Every finding on record at Senior Village Healthcare

Based on interview, observation, facility document and policy review, and the United States Food and Drug Administration 2022 Food Code, the facility failed to ensure food items were stored in a sanitary manner. Specifically, the facility failed to ensure opened items were properly labeled and dated in a facility freezer, failed to ensure items were labeled with a date and name prior to storage in the resident nourishment refrigerator, and failed to maintain temperature logs in the resident nourishment refrigerator.Findings included: The U.S. [United States] Food and Drug Administration 2022 Food Code, dated 2022, in section 3-501 Temperature and Time Control revealed, Ready-to-Eat, Time/Temperature Control for Safety Food prepared and held in a Food Establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 [degrees] C [Celsius] (41 [degrees] F [Fahrenheit]) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. The Food Code continued, Refrigerated, Ready-to-Eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations. An observation of a facility freezer was conducted with the Dietary Manager (DM) on 06/29/2026 at 9:01 AM. The observation of the freezer adjacent to the ice machine revealed: (1) one opened and undated vanilla ice cream container and (2) opened and undated sherbet containers. The DM discarded the vanilla ice cream and stated that the activities staff used the items. A follow-up observation was made of the facility freezer on 07/01/2026 at 11:15 AM. The observation revealed the same opened and undated vanilla ice cream from the first observation. During an interview on 07/01/2026 at 11:20 AM, the Director of Culinary Services (DCS) confirmed that the vanilla ice cream in the freezer was opened and not dated and should have been. During an interview on 07/02/2026 at 1:19 PM, the Administrator (ADM) stated he was surprised by the undated items found in dietary and said it was ultimately the responsibility of the DM. A facility policy titled, Dining Services Policy and Procedure Handling of Outside Food, dated 11/28/2017, indicated, 2. All outside food brought to dining services for storage will be properly secured and labeled as to prevent cross contamination and confusion with facility food. 3. Outside foods will be labeled with, the date it was brought into the dining services department for storage, the food item name and resident name if intended for an individual resident. 4. All outside foods will be subject to the same food handling/safety/storage practices as the facility foods. a. PHF/TCS [potentially hazardous foods and time /temperature control for safety] leftovers will only be kept for 24 hours and then discarded. b. Any container of food that has been directly eaten out of, will not be stored in the dining services department. c. PHF/TCS foods that were manufactured in a food processing facility, and have not been previously heated for service, will be kept for 7 days after the original package is opened. If it is unknown when the package was opened, the item will only be kept for 24 hours. An observation of the facility's resident nourishment refrigerator was conducted on 06/29/2026 at 2:40 PM. The observation of the resident nourishment refrigerator revealed:styrofoam container of Mexican food- no use-by date or name.opened 20-ounce bottle of vanilla coke- no use-by date or name.(1) opened jar of maraschino cherries- no use-by date or name. During an interview on 06/29/2026 at 2:43 PM, Certified Nursing Assistant (CNA) #3 stated nursing staff were responsible for maintaining the resident nourishment refrigerator. She stated the refrigerator was used for both residents and staff, and she was unsure of who the Styrofoam container of Mexican food belonged to. CNA #3 stated that the sandwiches in the bottom of the refrigerator were for residents. CNA #3 stated the nursing staff were responsible for ensuring all foods brought in for residents from families were labeled and dated. A follow-up observation of the facility's resident nourishment refrigerator was conducted on 06/30/2026 at 2:36 PM. The observation of the resident nourishment refrigerator revealed:the same opened jar of maraschino cherries- no use-by date or name.(1) opened bag of shredded [NAME] cheese- no use-by date or name(1) an opened bag of Monterey [NAME] cheese- no use-by date or name. During an interview on 06/30/2026 at 2:39 PM, Registered Nurse (RN) #2 stated nursing staff were responsible for ensuring items brought in for residents were labeled and dated. An observation of the facility's resident nourishment refrigerator was conducted on 07/01/2026 at 8:49 AM. The observation of the resident nourishment refrigerator revealed a temperature log on the refrigerator door. The first date entered was 06/30/2026, and indicated the temperature was 40 F. During an interview on 07/01/2026 at 9:11 AM, RN #2 stated the facility had no documentation, prior to 06/30/2026, to indicate they monitored the nourishment room refrigerator temperatures. During an interview on 07/01/2026 at 9:27 AM, the Regional Nurse Consultant stated there were no temperature logs for the resident refrigerator, and there should have been. During an interview on 07/01/2026 at 3:23 PM, the DM stated the kitchen was responsible for the resident refrigerators, though she did not realize that until recently. She knew the kitchen staff stocked the refrigerator with resident snacks, but they had not been monitoring the temperatures in the resident refrigerator. During an interview on 07/02/2026 at 1:19 PM, the ADM stated the nourishment refrigerator was used by staff and that resident snacks were stored in the bottom of the refrigerator. He stated that no one had been assigned to monitor the temperatures of the refrigerator.

Based on observation, interview, and facility policy review, the facility failed to provide a homelike environment for 8 (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) of 28 rooms. Specifically, the privacy curtains in eight resident rooms had visible stains of varying sizes.Findings included: A facility policy titled, Resident's Rights and Confidentiality, revised 08/01/2017, revealed, At the facility it is your responsibility to protect and promote the rights of each resident, including the following: and included, 29. The right to a safe, clean, comfortable homelike environment. A facility policy titled, Housekeeping Policies & Procedures, revised 06/29/2012, revealed, under the title, Basic Housekeeping Procedures, included, The housekeeping supervisor is responsible for the delegation of the facilities [sic] cleaning duties. During an observation in room [ROOM NUMBER] on 06/29/2026 at 10:49 AM, a dark, stained area was on the resident's pink privacy curtain. The stained area began at the bottom edge of the curtain and was an approximate foot in length and six inches in width. During a follow-up observation in room [ROOM NUMBER] on 07/02/2026 at 8:49 AM, the stained area remained on the bottom edge of the resident's pink privacy curtain. During an interview on 07/02/2026 at 9:09 AM, Certified Nursing Assistant (CNA) #3 stated housekeeping staff washed privacy curtains. CNA #3 said if staff noticed a stain on a privacy curtain, they reported it to the Administrator (ADM). CNA #3 stated she went into room [ROOM NUMBER] often but had not noticed the stained area on the privacy curtain previously. During an interview on 07/02/2026 at 9:20 AM, the Laundry/Housekeeping Director (LHD) stated that several privacy curtains at the facility were stained and needed to be replaced. She said she had been aware of the issue for years and that prior administrators had purchased some new privacy curtains, the blue ones. The LHD said the pink privacy curtains were the older curtains. The LHD said she had brought up the need to replace the older curtains with the ADM about a month or two prior, and the ADM was looking for replacement curtains. During a tour of the facility on 07/02/2026 at 9:40 AM with the LHD, the following observations were made: (1) room [ROOM NUMBER] - a brown stained area covered approximately one square foot of the pink privacy curtain.(2) room [ROOM NUMBER] - two pink privacy curtains had multiple large brown stained areas scattered along the curtains.(3) room [ROOM NUMBER] - a gray and brown stained area covered half a square foot of area along the bottom edge of the pink privacy curtain.(4) room [ROOM NUMBER] - a large gray and brown stained area covered between one to two square feet along the bottom edge of the pink privacy curtain.(5) room [ROOM NUMBER] - multiple large, discolored stained areas covered a square foot along the bottom edge and side corner of the pink privacy curtain. On the other side of the same curtain was a smaller brown stain that covered a few square inches.(6) room [ROOM NUMBER] - multiple dark brown stained areas were on the privacy curtain.(7) room [ROOM NUMBER] - a large brown discolored stain along the bottom edge of the pink privacy curtain.(8) room [ROOM NUMBER] - multiple dark brown discolored stains covered half a square foot area on the pink privacy curtain. During a follow-up interview on 07/02/2026 at 10:00 AM, the LHD confirmed all the discolored, stained areas on the privacy curtains were washed in and would not come out. She stated she had informed the ADM of the stains but was not sure whether he had observed the stains. The LHD stated she had previously washed pink privacy curtains, and they fell apart in the laundry, so she was hesitant to wash them. During an interview on 07/02/2026 at 9:31 AM, the ADM stated he had been at the facility for about a year and was slowly replacing the privacy curtains due to them being expensive. The ADM stated that the privacy curtains should be clean and said the LHD should monitor the curtains and notify maintenance if any needed taken down and washed. The ADM said he was unaware of any privacy curtains that were stained. During a follow-up interview on 07/02/2026 at 10:13 AM, the ADM stated he was unaware of stains on the privacy curtains or difficulties with washing the pink privacy curtains prior to the survey. The ADM said a few months prior, when he and the LHD discussed the issue with the pink privacy curtains; the facility had spare curtains. He stated he was unaware the facility no longer had spare curtains. The ADM stated his plan was to purchase a few privacy curtains at a time due to the cost; although he had not purchased any since he had been at the facility.

Based on observation, interview, record review, and facility policy review, the facility failed to provide care and treatment according to professional standards for a peripherally inserted central catheter (PICC) line (long, thin, flexible tube inserted through a peripheral vein in the upper arm and advanced to the large vein near the heart) for 1 (Resident #43) of 1 resident reviewed for PICC line. Findings included: A facility policy titled, Care and Removal of Peripherally Inserted Central Catheters (PICC) and midline Catheters, revised 12/18/2025, revealed, Sterile dressing changes will be performed every 7 days and immediately if the integrity of the dressing is compromised. An admission Record revealed the facility admitted Resident #43 on 06/16/2026. According to the admission Record, the resident had a medical history that included a diagnosis of effusion (excess fluid), left knee. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/22/2026, revealed Resident #43 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. The MDS indicated that the resident received intravenous (IV) medications within the last 14 days of the look-back period. Resident #43's Care Plan Report, revealed a focus area initiated on 06/22/2026, that indicated the resident was at risk for infection related to a PICC line. Interventions directed staff to perform a sterile dressing change every seven days and as needed. Resident #43's Order Summary Report, with active orders as of 07/01/2026, contained an order, dated 06/17/2026 for sterile dressing change and injection cap change within 48 hours of insertion of PICC and then every seven days and as needed. An observation on 06/29/2026 at 9:52 AM revealed Resident #43 had a PICC line dressing on the inside of the right upper arm. A handwritten date of 06/17/2026 (12 days prior) was observed on the PICC line dressing. The PICC line dressing was clean, dry, and intact, and showed no signs of infection. During a concurrent interview and observation on 06/30/2026 at 4:00 PM with Registered Nurse (RN) #2, Resident #43's PICC line dressing remained dated 06/17/2026 (13 days prior). RN #2 confirmed Resident #43 received IV antibiotics through the PICC line and that she administered the medication to the resident that morning. RN #2 confirmed that the physician orders were to change the PICC line dressing every seven days and stated that she would change the dressing at that time. During an interview on 07/01/2026 at 12:02 PM, the Director of Nursing stated it was her expectation that staff changed the PICC line dressing every seven days. During an interview on 07/02/2026 at 4:06 PM, the Administrator stated it was his expectation that the policy for dressing changes be followed.

Based on observation, interview, and facility document review, the facility failed to post complete nursing staffing data for 3 (06/29/2026, 06/30/2026, and 07/01/2026) of 4 days of the survey and failed to maintain the nurse staffing data for 18 months. This had the potential to affect all 43 residents who currently resided in the facility. Findings included: During an observation on 06/29/2026 at 8:30 AM, a facility document which included nurse staffing data was observed in the lobby of the facility. The document included the name of the facility, the date, the resident census for the day, and the total nurse staffing hours for the day. The document did not include the resident census and nurse staffing hours for each shift. During an observation on 6/30/2026 at 8:16 AM, a facility document which included nurse staffing data was observed in the lobby of the facility. The document included the name of the facility, the date, the resident census for the day, and the total nurse staffing hours for the day. The document did not include the resident census and nurse staffing hours for each shift. During an observation on 07/01/2026 at 8:19 AM, a facility document which included nurse staffing data was observed in the lobby of the facility. The document included the name of the facility, the date, the resident census for the day, and the total nurse staffing hours for the day. The document did not include the resident census and nurse staffing hours for each shift. A facility document dated 07/01/2026 revealed the census for the day, registered nurse (RN) hours, licensed practical nurse (LPN) hours, other direct care hours, and the RN coverage for the day. The document further indicated, Staffing assignments for the day of who is working and where the staff will be assigned is posted on the white board at the nurses' station. The document did not include the resident census and nurse staffing hours for each shift. During a concurrent observation and interview with the Staffing Coordinator/Human Resources (SC/HR) on 07/01/2026 at 11:39 AM, a dry erase board was observed. The dry erase board included the name of the facility, the resident census, and the dates 6/29/2026 through 07/04/2026 with the names of the nursing staff scheduled for each shift. The dry erase board did not include the resident census and nurse staffing hours for each shift. The SC/HR stated she did not keep hard copies of the data and erased the board daily. The SC/HR stated that she also created a nurse staffing document that was posted in the lobby each day. She stated the document posted in the lobby included the facility name, date, census for the day, and the total hours worked each day for registered nurses, licensed nurses, and certified nursing assistants. The SC/HR stated she posted the data daily and did not update the data for each shift. The SC/HR stated she created a new document each day and did not keep the previous documents. She stated she was unaware of the requirement to record the census and nurse staffing data per shift or to maintain the records for 18 months. During a concurrent interview on 07/01/2026 at 12:35 PM with both the Administrator (ADM) and the Director of Nursing (DON), the ADM stated he was not aware that the facility should retain nurse staffing data records for 18 months or that the nurse staff posting should include the census and nurse staffing hours per shift. The DON stated she was aware that nursing hours had to be posted daily, but she was not aware that the requirement was to post the information per shift or that the facility should retain the information for 18 months. The ADM stated he expected staff to follow the regulation. During an interview on 07/01/2026 at 2:06 PM, the Regional Nurse Consultant stated the facility did not have a policy on nurse staff posting, but that the facility should follow the federal and state regulation.

Based on observation, record review, and interview, the facility failed to ensure physicain's orders were followed as ordered for one (#32) of one resident reviewed for respiratory care. The Administrator reported 44 residents resided in the facility. Findings: Res #32 admitted to the facility with diagnoses of COPD, depression, and diabetes. A physician's order, dated 06/28/24, documented Oxygen 5 liters via NC if O2 sats are less than 90%. On 07/29/24 at 9:27 a.m., the resident was observed resting in bed with eyes closed. Oxygen settings were observd at 7 L/M with a nasal canula. On 07/30/24 at 12:25 p.m., the resident was observed wearing their oxygen. Oxygen settings were at 7 L/M via NC. On 07/31/24 at 9:32 a.m., the resident was observed sitting in their room watching tv. The resident was observed wearing oxygen with the setting at 7L/M via NC. On 08/01/24 at 10:00 a.m., the DON was made aware of the observations. The DON reported the physician's orders were not being followed.

Based on record review andinterview, the facility failed to ensure yearly nursing skill and competencies were completed for three (LPN #1, LPN #2, and RN #1) of the seven employees reviewed. The Adminstrator reported 44 residents resided in the facility. Findings: On 08/01/24 at 9:21 a.m., the skills and competencies for licensed nurses were reviewed. Three licensed nurse skills review had not been completed for , LPN #1, LPN #2, and RN #1, since 2022. On 08/01/24 at 11:44 a.m., the DON reported she did not realize the yearly skills and competencies had not been completed for the three licensed nurses.

Based on record review and interview, the facilty failed to follow/implement the Preparation for Medication Administration policy for one (#2) of four sampled residents reviewed for accidents. The Administrator reported 44 residents resided in the facility. Findings: Res #2 admitted to the facility with diagnoses of hypertension, diabetes, anxiety, and depression. An Incident Report, dated 04/04/24, documented the resident received another resident's medication. On 07/31/24 at 10:46 a.m., the facility's policy for Preparation for Medication Administration was reviewed. The Preparation for Medication Administration Policy, last revised 12/01/12, documented, Preparation- Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label. Administration- Residents are identified before medication is administered. The medication nurse or certified medication aide will turn to that resident's medication sheet, compare photo with resident and positively identify the resident. Each resident must have a completed Resident Information Sheet or similar form, with their photo attached at the appropriate location on the form. This form is included in the medication administration record and in the treatment administration record. Methods of identification include. - Checking identification band. -Checking photograph attached to medical record. -Calling resident by name. - If necessary, verifying resident identification with other facility personnel. On 08/01/24 at 09:47 a.m., the DON reported the resident wanted to wait on taking their medication so the DON put the resident's medications in the drawer of the medication cart. The DON reported they started getting another residents medications ready and the hospice staff and asked about a chart they couldn't find. The DON reported they put the medication cup of the resident they was working on in the drawer of the medication cart and went to get the chart for hospice. The DON reported when they returned to the medication cart that resident #2 came to the cart and wanted to take their medications at that time. The DON reported they retrieved the medication cup from the cart and administered the resident's medication. The DON reported they realized they had administered the resident the wrong medications by accident. The DON was asked if they had followed the facility policy and if resident #2's medication cup should have been placed in the drawer unlabeled when they refused the medications at the time they went to administer them. They reported no. On 08/01/24 at 10:51 a.m., the corporate nurse reported the DON did not follow the facility's policy

Based on record review and interview, the facility failed to ensure a PRN order for an antianxiety had a 14 day stop date for one (#3) of five sampled residents reviewed for unnecessary medications. The Administrator reported 44 residents resided in the facility. Findings: Res #3 admitted to the facility with diagnoses of dementia in other diseases with mild anxiety. A physician's order, dated 6/24/24, documented, Lorazepam Oral Concentrate 2 MG/ML (Lorazepam) *Controlled Drug* Give 0.25 ml by mouth every 2 hours as needed for ANXIETY/RESTLESSNESS, no stop date provided on the order. A Medication Regimen Review, dated 1/18/24, documented a request for physician to add a stop date. The physician signed the request with no response documented and no stop date was added to the Lorazepam. On 08/01/24 at 9:56 a.m., the DON reported the medication should have had a stop date added.

Based on record review and interview, the facility failed to refer a resident with a new mental health diagnosis to OHCA for a PASRR level II evaluation for one (#3) of one sampled residents reviewed for PASRR. The Administrator reported 44 residents resided in the facility. Findings: Res #3 admitted to the facility with diagnoses of atherosclerotic heart disease, diabetes, dementia, depression, and hypothyroidism. A review of the resident's record documented a PASRR level I was completed on 04/27/23. On 12/26/23, the resident received a new diagnosis of psychosis. The resident's record contained no documentation that OHCA was notified of the new mental health diagnosis. On 08/01/24 at 9:58 a.m., the DON reported that OHCA was not notified of the new mental health diagnosis.

Based on record review, observation, and interview, the facility failed to ensure residents were were free from unnecessary drugs related to inadequate monitoring for three (#2, #3, and #28) of seven residents whose medications were reviewed. The ''Resident Census and Conditions of Residents report documented 39 residents resided in the facility. Findings: 1. Res #3's physician order, dated 12/21/21, documented to administer [MEDICATION(S)] 10 mg in the afternoon for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders, dated 01/15/22, documented to administer [MEDICATION(S)] 25 mg two times a day and [MEDICATION(S)] 12.5 mg two times a day for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/21/22 at 4:08 p.m., CMA #1 was observed, during medication pass, to administer the blood pressure medications, [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)], without obtaining a blood pressure reading. On 04/25/22 at 8:12 a.m., the CMA was asked why she did not take the resident's blood pressure. The CMA stated the computer did not prompt her to do so. On 04/25/22 at 8:24 a.m., the DON was notified the resident's blood pressure was not taken before the administration of the blood pressure medications. The DON stated it was in the orders to obtain the blood pressure before administering the medication. She stated the information to prompt the CMA to take the blood pressure had not been added to the program. 2. Res #2's physician orders, dated 10/27/21, documented to administer [MEDICATION(S)] 50 mg two times a day and [MEDICATION(S)] 10 mg two times a day for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/25/22 at 7:16 a.m., CMA #1 was observed, during medication pass, to administer the blood pressure medications, [MEDICATION(S)] and [MEDICATION(S)], without obtaining a blood pressure reading. On 04/25/22 at 8:12 a.m., the CMA was asked why she did not take the resident's blood pressure. The CMA stated the computer did not prompt her to do so. On 04/25/22 at 8:24 a.m., the DON was notified the resident's blood pressure was not taken before the administration of the blood pressure medications. The DON stated it was in the orders to obtain the blood pressure before administering the medication. She stated the information to prompt the CMA to take the blood pressure had not been added to the program. 3. Res #28's physician order, dated 03/26/22, documented to administer [MEDICATION(S)] (an anticoagulant medication) 10 mg one time a day for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation of side effect monitoring for the anticoagulant. A physician order, dated 03/26/22, documented [MEDICATION(S)] 40 mg one time a day for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no assessment of the resident's [CONDITION(S)] provided. A physician order, dated 03/30/22, documented [MEDICATION(S)] 125 mcg one time a day for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The order documented to hold the medication if the resident's heart rate was less than 60 BPM. The March and April 2022 MARs documented the resident's pulse was only obtained for 2 of 27 opportunities before the [MEDICATION(S)] medication was administered. A quarterly MDS assessment, dated 04/01/22, documented the resident was moderately cognitively impaired, required extensive assistance of two people, received anticoagulant and diuretic medications. The current care plan documented the resident had cardiovascular problems. The care plan documented to administer [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] as ordered. The care plan documented to monitor and document any [CONDITION(S)] and abnormalities of urinary output. The care plan documented to monitor/record medication side effects and report to the physician as necessary. On 04/26/22 at 9:02 a.m., the DON stated the resident's pulse rate should have been obtained before administering the [MEDICATION(S)] medication. The DON stated there was no documentation of monitoring for the side effects of the anticoagulant [MEDICATION(S)]. On 04/26/22 at 10:13 a.m., the resident was observed sitting in her wheelchair in front of the nurse station. The resident's right foot had [CONDITION(S)], enough for her gripper sock to fit tautly unlike the left one. On 04/26/22 at 10:14 a.m., RN #1 stated she had not been monitoring the resident's [CONDITION(S)] and there was no documentation in the record pertaining to an assessment of the [CONDITION(S)]. The RN attempted to assess the [CONDITION(S)] at that time and the resident refused.

Based on record review, observation, and interview, the facility failed to ensure the medication error rate was less than 5% for two residents (#2 and #3) of six residents observed during medication pass. A total of 25 opportunities were observed with two errors. Total error rate was 8%. The ''Resident Census and Conditions of Residents report documented 39 residents resided in the facility. Findings: 1. Res #3's physician order, dated 12/21/21, documented to administer [MEDICATION(S)] 10 mg in the afternoon for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders, dated 01/15/22, documented to administer [MEDICATION(S)] 25 mg two times a day and [MEDICATION(S)] 12.5 mg two times a day for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/21/22 at 4:08 p.m., CMA #1 was observed, during medication pass, to administer the blood pressure medications, [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)], without obtaining a blood pressure reading. On 04/25/22 at 8:12 a.m., the CMA was asked why she did not take the resident's blood pressure. The CMA stated the computer did not prompt her to do so. On 04/25/22 at 8:24 a.m., the DON was notified the resident's blood pressure was not taken before the administration of the blood pressure medications. The DON stated it was in the orders to obtain the blood pressure before administering the medication. She stated the information to prompt the CMA to take the blood pressure had not been added to the program. 2. Res #2's physician orders, dated 10/27/21, documented to administer [MEDICATION(S)] 50 mg two times a day and [MEDICATION(S)] 10 mg two times a day for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/25/22 at 7:16 a.m., CMA #1 was observed, during medication pass, to administer the blood pressure medications, [MEDICATION(S)] and [MEDICATION(S)], without obtaining a blood pressure reading. On 04/25/22 at 8:12 a.m., the CMA was asked why she did not take the resident's blood pressure. The CMA stated the computer did not prompt her to do so. On 04/25/22 at 8:24 a.m., the DON was notified the resident's blood pressure was not taken before the administration of the blood pressure medications. The DON stated it was in the orders to obtain the blood pressure before administering the medication. She stated the information to prompt the CMA to take the blood pressure had not been added to the program.

Based on record review, observation, and interview, the facility failed to ensure physician ordered lab services were obtained for one (#19) of five residents sampled for unnecessary medications. The Census and Conditions of Residents form documented 39 residents lived in the facility. Findings: Res #19 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 2/15/22, documented the facility was to obtain a CBC, CMP, BNP, TSH, and T4. A care plan, dated 3/18/22, documented the facility was to obtain labs and x-rays as ordered and report significant findings to the physician. The care plan documented the labs required for the resident were CBC, CMP, TSH, and T4, every six months in March and September. A physician order, dated 3/28/22, documented the facility was to obtain a CBC, CMP, TSH, and T4 every six months starting on the 28th. On 4/25/22 at 11:55 a.m., the DON stated the procedure for lab draws was the nurses who received the orders would place them into the lab company's computer program used for the phlebotomist to see the orders. She stated the lab company sent someone to the facility Sunday through Thursday to do the lab draws. The DON stated she was unable to locate the lab results for February and March 2022. On 4/25/22 at 3:31 p.m., the administrator stated that the orders did not get placed into the laboratory software so it was not drawn as ordered.

Based on observation and interview, the facility failed to ensure food was stored, prepared, and served in a sanitary manner. The Census and Conditions of Residents form documented 39 residents lived in the facility. Findings: 1. On 04/20/22 at between 4:18 p.m. and 4:23 p.m., observations of the evening meal service in the dining room was made. CNA #1 sat down to assist a resident to eat and did not perform hand hygiene. Another resident was feeding herself at the table and was using a butter knife to eat. CNA #1 replaced the butter knife with a spoon and returned to assisting the first resident to eat without performing hand hygiene. On 04/20/22 at 4:24 p.m., CNA #2 was observed to move a chair between two residents and assisted both residents with their meal without using hand hygiene between residents. On 04/20/22 at 4:25 p.m., CNA #1 touched a resident's fork, put some meat on it, and gave the fork to the resident, then continued to assist another resident she was helping eat. Hand hygiene was not observed. CNA #1 was observed to take a dirty napkin from one resident, assisted her with a bite of food, and then returned to assist another she was assisting to eat. Hand hygiene was not observed. On 04/20/22 at 4:31 p.m., CNA #1 held a resident's hat in her hand while assisting a resident to eat. CNA #1 did not perform hand hygiene after touching the hat. On 04/20/22 at 04:32 p.m., LPN #1 used hand gel and sat down to assist a resident with a shake. LPN #1 then touched another resident's cup and assisted them with eating. The LPN then assisted the first resident again. Hand hygiene was not observed between residents while assisting with the meals. On 04/20/22 at 5:09 p.m., CNA #1 stated hand hygiene should be performed before you touch a resident or go from clean to dirty, also you should perform hand hygiene between residents while assisting to eat. On 04/21/22 at 5:29 p.m., the DON stated hand hygiene should be performed before and after feeding residents and in-between residents. The DON stated the staff should have hand sanitizer available during dining. 2. On 04/20/22 1:21 p.m., an initial tour of the kitchen was conducted. On 04/20/22 at 1:30 p.m., the inside of the lid of freezer #3 was observed broken all across the lid. Tape was observed to have been used in some areas on the inside of the lid. On 04/20/22 at 1:44 p.m., the DM stated she had reported the broken lid to the administrator and corporate. On 04/20/22 at 2:05 p.m., the ice machine was wiped with a clean white cloth on the inside. A dark black substance was on the cloth. The DM was standing there and saw the black substance. She stated she was not sure what it was but she would throw the ice out and clean the machine. She stated the ice machine was cleaned by a DA and herself. She stated it had not been cleaned in April. On 04/26/22 at 10:23 a.m., packages of ham was observed in the sink thawing and was not under running water. The dietitian was observed to turn the water on over the ham at 10:26 a.m. On 04/26/22 at 10:27 a.m., the DM stated the ham had been under running water. She said she must have turned off the water. On 04/26/22 at 10:35 a.m., the DM was observed to touch her mask several times while making the meat puree. She touched spoons for tasting the puree and then placed her mask back over her nose and mouth. At 10:38 a.m., DM was observed to obtain a spatula from the utensil holder on a rack, she touched the wide flat part (working end) of the spatula and scrapped the puree into the holding container. On 04/26/22 at 10:40 a.m., the DM stated she grabbed the spatula by the wrong end because that end was up.

Based on record review and interview, the facility failed to ensure a discharge summary was completed for one (#40) of one resident reviewed for discharge. The Census and Conditions of Residents form documented 39 residents lived in the facility. Findings: Res #40 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse note, dated 02/15/22 at 7:30 p.m., documented late entry, the resident transferred to another facility via wheelchair, belongings, and copy of MAR's, TAR's, and orders sent with resident. The clinical record contained no discharge summary. On 04/26/22 at 1:47 p.m., the DON stated she would have to look in the resident's record for a discharge summary. She stated she did not see a discharge summary in the resident record.

Based on record review and interview, the facility failed to follow their antibiotic stewardship program for one (#1) of one residents reviewed for infections. The Resident Census and Conditions of Residents report documented 39 residents resided in the facility. Findings: A facility policy, Antibiotic Stewardship, dated 12/20/17, documented in parts: .1. When the nurse suspects the resident has an infection, the nurse should perform the following: a. Complete a set of Vital Signs b. Interview the resident for symptoms c. Complete an assessment of the resident d. Complete the Loeb Minimum Criteria for Initiation of Antibiotics UDA [User Defined Assessment] e. Notify physician/practitioner of the resident change in condition and the above evaluation information. f. Notify lab if diagnostics are ordered and communicate diagnostic results to the physician when received . 4. The clinical team will track antibiotic use in the Q2 meeting to ensure appropriate use of antibiotics. The following will be included in Q2: a. Antibiotics will be reviewed for appropriate diagnosis, dose, route, and duration. b. Nursing documentation on progress notes or UDAs will be reviewed for appropriate initiation and follow-up for antibiotic use. c. A facility floor plan will be highlighted to show tracking and trending of antibiotic use and side effects of antibiotic use such as C-difficile or Antibiotic Resistance . e. Infection control forms (GLC-249 & GLC-734) will be reviewed to trend the use of antibiotics, and side effects from antibiotics (C-diff or Resistance) and the effectiveness of antibiotic stewardship program and/or any needed ongoing education. f. Education will be provided to the staff if indicated by the infection control tracking and trending . Res #1 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 04/14/22, documented a urinalysis with culture and sensitivity was ordered for collection. A nurse progress note, dated 04/15/22 at 5:38 p.m., documented the urinalysis results were received and sent to the physician. The note documented new order was received to start the resident on antibiotics for seven days for a urinary tract infection. A quarterly MDS assessment, dated 04/16/22, documented the resident required extensive assistance with most ADLs, and was frequently incontinent of bowel and bladder. A nurse progress note, dated 04/21/22, at 3:13 p.m., documented a clarification requested for the current antibiotic due to lab result not showing sensitivity. A new order was placed for a different antibiotic. On 04/26/22 at 9:39 a.m., the DON stated staff were educated on antibiotic stewardship during orientation, and the information was communicated between shifts on a nurses shift report sheet. She stated the staff are periodically re-trained via in-services and their in-house annual training program. She stated she pulled orders in the mornings so any issues could be communicated, and she reviewed documentation for issues to be addressed. On 04/26/22, at 9:50 a.m., the DON was unable to state if antibiotic stewardship was followed on Res #1. On 04/26/22, at 10:07 a.m., RN #1 stated she did not document the signs and symptoms to indicate the reason for the UA being ordered. She was able to recall Res #1 had complained of pain with urination prior to the order, but it was not documented in the chart. On 04/26/22, at 1:36 p.m., the DON stated during Q2 meetings, staff did not take the infection prevention book to review. She stated the forms listed in the Antibiotic Stewardship policy were not kept in the infection prevention book and she was unable to locate these forms. She was unaware of how to track and trend antibiotics for a resident. On 04/26/22, at 1:52 p.m., the Infection Preventionist stated tracking and trending was kept on the computer, reviewed in Q2 meetings, and during QAPI. She stated Res #1's antibiotic use during April was not tracked or trended. She stated the facility did not follow antibiotic stewardship for Resident #1 as outlined in the policy.

Based on record review and interview, the facility failed to ensure the physician responded to a pharmacy recommendation for one (#11) of five sampled residents whose medications where reviewed. The Census and Conditions of Residents form documented 39 residents lived in the facility. Findings: Res #11 was admitted to the facility with diagnoses which included anxiety disorder, major depressive disorder, and [CONDITION(S)] disorder. A Medication Regimen Review, dated 11/15/21, documented the pharmacist requested a reduction in any of the following listed medications: [MEDICATION(S)] (an antipsychotic medication) [MEDICATION(S)] (an antianxiety medication), [MEDICATION(S)] (an antianxiety medication), [MEDICATION(S)] (a anticonvulsant medication), or [MEDICATION(S)] (an antidepressant medication). The review was not signed by the physician or dated. The form documented the following: a recent decrease in [MEDICATION(S)] to 25 mg, history failed GDR times two of [MEDICATION(S)], and mental health declines GDR at this time. The documentation was not signed or dated. On 04/21/22 at 5:15 p.m., the administrator stated the she did not see a signature or date on the MRR for 11/15/21. The administrator stated the DON talked to the PA by phone and the DON was the one who had documented on the MRR for 11/15/21.

Based on record review, observation, and interview, the facility failed to develop a comprehensive person-centered care plan related to weight loss for one (#28) of three residents reviewed for nutrition. The administrator identified three residents with significant weight loss in the last six months. Findings: Res #28's quarterly MDS assessment, dated 12/15/21, documented the resident was moderately cognitively impaired; was independent and required setup help with eating; and was 65'' and weighed 214 lbs. A quarterly MDS assessment, dated 04/01/22, documented the resident was moderately cognitively impaired; required supervision/oversight and encouragement/cueing and set-up help with eating; weighed 159 lbs; had a significant weight loss; and was not on a physician prescribed weight loss program. On 04/26/22 at 2:38 a.m., the MDS coordinator stated the resident's weight loss was not care planned.

Based on record review and interview, the facility failed to reevaluate for preadmission screening and resident review (PASRR) level I after a change in mental health diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Census and Conditions of Residents form documented 39 residents lived in the facility. Findings: 1. Res #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A PASRR I assessment, dated 11/09/17, documented No to all questions regarding the resident having a serious mental illness. A PASRR I assessment, undated, documented No to all questions regarding the resident having a serious mental illness. The EHR documented Res #11 received a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The EHR documented Res #11 received a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The medical record revealed no documentation the OHCA was notified of the new diagnoses. The resident currently takes [MEDICATION(S)] (an antipsychotic medication) for [CONDITION(S)] disorder; [MEDICATION(S)] (an antidepressant medication) daily for major depression single episode; and [MEDICATION(S)] and [MEDICATION(S)] (antianxiety medication) for anxiety. On 04/21/22 at 10:30 a.m., the administrator stated they have been completing the PASRR's correctly and if a resident gets a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review and interview, the facility failed to accurately assess a resident's status related to anticoagulant use for one (#28) of five sampled residents whose medications were reviewed. The administrator identified four residents who received anticoagulant medication. Findings: Res #28's quarterly MDS assessment, dated 04/01/22, documented the resident had a surgical wound and received an anticoagulant one time during the seven day look-back period. A physician order, dated 03/26/22, documented to administer [MEDICATION(S)] (an anticoagulant medication) 10 mg one time a day for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The March and April 2022 MARs documented the resident received [MEDICATION(S)] six days of the seven day look-back period. On 04/26/22 at 10:38 a.m., the MDS coordinator stated the MDS should have read the resident received an anticoagulant six times instead of one.

Based on record review, observation, and interview, the facility failed to conduct a significant change assessment after a decline in two or more areas for one (#28) of eleven sampled residents whose MDS assessments were reviewed. The ''Resident Census and Conditions of Residents report documented 39 residents resided in the facility. Findings: Res #28's quarterly MDS assessment, dated 12/15/21, documented the resident walked with limited assistance, was frequently incontinent, weighed 214 lbs, was not on a physician prescribed weight loss program. The assessment documented the resident had no wounds, no pain, and no pain medication administered. A quarterly MDS assessment, dated 04/01/22, documented the resident did not walk, was always incontinent, weighed 159 lbs, had a significant weight loss, was not on a physician prescribed weight loss program. The assessment documented the resident had a surgical wound, occasional moderate pain, and received opioid medication seven days of seven day look-back period. On 04/26/22 at 10:36 a.m., the MDS coordinator stated the resident should have had a significant change assessment completed related to the decline in walking, incontinence, and weight loss.

Based on observation, interview, and record review, it was determined the facility failed to provide adequate assistance to prevent an accident for one (#10) of three residents reviewed for accidents and/or falls. The facility failed to provide two-person assistance when transferring the resident, which resulted in a fall with fracture. The Administrator reported 34 residents resided in the facility. Findings: Resident #10 was admitted to the facility on [DATE] with diagnoses which included dementia, benign neoplasm of cerebral meninges, history of falls, right artificial knee joint, and hypertension. A progress note, dated 04/25/20, documented the resident became weak and stepped sideways on her right ankle. The note documented the certified nurse aide (CNA) assisted the resident to the floor. The note documented an intervention of assist x 2 with transfers. A care plan, updated 05/01/20, documented an observed fall with minor injury on 04/25/20. The care plan documented the intervention of assist x 2 with transfers. A progress note, dated 06/29/20, documented the resident might be having a decline. The note documented the resident was not standing well and was very weak with transfers. There was no further documentation of a follow-up to this observation. An incident report, dated 07/24/20, documented CNA #1 was attempting to transfer the resident from the shower chair to a wheelchair. The report documented the CNA had to sit the resident on the floor related to the resident not being able to bear weight. The report documented the resident was assessed by the charge nurse and no apparent injury was noted. The report documented the resident did not complain of pain. The report documented an intervention to assist x 2 with transfers and a 72-hour post fall observation was started. The care plan, updated 07/24/20, documented fall interventions as assist x 2 with transfers, as well as the use of a Hoyer lift with 2-person assist. A progress note, dated 07/27/20, documented at approximately 9:00 a.m., the nurse was summoned to the resident's room due to the resident's increased weakness and increased signs of visible pain to the right lower extremity. The note documented the resident voiced an increase in pain to the right hip and right thigh. The note documented there was trace swelling noted to the right knee and right hip. The provider was contacted and a hip x-ray obtained which showed no fracture or hip dislocation. A progress note, dated 07/29/20 at 1:08 p.m., documented the resident was given Tylenol ES for complaint of right knee pain. A progress note, dated 07/29/20 at 2:04 p.m., documented a focused assessment was done related to increased swelling and discomfort with movement of the resident's right lower extremity, along with pain rated at a 10 of 10. The provider was contacted and an order received for x-ray of the right knee. A physician note by the nurse practitioner, dated 07/29/20, documented the reported fall on 07/24/20 with no apparent injury. The note documented on 07/27/20 nursing had reported the resident was having difficulty standing and severe pain with movement. The note documented an x-ray of the right hip showed no fracture. The note documented the resident continued to have pain with movement and now had moderate [CONDITION(S)] to the right knee and was tender to touch. An x-ray of the right knee was ordered which showed an obvious fracture and the resident was transported to hospital. The x-ray report of the right knee, dated 07/29/20, documented an acute angulated comminuted fracture through the distal femoral shaft with soft tissue swelling. An incident report was completed and an investigation implemented on 07/29/20 by the director of nursing (DON). A thorough investigation was conducted, which included interviews with other residents and all staff involved. A 72-hour post fall observation was conducted and documented by nursing staff. Complete assessments and monitoring of the resident was documented, along with close supervision by the nurse practitioner and physician. The facility provided documentation of in-services conducted related to transfers and incident reporting. The DON reported the falling star charts (fall program) and care plans were checked and updated as indicated for all residents. In-service logs documented the following training, dated 07/29/20: 1. Transfers - all Hoyer lift and sit to stand transfers to be 2-person assist, no exceptions. If a resident has been identified to be 2-person assist, they too will require 2-person assist with no exceptions. If a resident has a change in mobility, the nurse or DON are to be notified and falling star and POC will be updated. 2. Incident report charting - falls; full assessment must be complete before moving resident. The assessment needs to be correct and accurate. If a resident complains of pain, get an x-ray. A hospital consultation report, dated 07/30/20, documented the resident had a fall reported on 07/24/20. The report documented resident was initially supposedly able to ambulate and then became more and more painful and began to progressively not be able to ambulate over the next few days. The report documented surgical intervention would be needed to repair a right displaced periprosthetic distal femoral shaft fracture. On 05/12/21 at 1:45 p.m., CNA #1 reported she was giving the resident a shower on 07/24/20 and transferring the resident without a 2nd person for assistance. The CNA reported she was in the process of transferring the resident from the shower chair to her wheelchair. She stated usually the resident would bear weight well for transfers but that day her legs just gave out, she tried to catch the resident, but was only able to break her fall. The CNA reported the resident hit the floor really hard but landed on her bottom. She stated she did not witness her landing on her knees. The CNA reported she called for immediate assistance from the LPN in charge. The CNA reported the resident did not complain of any pain and no injury was noted. The CNA reported she took care of the resident for the rest of that shift and the resident did not complain of pain. The CNA reported being new at the time of the incident and did not know the resident needed more assistance with transfers. On 05/13/21 at 9:25 a.m., licensed practical nurse (LPN) #1 reported the resident had the fall on 07/24/20 and when she returned to work on 07/27/20, it was reported to her the resident had been able to bear weight without complaints of pain. She stated she noticed swelling of the right hip and thigh on 07/27/20 and the resident complained of right lower extremity pain. She stated the doctor was notified and an x-ray of the right hip was obtained. The LPN reported the resident was able to bear weight on her lower extremities from 07/24 to 07/29/20. On 05/13/21 at 1:30 p.m., the DON reported after the incident on 07/24/20 and the subsequent diagnosis of fracture on 07/29/20, all nursing staff were in-serviced on appropriate transfers to prevent accidents. The DON reported the resident should have been a two-person assist at the time of the fall on 07/24/20. The DON reported a resident's required transfer assistance was documented on the falling star chart in the resident's room and also on the resident's care plan. The DON reported new CNAs are required to train with another CNA for two weeks and receive fall prevention training in orientation. The DON reported she has had all CNAs demonstrate skills to her, in person, and she continues to monitor staff and ensure correct techniques are used and care plans are followed.

On 12/01/20, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to implement infection prevention and control practices to prevent the development and transmission of COVID-19. The facility failed to cohort positive residents to prevent the spread of COVID-19. The facility identified 28 positive residents in the facility at that time. The facility identified four residents who had continued to share rooms with their roommates after their roommates had tested positive for COVID-19. The facility did not separate the negative and positive residents into different rooms. On 12/01/20 at 7:40 p.m., Oklahoma State Department of Health (OSDH) verified the existence of the Immediate Jeopardy situation. On 12/01/20 at 8:00 p.m., the director of nursing (DON) and the acting administrator (adm) were notified of the IJ situation. On 12/01/20 at 8:45 p.m., an acceptable plan of removal was provided by the adm. The plan of removal, dated 12/01/20, documented the following: The facility will move any residents that are current positive patients effective immediately and cohort together. Positive residents will be cohorted with other positive patients and exposed patients will remain in rooms where possible based on room availability. IPO (Infection Preventionist) and DON will assess exposed residents for s/s (signs and symptoms) of covid based on q (every) 6 hr (hour) monitoring. The facility will in-service all staff on covid isolation and cohorting and all facets of the plan of removal will be completed by 11:59 pm on 12/1/2020. On 12/02/20 at 9:05 a.m., observations were made on the halls and residents #10, 8, 6 and #4 had been moved to new rooms to cohort with positive COVID-19 residents. The doors to the isolation rooms were observed to be closed and proper signage on the outside of the doors. The roommates who were exposed, #9, 7, 5, and #3, were observed to be quarantined in their original rooms. The in-service documents and phone log, dated 12/01/20, documented the last in-service was completed at 11:34 p.m. The in-service documented the scope of the meeting as cohorting residents. The in-services documented 39 staff were in-serviced. On 12/02/20, from 9:18 a.m. to 9:50 a.m., interviews with staff members were conducted. The staff members voiced they had attended an in-service over the proper way to cohort COVID-19 positive residents. The staff members voiced understanding of how to cohort residents. The staff members stated positive and negative residents should be separated. The IJ was removed as of 12/02/20 at 11:59 p.m., when all the components of the plan of removal had been completed. The deficient practice remained at a pattern with the potential for more than minimal harm. Based on observation, record review, and interview it was determined the facility failed to implement infection prevention and control practices to prevent the development and transmission of COVID-19. The facility did not cohort positive residents for 10 (#3, 4, 5, 6, 7, 8, 9, 10, 11 and #12) of ten sampled residents reviewed for cohorting. The administrator (ADM) identified 35 residents who resided in the facility. Findings: 1. The daily census reports documented female residents #5 and #6 were housed together in room [ROOM NUMBER] from 11/27/20 through 12/01/20. The monthly infection report documented a positive test result for female resident #6 on 11/27/20. The daily census report, dated 11/27/20, documented one COVID positive female resident was housed in room one and one positive female resident in room eleven. These two positive female residents did not have roommates, therefore left two beds open for any positive female residents. The 11/27/20 census report documented five positive males were housed alone in rooms 15, 18, 21, 22 and 23. The positive male residents did not have roommates. These male residents could have been cohorted to make two open rooms. The testing log documented resident #5 tested negative on 11/30/20. On 12/01/20 at 1:30 p.m., resident #5 and #6 were observed to be living in room [ROOM NUMBER]. On 12/01/20 at 2:15 p.m., the DON, registered nurse (RN) #1, and RN #2 were asked why the positive residents were not cohorted with other positive residents and why they were left in a room with a resident which was currently negative for COVID-19. RN #1 stated we are a small facility and the facility can not be set up to keep all the positive residents together. RN #1 stated if they moved these residents, they would be taking [MEDICAL CONDITION] up and down the hall around all the residents. RN#1 stated we were told we could leave the COVID positive residents in the rooms with their roommates because they were a high risk exposure and we did not have the room to move these residents. On 12/01/20 at 5:30 p.m., the DON, RN #2, and the acting adm were asked to look at the census. The three staff members were asked if there was any way these positive COVID-19 female residents could have been cohorted with another positive female residents. The three staff members all agreed there were other positive female residents which the positive COVID residents could have been cohorted. On 12/01/20 at 5:35 p.m., the adm stated it was the facility's policy to isolate residents for 20 days. The testing log documented resident #5 tested positive for COVID-19 on 12/02/20. On 12/02/20 at 10:17 a.m., the DON was asked why the positive residents were left in the room with negative residents and not cohorted. She stated it was her understanding the residents who were exposed were to be kept in place and the positive residents were to stay in the room with them. 2. The daily census reports documented male residents #11 and #12 were housed in room [ROOM NUMBER] from 11/21/20 through 12/01/20. The testing log documented male resident #11 tested positive for COVID-19 on 11/21/20. The testing log documented male resident #12 tested negative on 11/22/20. The testing log documented male resident #12 tested positive on 11/26/20. The daily census, dated 11/21/20, was reviewed for open rooms to cohort positive COVID-19 residents. The census documented two empty rooms [ROOM NUMBERS]. There were five positive males which did not have roommates in their rooms. These residents were in rooms 15, 18, 21, 22 and 23 which could have been cohorted to open up two empty rooms. 3. The daily census reports documented female residents #3 and #4 were housed in room [ROOM NUMBER] from 11/22/20 through 12/01/20. The monthly infection report documented resident #4 tested positive on 11/22/20. The daily census, dated 11/22/20, was reviewed for open rooms to cohort positive COVID-19 residents. The census documented two empty rooms [ROOM NUMBERS]. There were five positive males which did not have roommates in their rooms. These residents were in rooms 15, 18, 21, 22 and 23 which could have been cohorted to open up two empty rooms. The testing log documented resident #3 was tested on [DATE]. The result was verified as negative for COVID-19 by the DON. On 12/01/20 at 1:45 p.m., resident #3 and #4 were observed to be living in room [ROOM NUMBER]. 4. The daily census reports documented female residents #7 and #8 were housed in room [ROOM NUMBER] from 11/30/20 through 12/01/20. The testing log documented resident #8 tested positive for COVID-19 on 11/30/20. The testing log documented resident #7 was negative for COVID-19 on 11/30/20. The daily census, dated 11/30/20, was reviewed for open rooms to cohort positive COVID-19 residents. The census documented three positive female residents without roommates. There were six positive males which did not have roommates in their rooms. These residents were in rooms 15, 18, 20, 21, 22, and 23, which could have been cohorted to open up some empty rooms. On 12/01/20 at 1:50 p.m., female residents #7 and #8 were observed to be living in room [ROOM NUMBER]. 5. The daily census reports documented female residents #9 and #10 were housed in room [ROOM NUMBER] from 11/30/20 through 12/01/20. The testing log documented resident #9 tested negative for COVID-19. Resident #9 dated 11/30/20. The testing log documented resident #10 tested positive for COVID-19 on 12/01/20. The daily census, dated 12/01/20, was reviewed for open rooms to cohort positive COVID-19 residents. The census documented four positive female residents without roommates. There were six positive males which did not have roommates in their rooms. These residents were in rooms 15, 18, 20, 21, 22, and 23, which could have been cohorted to open up some empty rooms. On 12/01/20 at 1:25 p.m., female residents #9 and #10 were observed to be living in room [ROOM NUMBER].