the comprehensive care plan did not include a problem area, measurable goals, and interventions for the use of an anticonvulsant for restlessness and agitation. A physician order, dated 06/08/19, documented, [MEDICATION NAME] 50 mg .every evening .Restlessness and agitation . A review of the comprehensive care plan did not include a problem area, measurable goals, and interventions for the use of an antipsychotic medication. A discharge assessment, dated 06/10/19, documented the resident was severely impaired for daily decision making, had hallucinations and delusions, exhibited physical and verbal behaviors toward others. The assessment documented the resident had been administered an antipsychotic two days of the seven day look back period. A review of the comprehensive care plan did not include a problem area, measurable goals, and interventions for behaviors exhibited by the resident. On 10/03/19 at 12:36 p.m., the MDS/Care Plan Coordinator was asked who was responsible for updating the care plan. She stated each department was responsible for entering information into the care plan that is pertinent to their area. She was asked when a care plan was updated. She stated the care plan was updated with assessments, when the interdisciplinary team had input from a specific area, with new orders, and when an incident report was submitted. She was asked how it was decided what goes into the care plan. She stated from the nurses monthly meetings, when on an antipsychotic medication and/or antibiotic, when there is a fall, and incident reports. She was asked why the resident's care plan had not included a problem, measurable goal, and interventions related to the use of an antipsychotic and anticonvulsant for restlessness and agitation. She stated, The nurse that put it in, that is the step she missed. She was asked with the history of the resident's behaviors why there had not been a problem, measurable goal, and interventions in his care plan related to behaviors. She stated after he had the incident report it should have been updated. She stated that was the process after an incident report was submitted.

Based on interview and record review, it was determined the facility failed to order and complete lab for a serum level used to monitor the use of an anticonvulsant for one (#4) of three sampled residents whose lab work was reviewed. This had the potential to affect all 90 residents who resided in the facility. Findings: Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. The resident had been having increased behaviors of spitting, use of inappropriate language, yelling, and combativeness. A nurse note, dated 05/30/19 at 7:22 a.m., documented a new order had been received from the physician for [MEDICATION NAME] Acid 250 mg twice daily. The order included checking the [MEDICATION NAME] Acid Serum level in ten days. The [MEDICATION NAME] Acid Serum level would have been drawn by the lab on 06/10/19. A review of the lab orders in the resident's medical record, dated 05/30/19, documented as follows: ~Order Date - 05/30/2019; ~Status - Completed; ~Description - [MEDICATION NAME] Acid, Serum 1 time weekly for 1 week; ~Start Date - 06/10/2019 .Stop Date - 06/17/2019; and ~Frequency - Scheduled - First scheduled time is 06/17/2019 on the anytime time period. A nurse note, dated 06/10/19 at 8:37 p.m., documented at 7:00 p.m. the resident had been sent to the hospital emergency room to be evaluated and medical clearance for reoccurring physical behaviors toward another resident. The facility was asked for the results of the serum level lab work ordered for 06/10/19, which was the ten days after first starting the [MEDICATION NAME] Acid. The former administrator, now CEO, stated the lab had never been done. She stated it had been entered into the computer incorrectly and the first lab for a Serum level had been scheduled for 06/17/19. A discharge assessment, dated 06/10/19, documented the resident was severely impaired for daily decision making, had hallucinations and delusions, exhibited physical and verbal behaviors toward others. The assessment documented the resident required extensive assistance with personal hygiene, rejected care, was occasionally incontinent of bowel and bladder, and wandered the unit by self-propelling himself in a wheelchair. On 10/02/19 at 4:25 p.m., the former administrator was asked who was responsible for entering lab orders into the computer. She stated the nurse receiving the order. She stated the ADON then verified the order. She stated the lab order was on the treatment administration sheet which documented the lab to be drawn on (MONTH) 17th, because it had been added incorrectly. She stated the first lab should have been ordered for 06/10/19.

Based on observation and interview, it was determined the facility failed to prepare and distribute food in a sanitary manner for 86 residents who received meals from the dietary department. The faciltiy census was 86. Findings: 1. On 06/18/19, the noon meal was observed. LPN #3 was observed with her hands in the pockets of her uniform pants. She then delivered bowls of fruit to the residents in the dining room. Hand hygiene was not observed. ADON #1 touched a resident on the shoulder and then served another resident their meal in the dining room. Hand hygiene was not observed. She then gave a resident a bite of food in the dining room and touched another resident's glasses. On 6/19/19, the evening meal was observed. CNA #1 was observed to place a resident in their wheelchair up to the table. She then helped residents put on clothing protectors. She touched a residents hair and then took the resident's orders for the meal. She pushed her glasses up with her hand and then delivered a meal to a resident in the dining room without any hand hygiene. The CNA pushed up her glasses again and delivered another meal in the dining room. Hand hygiene not observed. She then went into the kitchen area and retrieved silverware. Hand washing was not observed. She scratched her face and then served another meal in the dining room. Hand hygiene was not observed. Cook #1 poured a glass of milk and carried the glass to the resident by the rim. CNA #2 adjusted a resident's hearing aid, took orders for the meal, then delivered a plate and bowl holding the bowl by the rim. Hand hygiene was not observed before serving the meal. A second meal was served in the dining room. Hand hygiene was not performed. LPN #4 was observed to pick up and move a rolling chair, then placed a clothing protector on a resident, touched a resident's wheelchair by the handle, and then retrieved a spoon. She then proceeded to feed a resident soup. Hand hygiene was not observed. She helped a resident with a cup and placed the cup back on the table by the rim. She then took a meal back to the kitchen and brought a plate back for the resident. Hand hygiene was observed. On 06/25/19, the noon meal was observed. CNA #3 was observed to stand at the food serving area and scratch her head. She then served ice cream to a resident in the dining room and sat down at the table to assist another resident with her meal. Hand hygiene was not observed. At 12:35 p.m., CNA #3 was asked how often she washed her hands during meal service and when she assisted residents to eat. She stated she washed her hands all day long. She stated she was not aware she had touched dirty things while serving and assisting residents to eat. On 06/25/19 at 2:46 p.m., the DON was asked about hand hygiene during meals. She stated the staff should be using hand gel in between each resident when serving meals in the dining room. 2. On 06/20/19, the noon meal preparation was observed. Kitchen tongs were observed laying in the French fries on the warming table. DA #1 was observed with gloves on while she added oil to the grill. She scraped the grill with the gloves on and then retrieve bread for grilled cheese sandwiches out of the package with the same gloves on. Hand hygiene was not observed. DA #2 was observed using a knife to cut up pork loin. She used the same knife to cut open the packaging of another pork loin. She then sliced the pork loin using the same knife she had cut into the package with. DA #1 was observed to touch her name badge, put on a pair of gloves, and placed corn bread in a clean pan. She was not observed to wash her hands. She then walked over and retrieved another clean pan with the same gloves on and brought the pan back over to the preparation area and continued to place corn bread in the pan with the same gloves on. DA #3 was observed while obtaining temperatures of the food. She used the thermometer and then wiped the thermometer on a towel that was laying on the steam table. She repeated this action several times during the observation of food temperatures. She removed her gloves laid the thermometer on the counter and washed her hands. Alcohol wipes were brought in by cook #1 and laid on the counter. The DA then obtained the temperature of the cold BBQ chicken salad and then wiped the thermometer on the towel and obtained the temperature of the cantaloupe. The DA was observed to touch the inside of the bowls when handing them to the DM as he served soup on the other side of the dining window. The plate covers stacked up in the window pass on the memory unit were observed to still be wet from being washed. 3. On 06/25/19, the noon meal was observed. Cook #2 was observed to enter the kitchen area and not wash her hands. She retrieved ice cream from the refrigerator and took it out to the residents. A scoop handle was observed laying on top of the ground meat. Cook #3 was observed as she carried plates from the dish area to the serving counter touching the eating surface of the plates. She then put on gloves and served food. She was not observed to wash her hands. She was observed to touch the plastic wrap and the menus that were laying on the counter and served food with the same gloves on. On 06/25/19 at 3:01 p.m., the director of dietary services was informed of the observations. He stated they instructed staff to wash their hands when they changed gloves. He stated staff should not be touching dirty things with or without gloves on and not wash their hands. He stated the staff should have used alcohol wipes when cleaning the thermometer. He stated the eating surfaces of the utensils should not be touched with hands or dirty gloves. He stated the scoop handles should not have been laying in the food and the staff should not cut open the packaging of the meat with the same knife she used to cut the meat.

Based on observation, interview, and record review, it was determined the facility failed to recognize pain and implement pain management interventions for one (#8) of six sampled residents who were reviewed for pain. This resulted in an actual harm for resident #8 when the resident experienced pain during the provision of catheter and incontinent care and no intervention was provided. The facility's census and condition report identified 39 residents were on a pain management program. Findings: A facility policy titled, Pain Management of the Elderly documented, "...NONSPECIFIC SIGNS AND SYMPTOMS THAT SUGGEST THE PRESENCE OF PAIN: Frowning, grimacing, fearful facial expressions, teeth grinding...Bracing, guarding, rubbing..." The facility's policy on pain, undated, documented, "PAIN RECOGNITION...What should you do if feel someone is in pain...Talk with them, sometimes just knowing someone cares can help...Report what you have observed to the nurse...Train direct care staff in the proper use of pain assessment tools...Promote a coordinated, aggressive approach to pain management throughout the facility...Nonspecific signs and symptoms that suggest the presence of pain: ...Frowning, grimacing, fearful facial expressions, teeth grinding... Bracing, guarding, rubbing...Resisting certain movements during care...AREAS OF PAIN OR DISCOMFORT TO ASSESS...Pattern...Duration...Location...Character...How much pain is being experienced...Severe or a great deal of pain...moderate pain...a little pain...No pain...What starts the pain or what if anything makes it worse...What makes the pain lessen or go away...Once the pain is assessed the care team which includes the resident, the family or responsibility, direct care staff and the physician need to discuss the issues and decide on a course of action. The Pain Management Program is then followed with regular assessments Emphasis needs to be placed on relieving pain..." Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. A pain care plan, dated 04/21/14, documented, "Problem: Pain...Polymyalgia Rheumatica...impaired mobility...S/P hip fx...sacral wound Goal: Resident will report pain to be a tolerable level. Approaches: Assess characteristics of pain: location, severity, on a scale of 1-10, type and frequency...Discuss with the resident factors that precipitate pain and what may reduce it. Instruct the resident about pain care and pain medications..." A pain assessment, dated 06/26/14, documented, "...Pain: Yes...Grimacing...Guarding...Restlessness...Pain assessment site location: Sacral wound site...Current level: 6...Worse pain gets (0-10): 10 Best pain gets...0...Increases with activity: Yes...Relieved by: Medication Management Relaxation Repositioning..." A quarterly assessment, dated 07/21/14, documented the resident had a BIMS score of 12. This score indicated the resident was moderately impaired with cognitive skills for daily decision making. The assessment documented the resident required assistance with ADLs, had a urinary catheter, was incontinent of bowel, experienced pain, and had received an antibiotic medication on seven of the last seven days. The current physician's orders [REDACTED]. [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg (ONE) TABLET [MEDICATION NAME] 500 mg (one) TABLET Oral...Give [MEDICATION NAME] 500 mg. one tablet every eight hours for twenty days..." On 07/31/14 at 4:15 p.m., catheter and incontinent care was observed for the resident. CNA #1 donned a gown in the hallway and stated the resident was in isolation. An isolation sign was observed on the resident's door. She placed several gloves from the isolation cart located outside the room into her pocket beneath the gown. She entered the room and did not close the door. She used hand sanitizer from her pocket and donned gloves from her pocket. She approached the resident and repositioned the resident from her left side to her back. The resident stated, "Oh, it hurts." The CNA stated, "I'm sorry." The CNA continued to reposition the resident and unfastened the resident's brief. There was a large amount of yellow colored liquid feces between the resident's legs and around the catheter tubing. The CNA replaced the brief and without removing her gloves went to the resident's closet. She touched the doors and opened the drawers. She returned to the resident with a container of disposable wipes. She pulled the brief down and taking the disposable wipes she wiped the catheter tubing and removed yellow feces from the tubing. The resident stated, "Oh, you hurt me." The CNA stated, "I'm sorry but I have to get this off." The CNA stated she had feces on her gown and had to change it. She removed her gown and gloves and went into the resident's bathroom and washed her hands. CNA #2 entered the room wearing a gown and gloves. CNA #1 stated, "Do you have plenty of gloves in your pocket." CNA #2 stated there should be some gloves in the room. CNA #1 left the room to get a new gown and more gloves. CNA #2 went to the resident's closet and found a box of gloves. CNA #1 returned to the room wearing a gown and gloves. CNA #2 went around the resident's bed and stood by the bed. CNA #1 removed the disposable wipes and cleaned the resident's catheter, wiping in a downward motion and used a new wipe each time. The resident cried out "Oh" as the CNA wiped the catheter and the resident's perineal area. The resident had her left knee bent and her right leg was straight and rotated inward. Without repositioning the resident's legs the CNAs' turned the resident to her left side. The resident again stated, "Oh. That hurts." The CNAs apologized and continued to hold the resident over on her side. CNA #1 rolled the soiled draw sheet, pad, and brief under the resident and placed a clean brief and pad under the resident's right side. There was not a clean draw sheet placed under the resident with the brief and pad. CNA #1 cleaned the resident's buttocks and anal area using the disposable wipes. During the care she touched and moved the resident's catheter and wound vac tubing. She removed her gloves, placed them in the resident's trash can and without washing or sanitizing her hands, donned gloves. Without repositioning the resident's legs the CNAs rolled the resident to her right side. The resident stated, "Oh that hurt me." The CNAs did not comment. After the resident was moved, she was on the edge of the bed and her head touched the nightstand. She grabbed CNA #1's gown and held onto it while the CNAs positioned the clean pad and brief under her and turned the resident onto her back. The pad was torn in the process of moving it under the resident and had an area of feces on the back side of the pad. CNA #2 stated, "We are going to have to change that again." CNA #2 removed her gloves and without washing or sanitizing her hands went to the resident's closet and retrieved a clean pad and brief. She asked CNA #1 if she had any more gloves. CNA #1 stated, "No." CNA #2 went to the resident's bathroom, removed her gown and placed it in the red biohazard container. She washed her hands and left the room. The resident continued to hold onto CNA #1's gown as the CNA stood by her bed and waited for CNA #2 to return. CNA #2 returned to the room wearing a gown and gloves. She stated, "I have more gloves." She lifted up her gown to show her uniform pocket which had gloves inside. CNA #1 removed her contaminated gloves. She went into the resident's bathroom, washed her hands, returned to the resident's bedside and retrieved a pair of gloves from CNA #2's pocket. They turned the resident again to her right side. The resident's head hung off the bed and touched the nightstand and the bedside table, which was up against the night stand. The resident stated, "Oh." The CNAs did not comment and continued to replace the contaminated and torn pad and brief. They turned the resident to her back. CNA #1 took a disposable wipe and cleaned the catheter again. There was yellow feces on the catheter. She removed her gloves and discarded them in the resident's trash can. She retrieved a pair of gloves from CNA #2's pocket and put them on. She continued to clean the catheter until there were no stains of feces visible on the wipe. She adjusted the catheter and wound vac tubing. She removed her gloves and without washing or sanitizing her hands, donned gloves and fastened the resident's brief." CNA #2 stated, "We need to adjust her." The CNAs looked at the pad and brief and stated they had not put a draw sheet under the resident. CNA #1 removed her gloves and without washing or sanitizing her hands went to the resident's closet and found a sheet. She folded the sheet and donned gloves. The CNAs again turned the resident and placed the sheet under the resident. They then turned the resident to her right side. The resident stated, "Oh." They placed pillows by the resident's head and legs as they repositioned the resident. The resident stated, "Oh, that hurt." CNA #1 removed the trash and placed it in the biohazard container. She removed her gloves, gown, washed her hands, and left the room. CNA #2 went to the door and asked her to hand her more gloves. CNA #1 handed her some gloves. CNA #2 donned gloves and lowered the resident's bed. She removed her gloves, washed her hands, and left the resident's room. The length of time of the care observed was 45 minutes from the time the care started until the care was completed. The resident grimaced, frowned, and appeared to be braced and guarded several times as the care was provided. Neither of the CNAs offered to wash the resident's hands after she had touched and held on to CNA #1's gown while the care had been provided. Neither of the CNAs were observed to report the resident had experienced pain to a nurse or CMA after they left the resident's room. On 08/01/14 at 2:00 p.m., LPN #1 was asked if she was the nurse in charge of the resident during the time the care was provided on 07/31/14. She stated, "Yes." She was asked if anyone had reported to her that the resident had been in pain during a lengthy provision of catheter and incontinent care. She stated she was unaware the resident had experienced pain and no one had reported that to her. The resident's MARs were reviewed with LPN #1. After she reviewed the MARs for 07/31/14, she stated the resident did not receive any pain medication until the next scheduled dose was given approximately two hours after the care was provided. She was asked if the resident's pain should have been reported and addressed. She stated, "Absolutely." She stated the resident also had as needed pain medication on the MAR and should have been given the medication. At 2:30 p.m., the RN unit manager was asked if the CNAs should report to the nurse when a resident experienced pain during care. He stated, "Yes." He was informed of the care observed on the resident. He was asked if he had observed the CNAs provide catheter/incontinent care. He stated he had observed some but not everyone. He was asked if the CNAs should have gathered supplies, been more organized regarding the care, washed their hands before and after care, after contaminating them, performed the care in a manner to prevent the spread of infections, and reported the pain to the nurse. He stated, "Yes." He stated he didn't know why they would not do things they should know to do. At 3:30 p.m., the DON, CEO, and the administrator were informed of the care and length of time it took to provide. They were asked if the CNAs should have reported the pain, been more organized regarding the care, assisted the resident into proper body alignment before repositioning, and washed their hands before care, after contaminating them, and after care. The DON stated yes and that the CNAs had been told many times to do those things.