Every finding on record at Signature Healthcare at Hillcrest

Based on observation, interview, and facility policy review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety which had the potential to affect residents who consumed meals from the kitchen. Observation of the kitchen, on 05/12/2026 and 05/13/2026, revealed food items uncovered in the freezer, two staff members not wearing a hairnet as required, and alternative food item prepared for lunch service, left uncovered and temped at an unacceptable temperature range (81 Degrees Fahrenheit).Review of the facility's revised policy, titled, Food Preparation, dated 02/2026, revealed all foods were prepared in accordance with the Food and Drug Administration (FDA) Food Code. The Dining Service Director / Cooks would be responsible for food preparation techniques which minimize the amount of time that food items were exposed to temperatures less than 135 Degrees Fahrenheit. Further, all foods would be held at appropriate temperatures, greater than 135 Degrees Fahrenheit for hot holding. Review of the facility's revised policy, titled, Staff Attire, dated 10/2023, revealed all dining service staff were to wear approved attire for the performance of their duties. Further, all staff members would take their hair off their shoulders, confined in a hair net or cap, and have facial hair properly restrained. Review of the facility's revised policy, titled, Food Storage, dated 02/2023, revealed the facility would ensure that all food items were stored properly in covered containers, labeled, dated, and arranged in a manner to prevent cross-contamination.Review of the facility's undated document, titled, Job Description Dining Service Director (DSD), revealed DSD would provide leadership and guidance to ensure that food quality standards, and food safety guidelines were met. Further review revealed that the DSD would ensure established sanitation and safety standards were maintained.Observation of the kitchen, on 05/12/2026 at 4:00 PM, revealed a box of pork chops stored in Freezer 2 (walk-in), in original container but had interior plastic uncovered, exposing food to air contaminants, and ice crystals had formed on the pork chops.Second observation of the kitchen, on 05/13/2026 at 11:30 AM:a)The Dietary Manager (DM) was observed improperly wearing a hairnet which exposed approximately 2 inches of hair on both sides of her face, and from behind her ears and around the back of her neck.b) Approximately 8-10 fish patties, a lunch meal alternative, were observed prepared and left exposed in drain baskets above the deep fryer and temped at 81-Degrees Fahrenheit. c) Dietary Aide was observed improperly wearing a hairnet exposing approximately 1-1/2 inches of hair above her forehead and on both sides of her face. During an interview with the DM, on 05/13/2026 at 11:55 AM, she stated that cross-contamination could occur if hairnets were not properly worn, noting all hair was to be covered or it could potentially be harmful to residents. She further stated the residents would not be happy to find hair in their food. An interview with Dietary Aide, on 05/14/2026 at 3:28 PM, was attempted but unsuccessful, left message to return call, but had no response. During a second interview with the DM, on 05/14/2026 at 10:00 AM, she stated her expectations for the dietary staff regarding hairnets being worn properly was to ensure all hair was covered to prevent potential infection control concerns of cross-contamination. She further stated her expectations for all staff that prepared and served food was to follow the facility's policy and procedures, and production sheets for maintaining appropriate food temperatures for food safety. Additionally, she stated policy and procedures regarding food safety practices should always be followed to ensure residents were provided safe and healthy foods, and noting that all contaminated foods should be eliminated immediately. During an Interview with DDM, on 05/14/2026 at 10:10 AM, she stated her expectations for all dietary staff was to follow facility policy and procedures ensuring hairnets were worn properly and all hair was covered. She further stated expectations for food safety included ensuring temperatures were in range for food being held for meal services. She stated foods such as fish patties that had an unsafe holding temperature should be discarded and staff should prepare new food items to ensure safety. She further stated she had reeducated the dietary staff on what those temperatures and procedures should be. She stated resident safety should always be the priority. During an interview with the Administrator, on 05/14/2026 at 4:00 PM, he stated his expectations of all dietary staff was to follow the facility's policies and procedures regarding food storage and safety. He further stated those policies and procedures were in place to ensure residents were kept safe and provided safe foods.

Based on observation, interview, and facility policy review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for all resident(s) in the facility. 1. Observation in the kitchen revealed staff with their hair nets not covering their hair as required. 2. Observation of the kitchen revealed multiple food items that were not covered in the freezer, food items in the refrigerator out of date per the manufacturer's use-by date. Continued observation revealed multiple food items dated with only a month and day and did not include the year for reference. Observation of metal pans revealed they were removed from cleaning and stacked without allowing sufficient dry time. Further observation revealed a food item held on the steam table for meal service that had a temperature below the required temperature of 135 degrees Fahrenheit. The findings include: Review of the facility's policy titled, Food: Preparation, revised ,d+[DATE], revealed all foods were prepared in accordance with the Food and Drug Administration (FDA) Food Code. Further review revealed all foods were to be held at appropriate temperatures, greater than 135 degrees Fahrenheit for hot holding. Review of the facility's policy titled, Food Storage: Cold Foods, revised ,d+[DATE], revealed all foods were to be stored, wrapped, or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Review of the facility's In-service titled, Receiving, dated [DATE], revealed safe food handling procedures for time and temperature control were to be practiced in the transportation, delivery, and subsequent storage of all food items. Further review revealed all food items were to be appropriately labeled and dated either through manufacturer packaging or staff notation. 1. Observation of the kitchen on [DATE] at 10:25 AM, with the Dietary Manager (DM) revealed [NAME] 1 was wearing a cap and a hairnet; however, had hair outside of the net in both the front and sides. Further observation revealed [NAME] 2 was wearing a hairnet with strands of hair hanging down on each side and the top of the hair revealed the hairnet receding back approximately three inches off her forehead exposing more hair. In interview with [NAME] 1 on [DATE] at 10:45 AM, he stated aware hairnets were used to prevent hair from falling into residents' food and contaminating the food. In interview with [NAME] 2 on [DATE] at 10:55 AM, she stated hairnets were important because hair could shed and get into the food served to residents. She stated residents could get choked and possibly suffer sickness, and said it would also be unpleasant for the residents if they discovered hair in their food. During interview on [DATE] at 5:36 PM, the DM stated staff were in-serviced once a month, and it was generally the same topics that dealt with all areas of the kitchen, including storage labeling, dating, hairnets, and food safety. She stated her expectations were for staff to wear hairnets and ensure their hair was appropriately covered. The DM said the hairnets sometimes slid up, but she expected staff to check to ensure their hair was covered when serving or preparing foods as they would not want to provide food to the residents that had hair in it. 2. Observation on [DATE] at 11:00 AM, of pans stacked on a storage shelf revealed the pans had been stacked wet and not allowed to air dry properly. Observation of a room off the kitchen revealed a shelf under the table top that had three large containers, labeled as rice and flour with the month and date (,d+[DATE]) noted; however, with no date to indicate when the items were opened or the use by date. Continued observation revealed a juice dispensing gun noted to be in a stainless steel overflow containing sludge and old gummed up juice and the juice nozzle had debris on the tip. Observation on [DATE] at 11:10 AM, of the walk-in refrigerator located in the dry storage pantry revealed a large plastic jar of mayonnaise had an opened date written on the side; however, with an expired manufacturer use-by date of [DATE]. Per observation, there was another unopened jar of mayonnaise with the same use-by date of [DATE]. Continued observation in the walk-in refrigerator revealed a container of parmesan cheese, block of cheese slices, and bag of mozzarella cheese had a month and date noted, but had no year listed on those food items. Further observation revealed a bag of Swiss cheese that was undated, and two bags of crispy onions with a month and date documented, but no year listed. Observation also revealed a 10-gallon container of white rice and a bag of toasted oats which were undated, and a container of unopened cereal that contained no date. Observation on [DATE] at 11:15 AM, of a stand up freezer in the kitchen revealed a box of fudge bars in the freezer door which was dated with only the month and date (with no year noted). Continued observation of the walk-in freezer revealed food items in original containers that were uncovered and exposed to air including frozen biscuits, two boxes of beef patties, breaded fish filets, and sausage patties. Additional observation revealed [NAME] 1 returning a box of beef patties back to the freezer that was observed as uncovered when stored in the freezer. In interview with [NAME] 1, on [DATE] at 11:20 AM, he stated the beef patties were supposed to be covered and said he was not aware the patty container was not covered properly. He said he understood the food could become freezer burnt and that could make residents sick. Additional observation of the kitchen on [DATE] at 4:30 PM, to observe food temperature of items maintained on the steam table revealed the pork chops had a temperature of 130 degrees Fahrenheit (which was below the required 135 degrees Fahrenheit). In interview with the Dietary Manager (DM) on [DATE] at 4:40 PM, she stated it was hard to measure the temperature for the pork chops as they were thin. She emphasized she had fifteen seconds to reheat them before they needed to be discarded. The DM reported staff were aware they were supposed to check the food temperature on the steam table to ensure the food held there was above 135 degrees Fahrenheit. During continued interview on [DATE] at 5:36 PM, the DM stated she expected staff to ensure the date on food products included a month and date. She said the dates would only include a year noted on items that expired in a new year; however, that was not required if the food item expired within the current year. The DM reported she was never trained that the year had to be included on the date outside of those date ranges. She stated regarding the steam table, she had instructed staff not to put food on the steam table before 30 minutes of serving and to check the food within two hours to ensure the temperatures were accurate. The DM said if the temperatures were found to be below the 135 degrees Fahrenheit range, she emphasized they had 15 seconds to reheat the food product back up to the correct temperature. She stated the pork chops were thin and it was difficult to get an accurate temperature with the thermometer. The DM said the food items in the freezer that were uncovered and exposed to air contaminants was not acceptable and she stated staff had been instructed food items needed to be in plastic freezer bags if they could not be covered in their original containers. She stated staff were expected to ensure all foods were checked regularly for expiration dates. Additionally, she stated food items that had a manufacturer's use-by date that food should be discarded before that use-by date. The DM reported the facility policy and dietary guidelines were to be followed by all staff and were important to protect residents from potential harm. She further stated she would be conducting an in-service to reeducate staff on continuity in the kitchen to ensure everyone was on the same page with their responsibilities. In an interview with the Administrator, on [DATE] at 12:28 PM, he stated his expectations were that Dietary staff had followed facility policy and guidance. He stated food safety expectations were to follow manufacturers use-by date versus a date that was marked by staff. He stated food should be stored, covered, and dated per policy. He further stated he had not found that opened or use-by dates would require a marked year but would require the month and day.

Based on interview, record review, and facility policy review, the facility failed to ensure residents and/or their representatives right to be informed of and participate in treatment. The facility failed to ensure consent for physical contact was obtained for two residents, Resident (R)203 and R209. R203's representative stated she had not been involved in the care planning for the resident. Record review revealed no documented evidence for physical contact consent between R203 and R209 located in the Electronic Medical Record (EMR) for R203. The findings include: Review of the facility policy, Resident Rights, reviewed 01/31/2025, revealed all residents had the right to be treated with respect and dignity, and those rights were to be promoted by the facility. Continued policy review revealed federal and state laws guaranteed certain basic rights to all residents of the facility. Further review revealed those rights included a resident's right to participate in decisions and care planning. 1. Review of the face sheet for R203 revealed the facility admitted the resident on 07/07/2023, and discharged the resident on 11/01/2024. Per EMR review, R203's diagnoses included unspecified dementia, anxiety disorder, and Alzheimer's Disease. Review of the Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 10/02/2024, revealed the facility assessed R203 to have a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated severe cognitive impairment. 2. Review of the face sheet for R209 revealed the facility admitted the resident on 01/04/2024, and discharged the resident on 09/20/2024. Continued EMR review revealed R209 had diagnoses that included unspecified dementia with other behavioral disturbance, unspecified psychosis, and anxiety disorder. Review of the MDS Assessment, with an ARD of 09/17/2024, revealed the facility assessed R209 to have a BIMS score of eight out of 15, indicating moderate cognitive impairment. Review of R209's EMR revealed a Progress Note dated 01/24/2024, which documented the resident having shadowing/fixation behavior. Continued review of the 01/24/2024 Progress Note revealed the Medical Director had been notified of R209's new behavior of shadowing other residents. Per review, the doctor had increased R209's Risperdal (an antipsychotic medication) to 1 milligram (mg) twice a day (BID). Further review of the 01/24/2024 Progress Note revealed MR after speaking with R209's daughter, the daughter stated resident had been known to have that behavior. In addition, review of the Progress Note revealed R209's daughter stated the resident previously targeted a family member she was close to and followed them around and had to be by their side at all times. Review of the Progress Note further revealed the daughter stated her son used to have a lock on his room because of this shadowing behavior by her mother. Review of the Progress Note for R209 dated 01/25/2024, documented by the Director of Nursing (DON), revealed the interdisciplinary team (IDT) reviewed a recent change of condition in the resident. Per review; the change in condition was related to R209 having shadowing behaviors towards other resident which per R209's family were normal behaviors for the resident. Review of the Progress Note for R209 dated 08/24/2024, documented by Licensed Practical Nurse (LPN) 7 revealed during rounds the nurse had to continuously get R209 out of the bed with R203. Continued review of the Note revealed R209 had also been told she could not stand over her (R203) while she was sleeping and stare at her. Further review revealed the LPN would be reporting to management the information regarding R209's increasing non compliance of this issue. Review of the Progress Note for R209 dated 08/26/2024, documented by LPN 8 revealed at the start of her shift while she had been performing medication (med) pass R209 had been standing over roommate (R203). Continued review revealed the Note's writer documented Was informed by a State Registered Nursing Assistant (SRNA) that R209 kept trying to get in bed with roommate the prior night. Further review revealed When I went to check back in on resident (R209) the resident was in bed with roommate, and got back in R203's bed three more times. In addition, review revealed R209 was taken to the dining area so roommate could sleep tonight. Review further revealed after R209 seemed to have calmed down, staff tried to let the resident lie on her own bed; however, she got back in roommate's bed and identified the roommate as her wife. Review of the Progress Note for R209 dated 08/27/2024, documented by LPN 9 revealed R209 continued obsessive and repetitive behavior towards roommate through shift. Further review of the Note revealed R209 followed roommate continuously, touching and grabbing roommate repetitively. Review of Progress Note for R209 dated 08/27/2024, documented by LPN 4 revealed the resident was found lying on her roommates bed during bed check. Continued review of the Note revealed R209 was checked and changed and the resident then proceeded to try and climb in roommate's bed again. Further review revealed R209 kept trying to go back down to room to climb in bed with roommate; hard to redirect. Further review of R203's EMR for the timeframe of 08/24/2024 to 08/27/2024, reveal no documentation noting the events described in R209's EMR. In addition, review of R203's EMR revealed no documented evidence of notification to the resident's representative related to the physical contact noted in R209's EMR, nor of documentation of consent by R203's representative for physical contact with R209. Review of the facility's, Summary of Investigation for Description of Occurrence revealed on 08/24/2024, staff found (R209) in bed with her roommate (R203) with both fully clothed. Continued review revealed neither resident was upset and they were separated. Further review revealed the facility's findings noted, Investigation revealed no sexual aggressiveness, rather it revealed companionship. Additionally, review revealed the facility's investigation determined it was unsubstantiated. In interview with the Director of Nursing (DON) and facility's Corporate Representative on 04/18/2025 at 10:20 AM, they stated there was no policy regarding residents who wanted physical contact (to share bed) or a form to sign related to. They said if a resident was unable to give consent then their representative was to be contacted and it would be documented in either the progress notes or under a care conference. They reported if residents were to be found in the same bed, with no sexual contact just in bed together, the family should be notified. They further stated it was not acceptable for the facility to make the decision that it was comforting for the residents, without the family/resident representative consent. In interview with R203's daughter/representative on 04/18/2025 at 11:09 AM, she stated she was notified by a nurse aide that her mother's roommate had been getting in bed with her (R203). She reported she was her mother's (R203's) Power of Attorney (POA) and said she was never notified by the facility, that R209 was getting in bed with her mother. She said she would never give consent for bed sharing. She further stated she believed it should have been her decision, as POA, not the facility's to decide if it was comforting to her mother to have R209 in bed with her. In interview with State Registered Nursing Aide (SRNA) 21 on 04/18/2025 at 12:40 PM, she stated she did not remember R203 and R209. The Aide stated however, one morning she came in and heard R203 yelling get off me and witnessed R209 lying on top of her (R203). She said she got R209 back into her own bed and reported the incident to the unit manager. She further stated that was the only time she had witnessed that type of event. In interview with the Administrator on 04/18/2025 at 12:50 PM, he stated he remembered both R203 and R209, who had both resided on the facility's dementia unit. He said he recalled R209 getting focused on people. The Administrator reported he did remember one time when R209 got in bed with R203; however, did not recall if R203's family was notified and did not recall it being called comfort measures. He further stated a resident's family should always be notified of anything like that.

Based on interview, record review and facility policy review, it was determined the facility failed to ensure the Comprehensive Care Plans were reviewed and revised after each Minimum Data Set (MDS) Assessment or a change in condition for three (3) of three (3) sampled residents (Residents #1, #2 and #3). The facility failed to revise Resident #1, #2 and #3's Comprehensive Care Plan to include the facility's MDS Assessments for two (2) staff assist during bathing and the use of the shower bed. On 02/26/2021, Resident #1 rolled from the shower bed landing onto the floor resulting in a Subdural Hematoma, Closed Bicondyle Fracture of the Right Femur and a six (6) centimeter Laceration of the Frontal Scalp without Foreign Body that required (9) nine staples. The findings include: Review of facility policy titled Comprehensive Care Plans, last revised 04/14/2021, with revision date of 07/19/2018, revealed a Comprehensive Care Plan that was person-centered to include the discharge plans and to meet the resident's preferences, goals while addressing the resident's medical, physical, mental, and psychosocial needs. Care plan interventions should be implemented after consideration of the resident's problem areas and their causes. Interventions were to address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers. The interventions were to reflect action, treatment or procedure to meet the objectives toward achieving the resident goals. Care plans were ongoing and revised as information about the resident and the resident's condition changed. The nurse/Interdisciplinary team (IDT) were responsible for the review and updating of care plans. The care plan should be a reflection of the current status of the resident and be updated with changes in the resident status, when there was a significant change in the residents condition and when the resident has been readmitted from a hospital stay. 1. Record review revealed the facility admitted Resident #1, on 08/04/2017, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed Resident #1 was readmitted back to the facility on [DATE] with a Subdural Hematoma and status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, record review revealed Resident #1's was readmitted to an acute care facility on 03/03/2021 with Increased Confusion, decreased Hemoglobin (Hgb), Altered Mental Status and Acute Blood Loss [CONDITION(S)]. Review of the Annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1 to require extensive assistance of two (2) staff assist with bed mobility and personal hygiene. The resident also was assessed as totally dependent on two (2) staff for transfer and bathing assistance, with the resident having upper and lower extremity impairment to one side. The resident had a Brief Interview Mental Status (BIMS) score of fourteen (14) out of fifteen (15) indicating cognitively intact with no behaviors noted. Review of Resident #1's Fall care plan, initiated 02/10/2019, revealed the goal was the resident would not sustain a fall related injury by utilizing fall precautions through the next review. Continued review revealed interventions to include: bed in the low position, mechanical sling lift for transfers, pressure reduction mattress, reclining back wheelchair, report falls to physician and responsible party, routine and as needed incontinent care, repositioning as tolerated, staff assist with bed mobility, transfers and toileting needs, use fall risk screen to identify risk factors as indicated. There was no documented evidence the facility revised the Care Plan to include two (2) staff assistance for bathing and extensive assistance of two (2) staff with bed mobility and personal hygiene, per the facility's MDS assessment. Review of Resident #1's care plan for Activities of Daily Living (ADL) function, initiated 05/27/2019, revealed interventions to include: 1/4 side rails (bilateral) as enablers related to weakness, mechanical sling lift for transfers, routine and as needed incontinent care, repostioning as tolerated, shampoo, shower or bed bath two (2) times weekly with partial bed baths on all other days. Review of the facility provided Fall Investigation, dated 02/26/2021, revealed without a second staff to assist, Certified Nursing Assistant (CNA) #1 was providing Resident #1 a shower on a shower bed (gurney). CNA #1 rolled Resident #1 to his/her side, to remove clothing, the shower bed siderail broke and Resident #1 fell from the shower bed and landed on the shower floor. Resident #1 was sent to the emergency department (ED), where the resident was diagnosed with a Subdural Hematoma, Closed Bicondyle Fracture of Right Femur and a six (6) centimeter Laceration of the Frontal Scalp without Foreign Body, that required nine (9) staples and was admitted to the hospital. Review of the Fall Investigation Event form, dated 02/26/2021, revealed the facility determined the root cause of the fall to be that Resident #1 required two (2) staff assist while removing clothing and turning the resident on the shower gurney. Continued review revealed contributing factors to be Resident #1 had contractures, paralysis to left side and drawn up at the right knee. Per the report, Resident #1 had been determined to be at high risk for falls, and had impaired safety awareness. On 08/05/2021 at 8:36 AM, interview with CNA #1, revealed he was on duty on 02/26/2021 and was assigned to provide care to Resident #1. Per interview, without a second staff assist, he was provided Resident #1 a shower using the shower bed. Continued interview revealed he rolled Resident #1 to his/her side to remove clothing from under the resident when the side rail fell and the resident rolled off the shower bed landing onto the floor injuring the resident. CNA #1 stated he was not aware that Resident #1 required a two (2) staff assist. Per interview, the CNA Care Plan (CNA assignment sheet) provided staff with the care needs of each resident to include the level of assistance each resident required. Continued interview revealed the facility did not provide him an assignment sheet (CNA care plan) the night of Resident #1's fall; however, he had worked there before and was familiar with the resident from the previous assignment sheet. Further interview revealed he had not been educated to use (2) two individuals when using the shower gurneys, and he was not using them at this time. Additionally, CNA #1 stated that the outcome of not utilizing an updated care plan to include the most recent facility assessments to utilize two (2) staff to provide showers could result in patient falls and injury. On 08/05/2021 at 8:23 AM, interview with Registered Nurse (RN) #1, revealed she was Resident #1's nurse on 02/26/2021. Per interview, Resident #1 had requested night showers. RN #1 stated that on 02/26/2021, she had assisted CNA#1 in transferring Resident #1 with the lift onto the shower bed, and had made sure the resident was on the shower bed to transport to the shower room. RN #1 stated that she had been in the shower room when they started the shower running and then left the shower room and returned to the nursing desk on Unit #1. She stated she left the CNA to shower the resident without a second staff to assist because the resident did not move on the shower bed. RN #1 stated while sitting at the desk, she heard a scream and entered the shower room and saw Resident #1 lying on the floor. RN #1 stated per the MDS, Resident #1 was a total care with two (2) person assist. RN #1 revealed the resident was a two (2) person transfer, could roll and once rolled, could stay in place. Continued interview revealed on the CNA assignment sheet, Resident #1 was a one (1) person assist, had always been a one (1) person assist. RN #1 stated information on the CNA assignment sheets was taken from the resident's Comprehensive Care Plan. Per interview the nursing staff could add interventions to the care plan and during the morning meetings, the nursing team reviews the care plans and CNA assignment sheets. 2. Record Review revealed the facility admitted Resident #2 on 03/09/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS, dated [DATE], revealed Resident #2 was assessed as having no behaviors, requiring total assistance of (2) two staff for bathing and transfers only occurring once or twice with (2) two staff. Resident #2 was further assessed as having Bilateral Lower Extremity (BLE) impairment, dependent on staff to do all of the effort for showers and bathing, able to roll left or right independently. The resident had a BIMS score of fifteen (15), indicating the resident was cognitively intact. Review of Resident #2's fall care plan, with problem start date of 02/23/2019, revealed staff were to assist with bed mobility and transfers. To use the lift for transfers with assistance. Staff were to lock brakes on bed/chair, etc., before transferring. Review of Resident #2's Activities of Daily Living (ADL) functional/rehabilitation care plan, initiated 02/23/2019, with interventions to include: shower with use of shower bed related to residents inability to sit safely in shower chair, 1/4 side rails (bilateral) as enablers, encourage showers/ hygiene, lift for transfers with assist, resident prefers a complete bed bath per CNA assignment sheet and a partial bed bath on other days and prefers not to take showers. There was no documented evidence the resident required extensive assistance of (2) two staff for bathing and transfers Interview with Resident #2, on 08/06/2021 at 10:49 AM, revealed one staff member provided his/her showers because there was not enough room for two staff members in the shower room. 3. Record review of revealed the facility admitted Resident #3 on 04/23/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS, dated [DATE], revealed Resident #3 required extensive assistance of two (2) staff with bed mobility and personal hygiene, two (2) staff assist with transfers and was a total assistance of two (2) staff with bathing. Resident #3 was assessed to have a BIMS score of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact, with no behaviors. The resident had bilateral upper and lower extremity impairment and was dependent on staff assist to roll to the left or right side. Review of Resident #3's ADL functional/rehabilitation care plan, initiated 01/18/2021, revealed interventions to include: shower with use of shower bed related to resident inability to sit up safely in shower chair, adaptive equipment per physician orders, 1/4 side rails (bilateral) as enablers, shampoo, shower/bath two (2) times weekly with partial bed baths on all other days. Continued review revealed staff were to assist with bed mobility, transfers, toileting, bathing, dressing and grooming. However, there was no documented evidence the resident required extensive assistance of two (2) staff for bathing and transfers. Interview with Licensed Practical Nurse (LPN) #3, on 08/05/2021 at 10:40 AM, revealed nurses could update interventions on the care plan. LPN #3 stated the Unit Manager (UM) or Assistant Director of Nursing (ADON) reviewed the care plan revisions made by staff to ensure interventions were appropriate. Additionally, LPN #3 stated that care plans were reviewed in the morning meetings and management would notify staff if the interventions were appropriate. Interview with UM #1, on 08/08/2021 at 1:49 PM, revealed she had to receive training on the duties related to care plans and needed help from the ADON and Director of Nursing (DON) when reviewing the residents care plan and inputting information. Additionally, the UM stated if something changed, like an event or care of the resident, they would add appropriate interventions and remove interventions that no longer applied in the whiteboard (morning) meeting with the UM, ADON and DON. UM #1 stated that CNA care plans (assignment sheets) were available for staff and were a summary of the comprehensive care plan and guided more to the CNA's. UM #1 stated that the UM would put them on the unit and in the absence of the UM, the ADON or the DON would print them out and they should be on the units. However, had not identified resident's using the shower bed had not had care plan revisions. Interview with MDS nurse, on 08/05/2021 at 4:21 PM, revealed the UM kept track of the CNA assignment sheets and MDS staff were to update care plans with each quarterly, and annual assessment. Additionally, the MDS nurse stated the UMs were to update the care plan with new interventions between MDS assessments. The MDS nurse stated if a new intervention were identified then it should be on the care plan. She stated the CNA assignment sheets were more specific to CNA's care and the sheets should include the care requirements of the residents. Continued interview revealed the CNA should provide care according to the CNA assignment sheet, and if it was not available they should not start the day without it. She stated if they provided care without the CNA assignment sheet, they were not following the plan of care for the resident. Additionally MDS stated that according to the case involving Resident #1's care, the plan of care was not being followed. The MDS nurse stated that the UM does the new orders and new interventions and the MDS does the care plan with the assessment (quarterly, annual and MDS assessments). Interview with Director of Nursing (DON), on 08/06/2021 at 2:24 PM, revealed Resident #1, Resident #2 and Resident #3's Comprehensive Care Plan had not been revised to include the facility's assessment that required two (2) staff assist. She stated she updated the care plan for Resident #1 on 08/05/2021 to include staff assist of two (2). The DON stated she had not changed Resident #2 and Resident #3's care plans to reflect the assistance of two (2) staff with showers. Interview with the DON, on 08/09/2021 at 9:47 AM, revealed the care plans were provided as a team; developed and based on resident needs. The DON stated care plans were always available electronically. Per interview, the CNA assignment sheet was a tool and staff could get the information about residents and they could ask the nurse. The DON stated that the care plans should be reviewed and revised with any condition change. Per interview, staff could go to the electronic profile of the resident to obtain care information. The DON stated the management team review the care plans in the white board (morning) meeting with the UM. Per interview, the UM for each hall was responsible to ensure the care plans were revised and the information was distributed to staff. The DON stated that Quarterly MDS Assessments were completed to see if residents have any changes with their ADLS. She stated she or the ADON may check a care plan; however, the facility did not have a system in place to ensure the UM had checked or revised the care plan. Additionally, the DON stated that her expectation was that the care plan was updated and available on the units. Interview with the Administrator (ADM), on 08/09/2021 at 10:01 AM, revealed he expected the Comprehensive Care Plan to be reviewed and revised, and the plan should reflect the most current resident care needs. The ADM stated care plans were reviewed by then IDT team and revisions were typically done by the Unit Manager (UM); but any of the IDT or management team could review and revise the care plan. Per interview, the UM was ultimately responsible for ensuring the care plan was reviewed and revised timely and oversight of the process was the responsibility of the DON and ADON.

Based on interview, record review, facility policy review, and manufacturer guideline review, it was determined the facility failed to ensure one (1) of three (3) sampled residents (Resident #1) received adequate supervision and assistance to prevent accidents. On [DATE], Resident #1 fell from a shower bed (gurney) while being assisted by one (1) Certified Nursing Assistant (CNA) during a shower, requiring Resident #1 to be transferred to an acute care facility for evaluation and treatment. Resident #1's fall from the shower bed (gurney) resulted in a six (6) centimeter long scalp laceration that required nine (9) staples, a Subdural Hematoma, and a Closed Bicondyle Fracture of the Right Femur. The findings include: Review of facility's policy Falls dated [DATE], revealed the facility's intent were to provide residents with assistance and supervision in an effort to minimize the risk of falls and fall related injuries. The policy further stated all residents would have a comprehensive fall risk assessment on admission/readmission, quarterly, and with significant change of condition and appropriate care plan interventions would be implemented and evaluated as indicated by the assessment. Review of facility's policy Safety and Supervision of Resident last revised [DATE], revealed safety risks and environmental hazards were identified through an ongoing basis by a combination of employee training, employee monitoring, and reporting processes. The policy also stated staff should make routine resident and environmental checks and employees should be trained and inserviced on potential accident hazards, how to identify and report accident hazards and to prevent avoidable accidents. Further review of the policy revealed staff used various sources to identify risk factors for residents, including information obtained from the medical history, physical exam, observation of the resident and the MDS. Review of facility's policy Safe Lifting and Movement of Resident revised [DATE], revealed in order to protect the safety and well-being of staff and residents, and to promote quality care, the facility used appropriate techniques and devices to lift and move residents. Resident safety, dignity, comfort and medical condition were incorporated into goals and decision regarding the safe lifting and moving of residents. Staff responsible for direct care would be trained in the use of manual and mechanical lifting devices. And staff would be observed periodically for adherence to policies and procedures regarding the use of equipment and safe lifting techniques. Further review of the policy revealed all equipment used would meet or exceed guidelines and regulations concerning resident safety. Safe lifting and movement of residents were part of an overall facility employee health and safety program, which involved employees in identifying problem areas and implementing workplace safety and injury- prevention strategies. Staff were provided training on safety, ergonomics and proper use of equipment and continual evaluation of the effectiveness of workplace safety and injury prevention strategies. Review of the Operation Instructions for Shower Bed USG 1200 Model, dated [DATE], revealed the operator was to never leave an at-risk user unattended on the bed. Continued review revealed EXAGGERATED USER MOVEMENT IN ANY DIRECTION OR ROLLING TO THE EDGE MAY CAUSE GURNEY TO TIP. DO NOT ROLL USER AWAY FROM YOU UNLESS THERE IS A PARTNER ON THE OTHER SIDE. Continued review revealed the guidelines directed the side rails were not to be used a a grab bar. Continued review revealed Safety/Maintenance Information, Check pipe and fittings for hairline fractures monthly, check all junctures to make certain the pipe and fittings do not pull apart, clean and lubricate casters monthly to avoid rust and wheel lock-up and to not subject product to temperatures below forty (40) degrees Fahrenheit or above one-hundred and forty (140) degrees Fahrenheit. Record review revealed the facility admitted Resident #1, on [DATE], with diagnoses which included Polymyalgia Rheumatica, History of Cerebral Vascular Accident ([CONDITION(S)]), Left Knee Contracture, Pain in Left Lower Leg, Need for Assistance with Personal Care, Dependence on Wheelchair with weakness to Left Upper Extremity, Impaired Mobility, Displaced Fracture of Lateral Condyle of Right Femur, and subsequent encounter for closed fracture with routine healing dated [DATE]. Review of the Annual Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility's assessment of activities of daily living (ADLs) for Resident #1 determined he/she required extensive assistance of two (2) with bed mobility and personal hygiene. The facility also assessed the resident to require the total dependence of two (2) staff with transfers and bathing. Further review of the MDS assessment revealed Resident #1 was assessed as having upper and lower extremity impairment to one side. Continued review of the MDS assessment revealed the resident had a Brief Interview for Mental Status (BIMS) score of fourteen (14) indicating the resident was cognitively intact and interviewable. Review of the facility's point of care Activities of Daily Living (ADL) category report, for MDS 3.0, date range of [DATE]-[DATE], revealed Resident #1 required assistance of two staff with bed mobility, transfers, and bathing. Review of Resident #1's Activities of Daily Living (ADL) Care Plan, dated [DATE], revealed the facility addressed the resident's need for assistance with activities of daily living to include bathing. However, the facility had not addressed the use of the shower bed or the amount of staff assistance needed to ensure the resident's safety per the MDS assessed need. In addition, the facility had not addressed safety concerns with the shower bed use, after the resident's fall from the shower bed on [DATE]. Review of Fall investigation, dated [DATE] at 12:55 AM, revealed Resident #1 was being showered in a shower bed by CNA #1, when the resident fell off the shower bed to the floor sustaining a scalp laceration that required nine (9) staples, a Subdural Hematoma, and a Closed Bicondyle Fracture of the Right Femur. The investigation revealed the resident required assistance of two staff while removing clothing and turning of the resident on the shower bed. It was also noted there were contributing factors of contracture's and paralysis on Left side, and the resident kept the right side pulled up at the knee. Resident #1 had been determined to be at high risk for falls, and had impaired safety awareness. The Root Cause analysis of the fall was documented as resident required (2) two assist while removing clothing and turning on the shower gurney. Review of a witness statement by Certified Nursing Assistant (CNA) #1, dated [DATE], revealed he providing a shower to Resident #1 when he/she fell from shower bed (gurney) and was not aware of the need for two (2) person assist with shower bed. The statement further revealed the CNA had the head of the shower bed elevated and while turning the resident on his/her left side to remove clothing beneath the resident, Resident #1 fell from the shower bed. Review of a witness statement by CNA #2, dated [DATE], revealed CNA #1 had come to his unit and asked for help with Resident #1. CNA #2 stated upon arrival to the shower room Registered Nurse (RN) #1 was with Resident #1. Resident #1 was lying on the shower floor with blood by his/her head; after RN #1 assessed the resident, CNA #1 and CNA #2 lifted the resident back onto the shower bed. CNA #2 revealed the rail on the shower bed (gurney) would not lock and they carefully took the resident back to his/her room and transferred the resident into his/her bed. The statement further revealed RN #1 had assessed the resident and bandaged the residents' head laceration. Review of a witness statement by RN #1, dated [DATE], revealed Resident #1 was assisted up with a mechanical lift by CNA #1 and RN#1, and placed in the shower bed (gurney) and taken to the shower room. RN #1 stated she was at the desk while CNA #1 was in the shower room showering Resident #1. The witness statement further revealed RN #1 stated CNA #1 had informed her when rolling the resident back a little, the rail went down, something from the bed fell and hit the floor, and Resident #1 fell to the floor. Continued review of the witness statement revealed RN #1 stated she had gone into the shower room and applied pressure to the resident's right forehead and the resident was lifted to the bed by the three (3) staff in the shower room, assisting the resident to the bed. RN #1 assessed Resident #1 who had complained of right leg and knee discomfort and a pressure dressing was applied to the forehead. Resident #1 was sent to the emergency room for evaluation. Review of Emergency Department (ED) records dated [DATE], revealed Resident #1 presented to the ED after a fall, while getting a shower on a shower bed (gurney), when the equipment broke and the resident fell to the floor. The resident complained of right knee, head pain and was unsure if he/she lost consciousness. The resident also had nausea and vomiting. The ED record revealed Resident #1 had a head laceration of six (6) centimeters (cm) of the frontal scalp, which required repair with nine (9) staples, and swelling and tenderness of the right knee. Further review of the ED note, revealed Resident #1 had an acute fracture of the distal right femoral metaphysis. Resident #1 was admitted to the critical care unit, and treated for a fall, Subdural Hematoma, Closed Bicondylar fracture of right femur and Laceration of scalp without foreign body. The hospital discharged the resident on [DATE]. Interview with Registered Nurse (RN) #1, on [DATE] at 8:23 AM, revealed Resident #1 was a total care with two person assist with bathing and transfers. She stated Resident #1 requested night showers and on [DATE], she assisted CNA #1 in transferring Resident #1, onto the shower bed, using the lift. RN #1 stated she left the shower room and returned to the nursing desk on Unit #1 leaving CNA #1 alone to shower the resident. She stated she left because the resident did not move while on the shower bed. RN #1 stated while sitting at the desk, she heard a scream and entered the shower room and saw Resident #1 lying on the floor. Interview with CNA #1, on [DATE] at 8:36 AM, revealed he was on duty on [DATE] and was assigned to provide care to Resident #1. He further stated no one was in the shower room with him and the resident was a one assist with showers to his knowledge. CNA #1 stated he had not been educated to use (2) two individuals when using the shower gurneys. Additionally, CNA #1 stated when using a shower bed it would be safer to have two staff present because a resident could fall off the shower bed. Interview with CNA #2, on [DATE] at 11:35 AM, revealed he had been summoned by RN #1 after Resident #1 had fallen off the shower bed. He stated he and RN #1 had retrieved the lift and transferred the resident to the bed. CNA #2 revealed he had looked at the shower bed (gurney) and the pins were still in but the rails were bent over like they were stripped, as if the glue had came out of them and were out of joint. CNA #2 further stated the staff were aware of the level of assistance a resident required by the CNA care plan (assignment sheet), however, they had not received them until about two (2) months ago. Interview with Director of Operations (DoO)/Maintenance, on [DATE] at 7:35 AM, and [DATE] at 3:40 PM, revealed the facility had no documentation of previous inspections of the shower bed prior to Resident #1's fall on [DATE]. Additionally, DoO stated the shower bed was in the dining room when he came to work on [DATE], he had no training on inspecting the shower bed, had not read the shower bed manual or had a current copy. He further stated he believed central supply might have a copy of the shower bed gurney, and when he inspected the shower bed he would check the brakes/pins and make sure there were no cracks in the pipe. Interview with Medical Director, on [DATE] at 12:55 PM, revealed his expectations regarding inspection, maintenance of equipment was that it would be good and in working condition and not expired. Medical Director additionally stated regarding the supervision and safety for residents during ADL care (such as showers, repositioning, baths, and transferring), his expectation was for everything to work perfectly, and he expected things to be in perfect order. Interview with Director of Nursing (DON), on [DATE] at 2:24 PM, and on [DATE] at 9:47 AM, revealed she updated the care plan for Resident #1 on [DATE] to include assist of two staff. The DON further stated she expected two staff members be present when providing showers for residents utilizing a shower bed to ensure the resident's safety. Interview with Administrator, on [DATE] at 8:54 AM, revealed there was no documentation of inspections of the shower beds prior to Resident #1's fall. The Administrator stated faulty equipment was to be locked out and tagged out and removed from the building, right then by the individual finding it; so that no one would use it. Additionally, the Administrator stated he expected maintenance would follow the maintenance policy, and the TELS system direction, regarding maintenance care of the equipment, but there was no training for maintenance prior to the fall. Additionally, Administrator stated Maintenance was responsible to inspect the equipment. However, the facility provided manufacturer's guidelines for shower bed 910, 915, and 920 models. However, the one that broke was a 1200 model, and root cause analysis of the fall was documented as resident required (2) two assist while removing clothing and turning on the shower gurney.

Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure a shower bed was maintained in safe operating condition and documentation of preventative maintenance (PM's) completed for resident care equipment for one (1) resident in a sample of three (3) residents (Resident #1). On [DATE], Certified Nursing Assistant (CNA) #1 was providing Resident #1 a shower in a shower bed (gurney). CNA #1 rolled Resident #1 to his/her side to remove clothing. The siderail of the shower bed broke and Resident #1 subsequently fell to the floor. Resident #1 was sent to an acute care facility emergency department where the resident was diagnosed with Subdural Hematoma, Closed Bicondyle Fracture of the Right Femur, Laceration of the Scalp requiring nine (9) staples. The resident was admitted to the acute care facility. The findings include: Review of facility policy, dated ,d+[DATE] and titled Maintenance Policy, revealed all personnel was to properly use and care for the equipment assigned and necessary for use in their work. All employees were expected and required to exercise due care and safety in the use of all facility equipment. An employee should not use equipment or supplies until he/she have been properly trained to utilize such materials. Review of the Suppliers Owners Manual for the shower bed/gurney, provided by the facility, not dated, revealed users should read and follow all directions and warnings before using the device. The device should not be operated without first reading and understanding the contents of the manual. Death or injury may result from the improper use of the device or failure to follow all directions and warnings. Further review of the manual revealed if the casters were used in a wet environment, they should be kept lubricated with white [MEDICATION(S)] paste or a similar lubricant, check pipe and fittings for cracking, fractured or other damage at least monthly, and at least monthly check all glued fittings by attempting to pull the PVC pipe out of the fittings. Product warranty period and coverage (parts) revealed warranty for Healthcare PVC devices were for five (5) years on the frame (of all PVC parts), and two (2) years on all other components including casters. The product should still be inspected, monitored, and cared for as described in the guide, as the device may need to be replaced sooner than expected in particular situations. Additional warnings revealed when using the device, the user shouldn't lean out of the device or shift weight in any manner which may pose a tipping risk. Review of the Operating Instructions of USG 1200 series shower bed (gurney), provided by the facility, revealed precautions: An at-risk user should never be left unattended on the bed. Exaggerated user movement in any direction or rolling to the edge might cause the gurney to tip. A partner/caregiver needs to be on the other side if a user was to be rolled away from you. Do not use siderail as a grab bar. Safety and Maintenance information included: checking pipe and fittings for hairline fractures monthly. All junctures should be checked to make certain the pipe and fittings have not pulled apart. Casters should be cleaned and lubricated monthly to avoid rust and wheel lock-up. Product should not be subjected to temperatures below 40 or above 140. Review of TELS (Maintenance Inspection Log) revealed no documented evidence the shower beds (gurneys) were inspected per the manufacturer's monthly recommendation. Inspections of shower beds (gurneys) were not documented until after Resident #1's fall from the shower bed on [DATE]. Record review revealed the facility admitted Resident #1 on [DATE] with diagnoses to included Polymyalgia Rheumatica, [CONDITION(S)] Disease, Anxiety Disorder, Adult Failure To Thrive (AFTT), Major Depressive Disorder, History of [CONDITION(S)] ([CONDITION(S)]), Left Knee Contracture, Pain in Left Lower Leg, Need for Assistance with Personal Care, Dependence on Wheelchair with weakness to Left Upper Extremity, Impaired Mobility and Dementia with Behavioral Disturbance. On [DATE], additional diagnosis of Displaced Fracture of of the Lateral Condyle of Right Femur, and subsequent encounter for closed fracture with routine healing were added. Review of the Annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessment of activities of daily living (ADLs) for Resident #1 required extensive assistance of two (2 ) staff assist with bed mobility and personal hygiene, and had been assessed to require total dependence with two (2) staff assist for transfer and bathing, with Resident #1 having upper and lower extremity impairment to one side, and to have a Brief Interview Mental Status (BIMS) score of fourteen (14) out of fifteen (15), indicating cognitively intact with no behaviors noted. Review of a witness statement by RN #1, dated [DATE], revealed Resident #1 was assisted up with a mechanical lift by CNA #1 and RN#1, and placed in the shower bed (gurney) and taken to the shower room. RN #1 stated she was at the desk while CNA #1 was in the shower room showering Resident #1. The witness statement further revealed RN #1 stated CNA #1 had informed her when rolling the resident back a little, the rail went down, something from the bed fell and hit the floor, and Resident #1 fell to the floor. Review of Emergency Department (ED) records dated [DATE], revealed Resident #1 presented to the ED after a fall, while getting a shower on a shower bed (gurney), when the equipment broke and the resident fell to the floor. The resident complained of right knee, head pain and was unsure if he/she lost consciousness. The resident also had nausea and vomiting. The ED record revealed Resident #1 had a head laceration of six (6) centimeters (cm) of the frontal scalp, which required repair with nine (9) staples, and swelling and tenderness of the right knee. Further review of the ED note, revealed Resident #1 had an acute fracture of the distal right femoral metaphysis. Resident #1 was admitted to the critical care unit, and treated for a fall, Subdural Hematoma, Closed Bicondylar fracture of right femur and Laceration of scalp without foreign body. The hospital discharged the resident on [DATE]. On [DATE] at 7:35 AM and [DATE] at 3:40 PM, interview with Director of Operations (DoO)/Maintence, revealed he had not performed routine inspections of the shower bed prior to Resident #1's fall on [DATE]. The DoO stated the he had no training on inspecting the shower bed. He stated he did not have a manual of the shower bed; but thought one could be obtained from central supply. Interview with Administrator, on [DATE] at 8:54 AM, revealed there was no documentation of inspections of the shower beds prior to Resident #1's fall. The Administrator stated faulty equipment was to be locked out and tagged out and removed from the building. He stated there was a maintenance log at the nursing station, but faulty equipment was removed from the building right then by the individual finding it, so that no one would use it. Additionally, the Administrator stated he expected maintenance would follow the maintenance policy and the TELS system regarding maintenance care of the equipment, but there was no training for maintenance prior to the fall. The facility provided manufacturer's guidelines for 910, 915, and 920 models, however,the one that broke was a 1200 model. Maintenance was responsible to inspect the equipment. Interview with Medical Director, on [DATE] at 12:55 PM, revealed he expected staff to inspection and maintain facility equipment. He stated each piece of equipment should be in good working condition and not expired.

Based on interview, record review, and facility policy review, it was determined the facility failed to honor a resident's preference related to the desire for showers, instead of routine bed baths for one (1) of three (3) sampled residents (Resident #1). The findings include: Review of the facility's policy, Resident Rights, undated, revealed it was the goal of the facility to promote the rights of each resident in the facility, and each resident had a right to a dignified existence, and self-determination. Review of the facility's policy, Kentucky Resident Handbook and Admission Information, last revised 03/04/2020, revealed the facility would promote the rights of each resident had a right to a dignified existence, and self-determination. Further review of the policy revealed the resident would be able to exercise his/her rights as a resident of the facility and receive services in the facility with reasonable accommodation of individual needs and preferences. Record review revealed the facility admitted Resident #1, on 08/04/2017, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessment of activities of daily living (ADLs), determined Resident #1 required the extensive assistance of two (2) staff with bed mobility and personal hygiene. In addition, required the total dependence of two (2) assist for transfers and bathing. The resident was noted to have upper and lower extremity impairment to one side. The facility conducted a Brief Interview Mental Status (BIMS) of Resident #1 and the resident scored a fourteen (14) which indicated the resident was interviewable. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed Resident #1 to require total dependence on two staff for bed mobility and extensive assistance with two staff for transfers/bathing and personal hygiene. Additionally, the facility assessment revealed Resident #1 was dependent on staff for showers and for rolling to left or to right. Resident #1's BIMS was a ten (10) during this assessment period indicating . Review of Point of Care History documentation, revealed Resident #1 had received only bed baths since 02/26/2021. Interview with Resident #1, on 08/04/2021 at 11: 05 AM, and 08/05/2021 at 3:34 PM, revealed the nurse aides told him/her after his/her fall on 02/26/2021, they were unable to give him/her a shower because there were no shower beds (gurneys) for use. Resident #1 further stated he/she preferred showers but was given bed baths. Interview with Certified Nursing Assistant, on 08/05/2021 at 8:36 AM, revealed the facility was not using the shower beds (gurneys) at this time. Interview with CNA #3, on 08/06/2021 at 12:06 PM, revealed she was unsure what was going on with Resdient #1 related to showers. Interview with Registered Nurse/Unit Manager (RN/UM) #2, on 08/05/2021 at 3:30 PM, revealed she was not aware of any problems with the shower beds (gurneys) or why Resident #1 was not provided a shower. Interview with Assistant Director of Nursing and Unit Manager #3, on 08/05/2021 at 3:45 PM, revealed that she did no know why staff were not providing Resident #1 showers. She stated the facility did have one shower bed in use. Interview with Unit Manager/Assistant Director of Nursing (UM/ADON), on 08/05/2021 at 3:34 PM, revealed she was not sure why the resident was not receiving showers. Interview with the Director of Nursing (DON), on 08/09/2021 at 9:47 AM, revealed if a resident wanted a shower, staff should provide the resident a shower; yet she did not know the reason the resident was not receiving showers. Interview with Administrator, on 08/09/2021 at 10:01 AM, revealed if a resident wanted a shower, staff should give the resident a shower.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to immediately inform (1) of four (4) sampled residents, Resident #1, of a significant change in his/her physical condition. Resident #1 tested positive for Covid-19 on 12/08/2020 and his/her results became available on 12/08/2020. The Assistant Director of Nursing (ADON)/Infection Preventionist accessed the resident's test result on 12/09/2020; however, there was no documented evidence the facility infromed the resident of his/her positive COVID-19 status. The findings include: Review of the facility's policy titled, Change of Condition, Revised 11/16/2019, revealed the facility would evaluate and document changes in a resident's health, mental, or psychosocial status and the resident and/or the resident's representative would be informed. Review of the Resident Face Sheet in Resident #1's clinical record, revealed the facility admitted the resident on 05/09/2018 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment completed by the facility, dated 11/03/2020, revealed Resident #1 scored a nine (9) out of a possible fifteen (15) on the Brief Interview for Mental Status (BIMs) indicating the resident was interviewable. Review, of Resident #1's COVID-19 test result, with a collection date of 12/07/2020, with a received date of 12/08/2020, and a report date of 12/08/2020, revealed the resident tested positive for COVID-19. Review of the physician's orders [REDACTED].#1's clinical record, revealed there was an open-ended order dated 12/09/2020, for Droplet Isolation Precautions r/t (related to) the resident's positive COVID-19 status. The order also indicated all care was to be provided in the resident's room. Review of the Progress Notes in Resident #1's clinical record, revealed a note dated 12/09/2020, time stamped 13:32 (1:32 PM), and documented by Social Services Staff #4. The note read as follows: resident notified of thirteen (13) residents testing positive for covid. All concerns and questions answered. The note did not confirm the social services staff informed Resident #1 of his/her own COVID-19 positive test result. Review of a document titled, COVID-19 Daily Monitoring, with an Observation Date of 12/09/2020 at 11:33 AM, and a Completed Date of 12/09/2020 11:35 AM, revealed, under the subtitle, Purpose of Assessment: Positive for COVID-19, had been selected by the creator of the form (a licensed nurse). The form did not include any indication the creator informed Resident #1 of his/her positive COVID-19 status. Interview, on 12/16/2020 at 12:49 PM with Social Services Staff #4, revealed she did not personally speak with Resident #1 on 12/09/2020, because she was not currently working on Unit 2 where Resident #1 lived. She said Social Services Staff #9 would have informed residents on that particular unit of the new number of COVID-19 positive residents and staff. She stated Social Services Staff #9 talked with Resident #1 on 12/09/2020, and informed Resident #1 of the 13 positive cases and answered any questions the resident had. Social Services Staff #4 said she did not speak with Resident #1, but she documented the information in Resident #1's record. She said she and Social Services Staff #9 tried to work together to get things done. Social Services Staff #4 stated the nurses usually informed residents with a BIMS score of eight (8) or above as soon as the test results were known. She said the nurses would also notify the resident's representative. Social Services Staff #4 said if there was a large number of positive test results, the social services staff members would assist the nurses with the notifications. A telephonic interview with Social Services Staff #9 was attempted but she did not return the call. A telephonic interview with Resident #1 did not occur because the resident did not answer his/her phone, upon two (2) attempts to phone the resident. Interview, on 12/16/2020 at 12:05 PM, with Resident #1's daughter, revealed Resident #1 received a COVID-19 test on Monday (12/07/2020), but she did not receive a call about Resident #1's COVID-19 positive result until late afternoon of 12/10/2020. She said just prior to that call, Resident #1 called to tell her that he/she just learned from SRNA #3, that he/she had tested positive for COVID-19. Resident #1's daughter said Resident #1 was upset about the news. Resident #1's daughter stated she did not have a chance to call a nurse on Unit 2 to question the result before Resident #1 called her again and told her that two (2) other staff (not identified) entered his/her room and told him/her that he/she had not tested positive for COVID-19. She said the resident seemed relieved to hear the second story. However, Resident #1's daughter stated between 5:00 and 5:30 PM, a nurse from Unit 2 called her to apologize, and said Resident #1 had tested positive for COVID-19. Resident #1's daughter said the nurse on the phone stated the nurse on duty on 12/09/2020 should have notified Resident #1 and his/her family. Resident #1's daughter stated that while on the phone with her, the nurse commented that the nurse working on 12/09/2020 had dropped the ball. Interview, on 12/16/2020 at 4:00 PM with SRNA #3, revealed when he found out that Resident #1 was positive for COVID-19 he assumed the resident was already aware of his/her COVID-19 positive status. SRNA #3 said when in Resident #1's room on 12/10/2020, the resident started talking about his/her body feeling sore. SRNA #3 said he referenced Resident #1's positive COVID-19 status as a possible reason he/she was feeling badly. SRNA #3 said the resident appeared to be surprised. He said Resident #1 stated he/she did not know he/she had COVID-19. SRNA #3 said at that point, he realized he may have overstepped by talking with the resident about COVID-19, so he asked a nurse to speak with Resident #1 about his/her COVID-19 status. SRNA #3 said he could not recall the name of the nurse. Interview, on 12/17/2020 at 2:00 PM with the Unit Manager (UM) #8, revealed she served as the UM for Unit 2 and was overseeing the Unit during the week it was converted to a COVID-19 unit (around 12/08/2020). She said she was not sure who spoke with Resident #1 after SRNA #3 had talked with him/her about his/her COVID-19 positive status. She said an agency nurse was working on Unit 2 that day and could have been the nurse that talked with Resident #1 after he/she had been talking with SRNA #3. However, she said she was not completely sure about that, and she did not know much about the situation. The UM said any licensed nurse could inform a resident of his/her COVID-19 test result. The UM said she thought it would be best if licensed nurse or a physician provided that kind of information, because they would be able to address any clinical questions the resident might ask. Interview, on 12/17/2020 at 2:30 PM with The UM #6 (for Units 1 and 2), revealed 12/10/2020 was her first day back at work after some days off. She stated she thought the facility received the COVID-19 test results on 12/09/2020, and that she placed a follow-up call to Resident #1's daughter on 12/10/2020. She said she was not exactly sure what happened earlier in the week, but apparently there was some mix up on 12/10/2020, and Resident #1 received two (2) different stories about his/her COVID-19 test results. She said Resident #1's daughter stated she had heard two (2) different stories, meaning that Resident #1 was positive for COVID-19, and then that he/she was not positive for COVID-19. UM #8 stated the licensed nurse should provide the resident's COVID-19 test results teh same day they received them, and be available for any questions the resident or family member(s) might have. She said the SRNA would not be tasked with providing COVID-19 test results to residents or to their families. Interview, on 12/17/2020, at 3:00 PM with the Assistant Director of Nursing (ADON)/ Infection Preventionist (IP), revealed COVID-19 testing for the residents occurred on 12/07/2020, and the results were available on 12/08/2020 at 6:19 PM. But, since that was after business hours, she viewed the test results on 12/09/2020. She said the facility would have until 5:00 PM on 12/10/2020 to notify the residents and family members of the test results. The ADON/IP said after receiving the results, she forwarded them to the managers responsible for the various nursing units. She stated someone in management should notify residents who tested positive for COVID-19. She said that individual should then document the resident tested positive, and that the resident received the test results. The ADON/IP stated the progress note in Resident #1's record, completed by Social Services Staff #4 on 12/09/2020, was general in nature and did not indicate Resident #1 was informed of his/her positive test result. She said the nurse would be required to complete the COVID-19 initial assessment after a resident tested positive for COVID-19. She said per her review of the assessment dated [DATE], 11:33 AM, the form did not provide evidence the resident was informed of his/her positive COVID-19 status. In an e-mail from the Facility Administrator, dated 12/16/2020, timed 5:44 PM, the Administrator confirmed that if a resident tested positive for COVID-19, notifying the resident of his/her positive test result should be documented in the clinical record in a progress note or via a Situation Background Assessment Recommendation (SBAR). An e-mail communication from the facility's Director of Nursing (DON), dated 12/17/2020, timed 2:41 PM, revealed Resident #1's test results, along with other residents' test results became available on 12/08/2020 at 6:19 PM, after business hours. She said the Administrative staff viewed the results on 12/09/2020, and the note completed by Social Services Staff #4, dated 12/09/2020, served as the resident's notification of his/her COVID-19 positive diagnosis. She said Resident #1's family was notified on 12/10/2020 by UM #6. A follow up interview on 12/17/2020 at 4:25 PM with the DON, revealed she thought Resident #1 was informed on 12/09/2020 of his/her test result, and Social Services Staff #4's choice of words in the note did not indicate Resident #1 was not informed of his/her COVID-19 positive status. Interview, on 12/17/2020 at 5:20 PM with the Administrator, revealed he thought the facility had notified Resident #1 in a timely manner of his/her positive COVID-19 test result, as evidenced by the progress note completed by the Social Services Staff Member on 12/09/2020. The Administrator said Resident #1 had a history of [REDACTED].

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment, for one (1) of twenty-eight (28) sampled residents (Resident #15). The facility failed to develop and implement a urinary incontinence care plan for Resident #15. The findings include: Review of the facility's policy, Comprehensive Care Plans, revised 07/19/18, revealed a person-centered Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident and the care plan will include how the facility will assist the resident to meet their needs, goals and preferences. Record review revealed the facility admitted Resident #15 on 08/23/18 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 08/30/18, revealed the facility was unable to assess the resident's Brief Interview for Mental Status (BIMS) score due to his/her severely impaired cognition. Further review of this Admission MDS revealed the facility coded the resident to be continent of bowel, who was frequently incontinent of bladder. Further record review revealed no evidence of a comprehensive care plan had been developed or implemented for Resident #15's noted urinary incontinence. Interview with MDS Coordinator #1, on 11/15/18 at 10:41 AM, revealed they did not care plan Resident #15's incontinence. She stated she just somehow failed to develop and implement a comprehensive care plan related to his/her noted incontinence. She stated it was important to make sure they have residents' care plans in place for the problems they have identified and assessed. Interview with the Director of Nursing (DON), on 11/15/18 at 1:16 PM, revealed she expected all staff to follow facility policies. She stated staff should have developed a urinary incontinence care plan for Resident #15 and she expected staff to make sure the appropriate care plans were in place for each resident.

Based on observation, interview, record review, and review of the facility's policies/procedures, it was determined the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections (UTIs) and to restore continence to the extent possible, for two (2) of twenty-eight (28) sampled residents (Resident #15 and Resident #27). The facility failed to assess Resident #15 upon admission for a baseline elimination status to see if retraining was an option. Additionally, an observation during Resident #27's catheter care by Certified Nurse Aide (CNA) #2 revealed she placed wash cloths on the resident's bed frame, which was an infection control issue. The findings include: 1. Review of the facility's policy, Bowel and Bladder Management, revised 07/19/18, revealed the facility will evaluate, monitor and track the resident's bowel and bladder pattern and will identify the need for early intervention. The policy further states the facility will evaluate bowel and bladder status upon admission, readmission, quarterly, annually and with significant change. The policy also states if a resident is incontinent, a baseline elimination status to assess bowel and bladder patterns will be completed upon admission, readmission, annually and with significant change, and the Interdisciplinary Team (IDT) will review bowel and bladder data to determine if retraining is an option or a pattern has been identified. Record review revealed the facility admitted Resident #15 on 08/23/18 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 08/30/18, revealed the facility was unable to assess his/her Brief Interview for Mental Status (BIMS) score due to the resident's severely impaired cognition. Further review of the Admission MDS revealed the facility coded the resident to be continent of bowel, but was frequently incontinent of bladder. Further record review revealed no evidence a baseline elimination status was completed to assess bowel and bladder patterns upon admission, for the IDT team to review bowel and bladder data, in order to determine if retraining was an option or if a pattern had been identified. Interview with MDS Coordinator #1, on 11/15/18 at 11:11 AM, revealed there was no bowel and bladder assessment for Resident #15 upon admission to the facility; however, there should have been an assessment according to facility policy. Interview with the Director of Nursing (DON), on 11/15/18 at 1:16 PM, revealed she expected staff to assess all residents' bowel and bladder status upon admission per the policy. She stated she was aware Resident #15 was not assessed upon admission and should have been assessed. She stated she expected all staff to follow facility policies. 2. Review of the facility's policy, Catheter Care Procedure, revised 09/07/17, revealed wash and dry hands thoroughly, put on gloves, using a clean washcloth, clean catheter, clean and dispose of used equipment, make sure resident is comfortable and the call light is in reach. Record review revealed the facility admitted Resident # 27 on 03/16/18 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 09/11/18, revealed he/she had a BIMS score of twelve (12), indicating the resident was cognitively intact. Further review of the Quarterly MDS revealed the facility coded the resident as always incontinent of bowel and the presence of a urinary catheter. Review of the Comprehensive Care Plan, initiated on 03/26/18, revealed the resident to be at risk for infection due to a history of UTIs. Observation of catheter care by CNA #2, on 11/14/18 at 12:32 PM, revealed the CNA sprayed three (3) wash cloths with perineal cleanser and placed all three (3) on the end of the wooden bed frame, then proceeded to do catheter care. Interview with CNA #1, who was assisting CNA #2 with care, on 11/14/18 at 12:55 PM, stated she usually put the wash cloths on a towel on the bed, not on the end of the bed frame, as that was a potential infection control issue. Interview with CNA #2, on 11/14/18 at 2:00 PM, revealed she should not have put wash cloths on the bed frame due to an infection control issue, and that she usually put them on a towel on the bed. Interview with Registered Nurse (RN) #1 (Charge Nurse), on 11/14/18 at 2:02 PM, revealed she could see it as an infection control problem by putting wash cloths, to be used for catheter care, on a wooden bed frame. Interview with the Assistant Director of Nursing (ADON), on 11/14/18 at 3:30 PM, revealed staff were permitted to use the perineal wash instead of soap and water for catheter care; however, it was her expectation that staff not put wash cloths to be used for catheter care on the end of a bed frame, as this would be an infection control issue.

Based on interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to ensure it maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise, for one (1) of twenty-eight (28) sampled residents (Resident #102). Resident #102 had a ten (10) percent (%) weight loss in a thirty (30) day timeframe; however, no documentation was provided related to Physician notification. The findings include: Review of the facility's policy, Department: Clinical-Title: Weight Monitoring, revised 07/11/18, revealed to identify residents who are at nutritional risk. The resident's weight will be monitored weekly upon admission/readmission for four (4) weeks and monthly thereafter or as indicated by the resident's condition or physician's orders [REDACTED]. Record review revealed the facility admitted Resident #102 on 10/13/15, and was re-admitted on [DATE], with [DIAGNOSES REDACTED]. Further record review revealed the facility assessed his/her cognition to be severely impaired with a Brief Interview for Mental Status (BIMS) score of ninety-nine (99), as indicated by the resident's Significant Change Minimum Data Set (MDS), dated [DATE]. Further review of the MDS revealed he/she required the assistance of one (1) staff with eating/feeding. Review of the Medical Nutrition Review, dated 10/24/18, revealed his/her weight on 10/17/18 was 114 pounds (lbs) and was 131.6 lbs from the previous month. Review of his/her weight on 11/05/18 was noted to be 114.2 lbs. Review of the fourteen (14) day review revealed his/her weight was 111.4 lbs, down ten percent (10%) in the past thirty (30) days. Additional review revealed Resident #102 consumed twenty-five to one hundred percent (25%-100%) of meals, and received Med Pass (dietary supplement). Review of a Progress Nutritional note, dated 10/30/18 at 8:35 AM, written by the Registered Dietitian (RD) revealed after doing the fourteen (14) day weight review, his/her weight was 111.4 lbs, down ten percent (10%) from the past thirty (30) days. Further review of the note revealed the resident was assisted by staff with meals, consumed an average of twenty-five percent (25%) of his/her pureed, No Added Salt (NAS) diet, and was on a dietary supplements three (3) times per day (TID). Additionally, the resident had a surgical wound, a cast on the left arm, and a splint on the right arm. Interview with the RD, on 11/15/18 at 4:06 PM, revealed Resident #102 was scheduled to be observed, and she was aware of the weight loss on 10/30/18. She further revealed med pass was added and the resident was already on fortified foods; however, the Physician had not been made aware of the weight loss. Interview with the Assistant Director of Nursing (ADON), on 11/15/18 at 4:08 PM, revealed even though the attending Physician was made aware of the resident's re-admission, it was not specified about the resident's 10% weight loss, and it was her expectation the Physician be made aware of all significant weight loss per facility policy.

Based on observation, interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to ensure that a resident who needs respiratory care, including [MEDICAL CONDITION] care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences, for one (1) of twenty-eight (28) sampled residents (Resident #50). The facility failed to provide appropriate [MEDICAL CONDITION] care for Resident #50 per facility policy. The findings include: Review of the facility's policy [MEDICAL CONDITION] Care, effective date 10/30/2017, revealed to maintain airway patency, prevent infections and prevent skin breakdown at the stoma site. Further review of the policy revealed staff are to bring properly functioning equipment to the room and apply pulse oximeter, wash hands thoroughly and apply clean gloves and other Personal Protective Equipment (PPE) as needed to maintain standard precautions, remove soiled [MEDICAL CONDITION] dressing and discard, wash and dry hands thoroughly, put on sterile gloves, and establish sterile field. [MEDICAL CONDITION]: open kit, remove sterile field drape, dump contents on to sterile field, poor half sterile water into one basin and half in the other basin, saturate sponges in the sterile water basin, squeeze out excess water and place on sterile field, moisten the cotton tipped applicators in sterile solution, gently clean the skin around the tube using dampened sterile cotton tipped applicator or gauze pads, wipe from center outward only once with each gauze or applicator and discard, assess the stoma site and surrounding skin for redness, swelling and drainage, place new [MEDICAL CONDITION] around the tube and under [MEDICAL CONDITION] and the tube ties, unlock and remove inner cannula with one (1) hand while holding outer cannula in place with the other hand, and replace with new disposable inner cannula making sure to lock in place if cannula is a locking cannula. Record review revealed the facility readmitted Resident #50 on 02/08/11 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 10/01/18, revealed the facility was unable to assess his/her Brief Interview for Mental Status (BIMS) score due to the resident's severely impaired cognitive status. Further review of the MDS assessment revealed he/she received [MEDICAL CONDITION] care. Review of the physician's orders [REDACTED]. Observation of [MEDICAL CONDITION] care for Resident #50, on 11/14/18 at 10:00 AM, provided by Registered Nurse (RN) #2 revealed she placed a pulse oximeter on the resident's finger. She then opened [MEDICAL CONDITION] and applied sterile gloves. She removed Resident #50's [MEDICAL CONDITION], and then removed the disposable inner cannula using both hands and threw it in the trash can. RN #2 then provided brief tracheal suctioning and grabbed a dry gauze from [MEDICAL CONDITION]. She proceed to wipe in a circular motion around the outer cannula opening several times with the same dry gauze, wiping from outward to the center. RN #2 then threw the gauze in the trash can and removed her sterile gloves and put on another set of sterile gloves without washing her hands in between. Further observation revealed RN #2 placed a new [MEDICAL CONDITION] around [MEDICAL CONDITION] without cleaning the area or assessing the area. She opened the new disposable inner cannula package, removed the inner cannula from the package, and inserted the new inner cannula. RN #2 then disposed of her gloves and other items. Interview with RN #2 revealed she was done [MEDICAL CONDITION]. Further interview with RN #2, on 11/14/18 at 4:48 PM, revealed she knew she had left several steps out during [MEDICAL CONDITION]. She stated she knew she broke the sterile field and left out several steps of the policy/procedure. She stated she was expected to follow the policies/procedures of the facility. Interview with the Director of Nursing (DON), on 11/15/18 at 1:17 PM, revealed she expected staff who [MEDICAL CONDITION] to complete it in accordance with professional standards and follow the facility policies/procedures.

Based on observation, interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to ensure a resident remains as free as possible from unnecessary [MEDICAL CONDITION] medications, for one (1) of twenty-eight (28) sampled residents (Resident #32). Resident #32 was prescribed an antipsychotic medication for an inappropriate diagnosis. The findings include: Review of the facility's policy, [MEDICAL CONDITION] Medications, revised 09/05/18, revealed Physicians and mid-level providers will use [MEDICAL CONDITION] medications appropriately working with the interdisciplinary team to ensure appropriate use, evaluation and monitoring. Under the Guidelines section, revealed the facility will make every effort to comply with State and Federal regulations related to the use of [MEDICAL CONDITION] medications in the long-term care facility to include regular review for continued need, appropriate dosage, side effects, risks and/or benefits. Record review revealed the facility admitted Resident #32 on 11/18/14, and was readmitted on [DATE], with [DIAGNOSES REDACTED]. Observation of Resident #32, on 11/14/18, revealed he/she was sitting on a couch with his/her eyes closed, on the Alzheimer's secure unit. Further observation, on 11/15/18 at 10:30 AM, revealed he/she was self-ambulating around the unit, slightly anxious, and displaying aggression. Review of the Comprehensive Care Plan revealed he/she was care planned for At Risk for Signs/Symptoms of [MEDICAL CONDITION] Medications dated 11/26/14, and care planned for Active and/or At Risk for Behavior Problems related to Resident to Resident Altercation, dated 10/19/17, and related to History of Physical Outbursts and Challenging Behaviors. Review of the physician's orders [REDACTED]. Interview with the Medical Director/Physician, on 11/15/18 at 2:42 PM, revealed he was aware Risperdone was not an appropriate medication to be used for a [DIAGNOSES REDACTED]. He stated this was the only medication which seemed to work for him/her as he/she had been extremely anxious and very aggressive. Interview with the Assistant Director of Nursing (ADON), on 11/15/18 at 3:00 PM, revealed she was aware Risperdone was not an appropriate medication to be given for a [DIAGNOSES REDACTED]. She stated she was aware physical violent outbursts would be a behavior, not a diagnosis.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to notify the responsible party of a need to alter treatment by changing the resident's anticoagulation (blood thinner) medication for one (1) of three (3) sampled residents (Resident #1). On 01/05/18, Resident #1's Physician prescribed to change the Resident's anticoagulant medication from [MEDICATION NAME] to Eliquis (blood thinner); however, the facility failed to notify the resident's responsible party of the change in the resident's treatment. The findings include: Review of the facility policy titled Change in Condition, not dated, revealed the facility will evaluate and document changes in a resident's health, mental, or psychosocial status in an efficient and effective manner; to relay evaluation information to the Physician and to document actions to include but not limited to the following: a need to alter treatment. The facility will notify the resident's representative, consistent with his/her authority, of change and follow through completed by the facility, and document in the medical record. Record review revealed the facility admitted Resident #1 on 07/06/17 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of eleven (11). Review of Resident 1's Physician Orders, dated 01/05/18, revealed Licensed Practical Nurse (LPN) #1 received a telephone order to obtain [MEDICATION NAME] time/international normalized ratio (PT/INR) daily until (INR) was less than two (2), then discontinue [MEDICATION NAME] medication and start Eliquis 2.5 milligrams (mg) by mouth (po) twice a day (BID). Review of Resident #1's Electronic Medication Administration Record [REDACTED]. Interview with LPN #1, on 04/18/18 at 11:40 AM, revealed she received and transcribed the order to change Resident #1's medication ([MEDICATION NAME] to Eliquis). LPN #1 stated, it is the responsibility of the nurse receiving the Physician's Order to notify the resident and/or responsible party of any changes in treatment. Interview revealed LPN #1 did not notify Resident #1 and/or designated Power of Attorney (POA)/responsible party of the medication change. Interview with Resident #1's POA, on 04/17/18 at 4:13 PM, revealed she was not made aware of the medication change from [MEDICATION NAME] to Eliquis until 02/11/18. Interview revealed Resident #1 had a history of [REDACTED]. Interview with Registered Nurse (RN) #1, on 04/18/18 at 11:52 AM, revealed when a nurse received and/or transcribed a Physician's Order, it was the nurse's responsibility to notify the resident and/or responsible party of any treatment changes. Interview revealed if the resident and/or family have not been notified of any changes to treatment, she expected the nurse to note it on the twenty-four (24) hour shift report for the oncoming nurse to notify the resident and/or family of any changes. Interview with the Assistant Director of Nursing (ADON), on 04/18/18 at 12:00 PM, revealed if there was a POA involved in the resident's care, the facility was responsible to notify the POA of any changes of condition or treatment, unless the resident indicated otherwise. Interview revealed the POA should have been notified about Resident #1's medication change from [MEDICATION NAME] to Eliquis. The ADON revealed the facility was not informed Resident #1 had a heart valve replacement as it was not listed in the history of [DIAGNOSES REDACTED].

Based on interview, record review, and facility policy review, it was determined the facility failed to follow the interventions of the care plan for one (1) of twenty-four (24) sampled residents (Resident #12). Resident #12 was care planned for the assistance of two (2) staff for bed mobility and incontinent care; however, on 06/21/16, State Registered Nurse Aide (SRNA) #1 provided Resident #12 incontinent care and assisted with bed mobility without another staff present as care planned. SRNA #1 had to assist the resident to the floor holding the resident under the arms. Resident #12 sustained a left humerous fracture and the physician and family decided not to perform surgery due to the resident's age and diagnoses. The findings include: Review of facility policy Care Plans-Comprehensive dated 06/01/15, revealed an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Further review revealed the comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the Resident Assessment Instrument. Each resident's comprehensive care plan is designed to incorporate identified problem areas; incorporate risk factors associated with identified problems; and aid in preventing or reducing declines in the resident's functional status and/or functional levels. Record review revealed the facility admitted Resident #12 on 10/09/13 with diagnoses, which included [MEDICAL CONDITIONS] Contracture, [MEDICAL CONDITION], and [MEDICAL CONDITION]. Review of the Significant Change Minimum Data Set (MDS) assessment, dated 06/27/16, revealed the facility assessed Resident #12's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of five (5) which indicated the resident was not interviewable. In addition, the facility assessed the resident was dependent of staff for all Activities of Daily Living (ADLs) with the assist of two (2) staff for care. Review of Resident #12's Comprehensive Care Plan for Incontinence of Bowel and/or Bladder, dated 07/20/14, and for ADL Self Care Deficit, dated 07/30/14, revealed to provide the assistance of two (2) with toileting; and turning and repositioning. Further review revealed the two (2) was marked out and a three (3) wrote above the two (2), indicating the need for three (3) staff. The revision to three (3) was completed after the fall on 06/21/16 per the Assistant Director of Nursing on 08/25/16 at 2:00 PM. Review of Certified Nurse Aide (CNA) Care Guide, undated, revealed Resident #12 should be assisted with bed mobility by two (2) staff. Review of the Situation Background Assessment Recommendation (SBAR), dated 06/21/16 with no documented time, and Nursing assessment dated [DATE] at 4:30 AM; and interviews with SRNA #1 on 08/25/16 at 9:40 AM, and LPN #5 on 08/24/16 at 3:02 PM, revealed on 06/21/16 at approximately 4:30 AM, SRNA #1 was providing incontinent care and when she turned the resident away from her, the resident's foot rest slid on the mattress due to the fitted sheet not completely on bed and the resident's feet slid off the bed. SRNA #1 had to reach across the bed and by putting her hands underneath the resident's armpits she lowered the resident to the floor. The SRNA called for the nurse. The resident showed no signs of pain and there was no joint deformity observed. Further interview with SRNA #1 on 08/25/16 at 9:40 AM, revealed the resident was care planned for two (2) staff for bed mobility and incontinent care and she should have looked at the care plan. Interviews on 08/25/16 with SRNA/Certified Medication Aide (CMA) #7 at 2:28 PM, LPN #1 at 4:05 PM, and Family Member #1 at 1:20 PM, revealed Resident #12 was grimacing, moaning and groaning on 06/22/16 when the resident's left arm was touched. The family member requested an X-Ray and mobile x-ray came. Review of the Radiology Report, dated 06/22/16 at 6:38 PM, from the facility mobile X-Ray provider revealed a complete displaced subacute left humeral surgical neck fracture. Review of the hospital X-Ray Report, dated 06/23/16 at 11:16 AM, revealed status [REDACTED]. The findings included fractures involving the proximal humeral head with extension to greater tuberosity and slight anterior displacement. Interviews on 08/25/16 with SRNA #3 at 10:34 AM, SRNA #4 at 1:28 PM, and SRNA #5 at 1:34 PM, revealed that Resident #12 has always been assist of two (2) for bed mobility due to his/her size. Interview with LPN #2, on 08/25/16 at 4:31 PM, revealed the SRNA was to have two (2) people for bed mobility and following the care plan would have prevented the fall. Interview with the Director of Nursing (DON) and Administrator on 08/25/16 at 5:04 PM, revealed they were not aware that bed mobility had occurred with one (1) assist with Resident #12 until the incident occurred on 06/21/16. The DON stated she assumed the care plan was being followed however after the investigation was completed it was determined the root cause was due to not following the care plan and providing care with one (1) assist. Both the DON and Administrator revealed they expected the care plan to be followed and for staff to ask for assistance if needed. The DON stated that assistance was available for SRNA #1 and she failed to ask for assist and therefore the accident would have been prevented if there would have been two (2) person assist. Interview with Resident #12's Physician on 08/25/16 at 5:14 PM, revealed the fracture was due to the accident and they (the family and himself) decided against surgery due to the resident's age and diagnoses.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of twenty-four (24) sampled residents received adequate supervision and assistance devices to prevent accidents (Resident #12). Resident #12 was assessed and care planned for needing the assistance of two (2) staff for bed mobility and incontinent care. However, on 06/21/16, State Registered Nurse Aide (SRNA) #1 provided incontinent care to Resident #12 and assisted the resident with bed mobility without adequate supervision (two {2} staff). SRNA #1 turned the resident away from her, and the resident's feet slid off the bed and SRNA #1 had to reach across the bed holding the resident under the arms and lower him/her to the floor. Resident #12 sustained a left humerus fracture; however, the physician and family decided against surgery due to the resident's age and diagnoses. The findings include: Review of facility policy titled, Falls, dated 06/01/15 revealed it was the intent of this facility to provide residents with assistance and supervision in an effort to minimize the risk of falls and fall related injuries. Further review revealed all residents would have a comprehensive fall risk assessment on admission, quarterly, and with significant change of condition and appropriate care plan interventions would be implemented and evaluated as indicated by assessment. Record review revealed the facility admitted Resident #12 on 10/09/13 with diagnoses, which included Osteoarthritis, Schizophrenia, Neuropathy Contracture, Parkinson's disease, and Chronic Obstructive Pulmonary Disease. Review of the Significant Change Minimum Data Set (MDS) assessment, dated 06/27/16, revealed the facility assessed Resident #12's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of five (5) which indicated the resident was not interviewable. In addition, the facility assessed the resident was dependent on staff for all Activities of Daily Living (ADLs) with the assist of two (2) staff for care, except eating which required the assist of one (1) staff. Review of Resident #12's Comprehensive Care Plan for Incontinence of Bowel and/or Bladder, dated 07/20/14, revealed to provide assist of two (2) with toileting, on the care plan, the two (2) was marked out and a three (3) wrote above the two (2), indicating the need for three (3) staff. Review of the ADL Self Care Deficit Care Plan, dated 07/30/14, revealed the resident was to have been turned and repositioned routinely and as needed, with two (2) assist with the two (2) marked out and a three (3) wrote above the two (2), shifting weight to enhance circulation. Interview with the Assistant Director of Nursing (ADON) on 08/25/16 at 2:00 PM, revealed the care plan was revised to the assistance of three (3) for bed mobility and toileting after the fall on 06/21/16 per the Review of Certified Nurse Aide (CNA) Care Guide, undated, revealed Resident #12 should be assisted with bed mobility by two (2) staff. Review of the Situation Background Assessment Recommendation (SBAR), dated 06/21/16 with no documented time, revealed SRNA #1 attempted to change Resident #12 and the foot rest slid on the mattress (fitted sheet not completely on bed) and resident slid. The SRNA assisted the resident. No changes were observed in the resident with the resident evaluation. Family notified at 5:45 AM and physician notified on 06/21/16 with no time. Review of the Nursing Assessment, dated 06/21/16 at 4:30 AM, revealed, A fall with no injury and the SRNA yelled for the nurse to come to Resident #12's room. The foot cushion came out from underneath the resident, and the SRNA assisted the resident to the floor. BIMS score indicated severe impairment. No pain and no extremities or joint deformity. Interview with SRNA #1, on 08/25/16 at 9:40 AM, revealed she was providing incontinent care to Resident #12 on 06/21/16. She stated she rolled the resident away from her to provide care and the resident's heel boot slipped off the side of the bed and the resident's legs started going off the bed. The SRNA further stated she got in the bed on her knees and she put her arms and hands under the resident's armpits and tried to ease the resident to the floor with her body weight. She then yelled for the nurse as the resident was sitting upright in the floor beside the bed. The SRNA revealed the resident does not really talk and did not show signs of pain; however, his/her body was shaking as though he/she was scared. She further revealed Licensed Practical Nurse (LPN) #5 asked if the resident was hurt and the resident did not reply. The SRNA revealed the care plan stated the resident was two (2) assist at the time of the fall and she was not sure why she did not ask for help for incontinent care and bed mobility. She stated she had not had any problem with one (1) person assist in the past but she should have looked at the care plan and followed the directions. Interview with LPN #5, on 08/24/16 at 3:02 PM, revealed SRNA #1 called out for help, on 06/21/16 around 4:30 AM, and the SRNA stated Resident #12 was in the floor. LPN #5 stated when she entered the room SRNA #1 was across the bed reaching with her arms under the resident's arms. She revealed she was able to perform range of motion to all extremities with no signs of pain and the resident was assisted the appropriate way with two (2) assist back to bed. Interview with LPN #2, on 08/25/16 at 4:31 PM, revealed she was charge nurse of another hall on 06/21/16 when the incident occurred, but came to assist and fill out the SBAR as the charge nurse of this hall (LPN #5) had another fall as well and she was new to the facility. She stated Resident #12 was in the bed when she arrived and did not display verbal signs of pain but she noticed the resident was shaking. LPN #2 called the Unit Manager, by phone, because Resident #12 has never fallen at the facility and it is routine to call the Unit Manager. LPN #2 revealed SRNA #1 told her the resident's fitted sheet elastic was not on the mattress and the resident shifted when she turned him/her. LPN #2 further stated the SRNA was to have two (2) people for bed mobility and following the care plan would have prevented the fall. Interview with SRNA #6 on 08/25/16 at 2:18 PM, revealed she worked on 06/22/16 on the 2PM-10PM shift and Resident #12 would make facial grimaces when his/her left shoulder was touched or was repositioned. She stated she reported to the nurse. Interview with SRNA #5 on 08/25/16 at 1:34 PM, revealed she worked 2PM-10PM on 06/22/16 and noticed on her first round while providing incontinent care to Resident #12, the resident was grimacing and had tears in his/her eyes. SRNA #5 revealed she reported the resident's pain to the nurse. She stated the resident has always been a two (2) assist with bed mobility. Interview with SRNA/Certified Medication Aide (CMA) #7 on 08/25/16 at 2:28 PM, who worked 06/22/16 from 2 PM-10PM revealed SRNA #2 came and told her that Resident #12 was complaining of pain and she went into the room where the resident and the family member was located. CMA #7 stated she located LPN #1 and explained the family member requested an X-Ray because the family member thought the resident's arm was broke. The CMA revealed she verified the resident was grunting and moaning when the SRNAs turned and touched the resident's left arm. Interview with LPN #1 on 08/25/16 at 4:05 PM, revealed she worked on 06/22/16 2PM-10PM and was not aware the resident had fallen as she was not the nurse for that hall. She did assess the resident and spoke with family member regarding Resident #12 discomfort in his/her left arm. She further revealed the daughter stated that every time the resident was moved, his/her arm hurts. LPN #1 revealed the resident speaks with his/her expressions and she was grimacing. She stated she did not perform full range of motion (ROM) as barely touching the resident's left arm she would complain of pain. She stated the family member requested an X-Ray and she gladly complied. She further revealed the X-Ray technician came before she left for the night but she did not receive the results. Review of the Radiology Report, dated 06/22/16 at 6:38 PM, from the facility mobile X-Ray provider revealed a complete displaced subacute left humeral surgical neck fracture. Review of the hospital X-Ray Report of the resident's left humerus, dated 06/23/16 at 11:16 AM, revealed fractures involving the proximal humeral head with extension to greater tuberosity and slight anterior displacement. Interview with Family Member #1, on 08/25/16 at 1:20 PM, revealed she was notified on the morning of 06/21/16 that Resident #12 had an assisted fall with no injury. She stated when she visited on 06/21/16, she did not notice Resident #12 was in pain; however, on 06/22/16 at around 8:15 AM, she noticed the resident was moaning in pain when a SRNA and LPN #3 was moving him/her in the bed. She revealed LPN #3 stated that Resident #12 must be sore from the fall. Family Member #1 stated she visited again on 06/22/16 at approximately 4:30 PM and touched the resident's shoulder and he/she hollered in pain. She revealed she found LPN #1 and requested an X-Ray and the next morning on 06/23/16, she found out that the resident's arm was broke. She revealed there was supposed to be two (2) people to turn Resident #12 but was told there was only (1) person. Interview with the Director of Nursing (DON) and Administrator on 08/25/16 at 5:04 PM, revealed they were not aware that bed mobility had occurred with one (1) assist with Resident #12 until the incident occurred on 06/21/16. The DON stated she assumed the care plan was being followed however after the investigation was completed it was determined the root cause of the fall was not following the care plan and providing care with one (1) assist. Both the DON and Administrator revealed they expected the care plan to be followed and for staff to ask for assistance if needed. The DON further revealed that assistance was available for SRNA #1 and she failed to ask for assistance and therefore the accident would have been prevented if there would have been two (2) person assist. Interview with Resident #12's Physician on 08/25/16 at 5:14 PM, revealed the fracture was due to the accident and they (the family and himself) decided against surgery due to the resident's age and diagnoses.

Based on observation, interview and review of the facility's policy/procedure, it was determined the facility failed to provide a safe, sanitary, and comfortable environment to prevent infection for two (2) residents of twenty-four (24) sampled residents (Resident #4 and Resident #7 ). Observations on 08/24/16, revealed Certified Nursing Assistants (CNA's) failed to provide proper incontinent care by not removing gloves and washing hands after completing incontinent care for Residents #4 and #7. The CNAs continued to dress the resident while touching the linens and the residents clothes while wearing the contaminated gloves. The findings include: Review of the facility's policy/procedure, Perineal Care Male or Female (undated), revealed documentation to include, after cleaning the perineum, apply ointment or cream as needed. Discard disposable equipment and supplies in designated containers. Discard towels/wash cloths in soiled laundry container. Remove and discard gloves. Wash and dry hands thoroughly. 1. Record review revealed the facility admitted Resident #4 on 04/14/14 with [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set (MDS) assessment, dated 06/06/16, revealed the facility assessed Resident #4's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of four (4), which indicated the resident was not interviewable. The resident required the extensive assistance of two (2) staff for bed mobility, transfer, hygiene. Further review revealed the resident was incontinent of bowel and bladder. Observation, on 08/24/16 at 1:50 PM, revealed Certified Nursing Assistant (CNA #5) was providing incontinent care for Resident #4, who was incontinent of bowel. After providing incontinent care, CNA #5 failed to remove the contaminated gloves and wash her hands. Further observation revealed CNA #5 touched the residents bed linens, personal clothes and adjusted the call light while wearing the contaminated gloves. Interview with CNA #5, on 08/25/16 at 10:55 AM, revealed she was aware of the facility policy to remove gloves and wash her hands after completing incontinent care, but just got in a hurry and did not do it. 2. Record review revealed the facility admitted Resident #7 on 12/15/15 with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, dated 06/20/16, revealed the facility assessed the resident's cognition as severely impaired with a BIMS score of zero (0), which indicated the resident was not interviewable. Further review of the MDS assessment revealed the resident required the extensive assistance of two (2) for all activities of daily living (ADL's) and was incontinent of both bowel and bladder. Observation on 08/24/16 at 11:00 AM, revealed CNA #8 provided incontinent care for Resident #7, who was observed incontinent of bladder. After providing incontinent care, CNA #8 failed to remove the contaminated gloves and wash her hands. Further observation revealed CNA #8 touched the residents linens, personal clothes and pushed up her glasses several times, while wearing the contaminated gloves. Interview with CNA #8 on 08/25/16 at 11:00 AM, revealed she realized the importance of removing gloves and washing hands prior to resident contact after providing care. She further revealed she had been educated on the proper technique for providing incontinent care, but she does not work the floor that much any more and didn't think about taking her gloves off and washing hands until she was finished with the resident. Interview with Unit Manager #2 on 08/25/16 AT 10:55 AM, revealed she expected both CNA's to have removed their gloves and washed their hands after providing incontinent care. She stated she expected both CNAs to know better because they were seasoned CNA's. Interview with Assistant Director of Nursing (ADON), on 08/25/16 at 1:30 PM, revealed she expected both CNAs to have followed the facility policy related to handwashing and incontinent care. She sated the staff had recently completed their annual competency skills check off.

Based on interview, record review and review of the facility's policy and procedure it was determined the facility failed to ensure services provided met professional standards of care for one (1) of three (3) sampled residents (Resident #1). Staff failed to ensure a [MEDICATION NAME] was removed at night before administrating another patch which could cause the resident to build up a tolerance and the medication become ineffective. The finding include: Review of facility policy and procedure, titled, [MEDICATION NAME] Delivery System (Patches) section 7.25, dated 09/08, revealed staff should check the last site of application an select a new appropriate site, rotating in accordance with the manufacturer's recommendations. The application site should be clean, dry and hairless area on the body for patch replacement. Remove old patch from the body and dispose of properly. Label patch with date and nurse's initials. Review of Lippincott Manual of Nursing Practice (10) Tenth Edition, revealed reapply [MEDICATION NAME] medication at the same time every day to ensure a continuous effect, but alternate the application site to avoid skin irritation. Document the name of the medication, the dose, and the date and time of administration in the patients Medication Administration Record [REDACTED]. Record review revealed the facility admitted Resident #1 on 07/10/15 with [DIAGNOSES REDACTED]. Review of Admission Physician Orders, dated 07/10/15, revealed an order for [REDACTED].#2 and LPN #3 on 07/10/15. Review of Resident #1's July 2015/15, August 2015, September 2015, and October 15 MAR indicated [REDACTED]. Record review of emergency room (ER) Medical Record, dated 10/07/15, revealed Resident #1 was transported to the ER from the [MEDICAL TREATMENT] treatment center and ER staff found three (3) [MEDICATION NAME] 0.4 mg/hr on Resident #1, one (1) undated patch, one (1) patch dated 09/30/15 and one (1) patch dated 10/07/15. Interview with Licensed Practical Nurse (LPN) #1, on 10/11/15 at 3:30 PM, LPN #3 on 10/12/15 at 12:45 PM, and LPN #2 on 10/12/15 at 1:24 PM, revealed it was the facility standard of practice to ensure that all [MEDICATION NAME]es are removed nightly. The LPNs stated the removal of the [MEDICATION NAME] was never placed in the Easy Medication Administration Record [REDACTED]. Further interview with LPN #2 and LPN #3 revealed they were the nurses who took off the order for the patch and they should have contacted the physician to clarify the order and get an order to remove the patch in the evening. Interview with Registered Nurse (RN) #1, on 10/12/15 at 2:12 PM, revealed she was the nurse who applied the [MEDICATION NAME] on Resident #1 on 10/01/15. She stated she should have looked at Resident #1 to verify that he/she was patch free, but it was the facility policy for all [MEDICATION NAME]es to be removed the evening. She further revealed the nurse working the evening shift on 09/30/15 was not reminded to remove the patch as there was nothing in place to indicate the patch needed to be removed. Interview with Resident #1's Physician, on 10/12/15 at 5:22 PM, revealed all patches should be documented to include where applied, along with the nurses initials of who applied the patch. The Physician stated he did not think he needed to write an order to remove the patch because it was a standard of practice that all nurses should know to remove a [MEDICATION NAME] every night. He further stated there should never be (3) three patches on a resident unless there is a specific order to do so. Interview with a Pharmacy Consultant, on 10/12/15 at 1:52 PM, revealed a [MEDICATION NAME] should be removed every evening to ensure the resident does not build up a tolerance to the medication and it become ineffective. Interviews on 10/13/15 with the Assistant Director of Nursing (ADON) at 10:21 AM, and the Director of Nursing (DON) at 10:30 AM revealed it is a nursing standard of practice to remove a [MEDICATION NAME] in the evening, and if it had been on the MAR indicated [REDACTED]. The ADON and DON stated there should have been something on the MAR indicated [REDACTED].

Based on interview, record review and review of the facility policy and procedure, it was determined the facility's system to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being related to the removal of used [MEDICATION NAME]es was effective for one (1) of (3) three sampled residents (Resident #1). Resident #1 was ordered [MEDICATION NAME] (heart medication) 0.4 milligram (mg)/hour (hr) patch to be applied every morning on 07/10/15; however; there was nothing in place to ensure the patch was removed every night. Resident #1 was found to have (3) three patches on his/her chest, (1) one undated, (1) one dated 09/30/15 and (1) one dated 10/07/15 upon admission to emergency room for [MEDICAL CONDITION] (low blood pressure) from a [MEDICAL TREATMENT] center on 10/07/15. The findings include: Review of the facility policy, titled [MEDICATION NAME] Delivery System (Patches) section 7.25, dated 09/08, revealed to check last site of application and select a new appropriate site, rotating in accordance with the manufacturer's recommendations. The application site should be clean, dry and hairless area on the body for patch replacement. Remove old patch from the body and dispose of properly. Label patch with date and nurse's initials. Review of Lippincott Manual of Nursing Practice (10) Tenth Edition, revealed, reapply [MEDICATION NAME] medication at the same time every day to ensure a continuous effect, but alternate the application site to avoid skin irritation. Document the name of the medication, the dose, and the date and time of administration in the patients Medication Administration Record, [REDACTED]. Record review the facility admitted Resident #1 on 07/10/15 with [DIAGNOSES REDACTED]. Review of the Physicians Orders, dated 07/10/15, revealed an order for [REDACTED]. Review of Resident #1's July 2015, August 2015, September 2015 and October 2015 Medication Administration Records (MAR's) to apply (1) one [MEDICATION NAME] 0.4 mg/hr patch onto the skin daily for [MEDICAL CONDITION]; however; there was no place documented for staff to initial to ensure staff removed the patch in the evening. Review of the emergency room (ER) Medical Record, dated 10/07/15, revealed Resident #1 was transported to the ER from the [MEDICAL TREATMENT] treatment center and ER staff found three (3) [MEDICATION NAME] 0.4 mg/hr patches on Resident #1, one (1) undated patch, one (1) patch dated 09/30/15 and one (1) patch dated 10/07/15. Interview with Licensed Practical Nurse (LPN) #3, on 10/12/15 at 12:45 PM, revealed Resident #1 was admitted with a Physician order for [REDACTED].#3 stated she should have contacted the physician to obtain an order to remove the patch in the evening. Further interview revealed the removal of the [MEDICATION NAME] was never placed in the Easy MAR (EMAR), therefore; it would not have triggered the evening shift nurse to know when to remove the patch in the evening. LPN #3 stated it is a nursing standard of practice to remove a [MEDICATION NAME]es every evening. Interview with LPN #2, on 10/12/15 at 1:24 PM, revealed it was the facility standard of practice to ensure that all [MEDICATION NAME]es are removed nightly. LPN #2 stated she was one of the nurse's who took off Resident #1's physician order and they should have called and got an order to remove the patch in the evening. LPN #2 further stated by not placing the documentation on the EMAR to remove the patch in the evening there was no reminder to licensed staff to remove the patch. Interview with Licensed Practical Nurse (LPN) #1, on 10/11/15 at 3:30 PM, revealed she has not provided care for Resident #1; however, the facility standard of practice was to ensure that all [MEDICATION NAME]es are removed nightly. LPN #1 stated there needs to be something in place on the resident's MAR indicated [REDACTED]. Interview with a Pharmacy Consultant, on 10/12/15 at 1:52 PM, revealed a [MEDICATION NAME] should be applied daily in the early morning hours and should be removed off in the evening hours. The Pharmacy Consultant stated the reason why the [MEDICATION NAME] should be taken off every night is so the resident does not build up a tolerance to the medication and it become ineffective. He stated the patch should always be removed at night to give the body a break from the patch a minimum of (6) six to (8) eight hours because over the course of time, the patch/medication could become ineffective. Interview with the Director of Nursing (DON), on 10/13/15 at 10:30 AM, revealed it is a standard of nursing practice to remove a [MEDICATION NAME] every evening, and she would expect all licensed staff to follow the nursing standard of practice. Further interview revealed, it is our facility policy to remove [MEDICATION NAME]es at night, and there should have been something on the MAR indicated [REDACTED].

Based on observation, interview, and review of the facility policy, it was determined the facility failed to provide a safe and sanitary environment to prevent the development and transmission of disease and infection related to one (1) of twenty-four (24) sampled residents (Resident #1), regarding the improper handling and disposal of linens, after urinary catheter care. In addition, the facility failed to ensure glucometers were properly disinfected after each use, with an antimicrobial wipe. Observation of blood sugar monitoring of one (1) unsampled resident (Resident A) revealed the staff were utilizing alcohol wipes to disinfect the glucometers. Unsampled Resident A was one (1) of eleven (11) residents who required blood glucose monitoring. The findings include: 1. A review of the facility policy for Clean Glucometer, dated 06/01/15, revealed the glucometers were to have been cleaned after each use with either an Environmental Protection Agency (EPA) registered detergent/ germicide with a turberculoidal or Hepatitis B Virus (HBV)/ Human Immunodeficency Virus (HIV) label claim, or a dilute bleach solution of 1:10 or 1:100 concentration. Observation of a Medication Pass, on 08/20/15 at 8:53 AM, revealed Unsampled Resident A had received blood sugar monitoring, utilizing a glucometer and after the testing, Licensed Practical Nurse (LPN) #1 cleaned the glucometer with an alcohol wipe. Interview with LPN #1, on 08/20/15 at 8:55 AM, revealed the LPN had been cleaning the glucometers with alcohol wipes for approximately fourteen (14) months, as long as I've been working here, and was not familiar with the facility policy or the Centers for Disease Control (CDC) guidelines. Observation of a medication pass, on 08/20/15 at 8:40 AM, and subsequent interview with Registered Nurse (RN) #1, revealed she generally cleans the glucometer with an alcohol wipe after the machine is used for a fingerstick blood sugar. RN #1 stated she was not familiar with the manufacturer's recommendation for cleaning the glucometer. Interview with the Assistant Director of Nursing (ADON), on 08/20/15 at 11:00 AM, revealed the staff should have been utilizing the detergent wipes and they had been trained on the policy, with inservicing verification, dated 04/24/15. Interview with the Director of Nursing (DON), on 08/21/15 at 8:30 AM, revealed the facility should have been utilizing an antimicrobial wipe that was bleach free, as this was specific to the manufacture's recommendations that called for a mild detergent for cleaning, had less drying time and less harmful to the glucometer than the bleach, yet still effective to kill the viruses in the CDC Guidelines. However, due to a change in staff and the re-ordering process, the correct product had not been re-ordered and was not in stock or available on the floors. The blue label antimicrobial was in stock, however, the facility policy called for a red label antimicrobial product. Additionally, the DON stated there had not been an outbreak or report of HBV or HIV at the facility. Interview with the Administrator, on 08/21/15 at 10:25 AM, revealed he would have expected the staff to have followed the facility policy in cleaning the glucometers. 2. Review of the facility's policy and procedure, titled Standard Precautions, revised 08/2007, revealed Standard precautions shall apply to the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. 7. Linen: Handle, transport, and process used linen soiled with blood, body fluids, secretions, excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and avoids transfer of microorganisms to other residents and environments. Observation of urinary catheter care, on 08/19/15 at 12:35 PM, revealed Certified Nursing Assistant (CNA) #1 performing catheter care for Resident #1. During the cleaning procedure, CNA #1 laid soiled wash cloths, which had been used to clean the catheter and the resident peri-area, on the bed side table. Interview with CNA #1, on 08/19/15 at 1:40 PM, revealed she was aware of the need to placed soiled linens in a plastic bag and to not place them on a bed side table due to the risk of infection control. Interview with CNA #2, on 08/19/15 at 1:42 PM, revealed she witnessed CNA #1 place the soiled linens on the bedside table of Resident #1 and she revealed the linens should have placed in a plastic bag due to the risk of infection. Interview with the DON, on 08/21/15 at 8:44 AM, revealed she expected the CNA to have placed the soiled linens in a plastic bag and not on the bed side table.

Based on observation, record review, family interview, staff interview, and a review of the facility's policy/procedure, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well being for ten residents (#1, #2, #3, #4, #5, #6, #8, #9, #13, and #25), in the selected sample of twenty-eight residents, related to the assessment, care, monitoring, evaluation and treatment of [REDACTED]. Resident #9 was first identified with a rash on 04/20/11 and has had itching for 14 months. Resident #1 was first identified with a rash on 12/05/11 and developed [MEDICAL CONDITION] due to the rash. Resident #3 was first identified with a rash on 12/16/11 and was administered [MEDICATION NAME] because the itching was causing the resident to be anxious. This failure caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 04/19/12 and found to exist on 12/05/11 and was ongoing. Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care F309. The facility was notified on 04/19/12. It was determined the Immediate Jeopardy was removed on 04/22/12, non-compliance continued with the scope and severity of an "E," based on the facility's need to monitor for the on-going effectiveness of the corrective action taken and to ensure evaluation through the facility's Quality Assurance process. (Refer to F441 and F490) Findings include: A review of the facility's policy/procedure, "Infection Control, Infectious Diseases, Scabies Management," revised January 2007, revealed procedures that included Implementation of Contact Precautions (due to the communicability of scabies) until a [DIAGNOSES REDACTED]. A private room is indicated but if not possible, obtain a physician's orders [REDACTED]. Cover the wrist area by the gown and pull the gloves over the cuff of the gown. treatment of [REDACTED]. The facility did not have an Infection Control policy that addressed rashes. 1. A record review revealed the facility admitted Resident #1 on 05/13/09 with [DIAGNOSES REDACTED]. A review of the physician's progress notes, dated 12/05/11, revealed Resident #1 complained of a rash and the Advanced Practice Registered Nurse (APRN) documented observing small scabbed areas on the right upper chest. The APRN ordered [MEDICATION NAME] cream 0.1% (an anti-[MEDICAL CONDITION] cream) to be applied to the chest twice daily for ten days to treat the rash. A review of weekly skin assessments, dated 12/08/11 through 12/19/11, revealed a rash was present on the resident's right chest, right arm and left buttocks, then both arms, the trunk and back of the neck with some improvement noted on 12/19/11. The rash presented as pale pink on 12/23/11 through 12/26/11, and started to reappear on the chest, on 12/27/11, as red areas. On 01/05/12, the facility treated Resident #1 for scabies per orders from the Dermatology Clinic. A rash was noted to spread to the left shoulder on 01/08/12, and by 01/15/12, the rash was documented as spreading to the upper torso. Documentation, on 01/21/12, revealed the resident continued to complain of itching. On 01/31/12, the rash was noted on the right side of the chest, as well as scratched areas on the left upper arm. A review of the annual Minimum Data Set (MDS) assessment, dated 03/14/12, revealed the facility assessed Resident #1 as severely cognitively impaired and required extensive assistance of one to two staff for most activities of daily living. Further review revealed, on 03/20/12, a rash was noted on the resident's neck and he/she complained of itching. Review of a pathology report of a punch biopsy from the right shoulder, dated 03/22/12, revealed "a pattern that was mostly suggestive of scabies with an intense [MEDICAL CONDITION] reaction". The biopsy, dated 03/22/12, confirmed a [DIAGNOSES REDACTED]. An interview with the Physician's Assistant from the Dermatology Clinic, on 04/18/12 at 1:39 PM, revealed the pathology report of Resident #1's biopsy, dated 03/22/12, confirmed a [DIAGNOSES REDACTED]. Record review revealed, on 04/05/12, the resident was noted with multiple small to large sized red raised "bumps" around the neck, on the left arm, lower extremities, the abdomen, chest and left inner thigh. A review of the comprehensive care plan, updated 04/05/12, revealed a problem due to biopsy results with an approach "to apply [MEDICATION NAME] cream 5% (treatment for [REDACTED]." Record review revealed, on 04/13/12, the left side of Resident #1's face, ear lobe and throat were swollen and warm to touch, and the resident complained of pain upon touch. The facility treated Resident #1 a third time for scabies, and he/she received an antibiotic for a [DIAGNOSES REDACTED]. Another care plan update, on 04/13/12, related to the complaint of itching revealed an approach "to apply [MEDICATION NAME] cream 5% to the scalp only and wash off in the morning." An observation, on 04/13/12 at 10:30 AM, revealed Resident #1 was in his/her room sitting in a wheelchair (w/c) beside the bed. The left side of Resident #1's face and top lip was red and swollen. The resident pulled back his/her left ear to reveal the back of the ear and the hairline. Resident #1 stated there were "bugs" in his/her bed and he/she itched and clawed from head to toe. The resident stated he/she was "broke out all over" and cannot sleep at night. Resident #1 pulled up his/her pant legs and sleeves which revealed a rash over his/her arms and legs. An interview with Resident #1's family member, on 04/14/12 at 5:00 PM, revealed the resident started to itch after his/her roommate developed a rash in November 2011. She stated she was told by a family member of the roommate that the resident had Scabies. She stated Resident #1 was seen by a physician who informed the family that the rash looked like scabies and treated the resident for it. She stated Resident #1 continued to complain of itching from January through April and she believed the resident has had scabies the entire time. She further stated staff never used any type of isolation precautions while providing care during treatment for [REDACTED]. An interview on 04/18/12 at 2:00 PM with Licensed Practical Nurse (LPN) revealed residents with rashes are monitored daily by way of weekly skin audits. 2. A record review revealed the facility admitted Resident #2 on 10/21/08 with [DIAGNOSES REDACTED]. Review of daily skin assessments, dated 10/24/11, revealed Resident #2 showed signs and symptoms of a skin rash. Review of the Treatment Administration Record dated 11/01/11-11/30/11 revealed orders dated 10/24/11 for [MEDICATION NAME] cream to be applied to arms chest and abdomen every shift for a [DIAGNOSES REDACTED].) A review of physician's orders [REDACTED]. Resident #2 presented to the clinic with all the clinical symptoms so he felt it was safe to treat him/her as such. A skin assessment on 11/07/11 documented "skin condition improving" this documentation of the rash. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of a skin assessment completed on 12/29/11 revealed the facility assessed and determined the "rash to torso now spreading to the front of legs, treatment in place." Further review of the 12/2011 (MAR) revealed the facility administered [MEDICATION NAME] 10 mg to Resident #2 on 12/31/11 for complaint of itching. The facility did not provide evidence of any further actions taken after the skin assessment showing signs and symptoms of the worsening of the rash. Further review of daily skin assessments, dated for 01/2012, revealed the facility assessed Resident #2 as continuing to have signs and symptoms of a skin rash during that period of time. Review of the Treatment Administration Records (TAR) for 01/12 revealed no documentation of a change in treatment. Review of the MAR indicated [REDACTED]. Further review of daily skin assessments, dated for 02/2012, revealed the facility assessed Resident #2 as continuing to have signs and symptoms of a skin rash during that period of time. Review of the Treatment Administration Records (TAR) for 02/12 revealed no documentation of a change in treatment. Review of the MAR indicated [REDACTED]. Further review of daily skin assessments, dated for 03/2012, revealed the facility assessed Resident #2 as continuing to have signs and symptoms of a skin rash during that period of time. Review of the Treatment Administration Records (TAR) for 03/12 revealed no documentation of a change in treatment. Review of the MAR indicated [REDACTED]. Review of a significant change MDS dated [DATE] revealed the facility assessed Resident #2's cognition as intact and requiring extensive assistance of one to two staff for bed mobility, transfer and most activities of daily living. An interview on 04/13/12 at 10:30 AM with Resident #2, revealed he/she had a rash but it was better now, he/she stated the rash had itched "something terrible". On 04/17/12 at 4:50 PM, Resident #2 stated staff did not don gowns or any type of protective garment, other than gloves when providing care for him/her. Further review of the MAR, dated 04/01/12- 04/30/12, revealed Resident #2 was administered the medication [MEDICATION NAME] 10 mg for itching on 04/24/12 by the facility. Review of the comprehensive care plan, dated 05/18/11, revealed a goal for "bumps on my skin will heal by the next review," with an approach to "monitor the bumps on my skin and notify the MD if not healing." The care plan did not reflect changes in treatment of [REDACTED]. Further review of daily skin assessments, dated 10/24/11 through 03/18/12, revealed Resident #2 was never free of the signs and symptoms of a skin rash during that period of time. Resident #2 was treated by the facility for Scabies during a facility wide mass treatment. An interview on 04/18/12 at 2:00 PM with Licensed Practical Nurse (LPN) revealed residents with rashes are monitored daily by way of weekly skin audits. 3. A record review revealed the facility admitted Resident #3 on 06/25/11 with [DIAGNOSES REDACTED].#3 as cognitively intact and requiring extensive assistance of one to two staff for all care. Review of the weekly Non-Pressure Skin Condition Report dated 12/16/11 revealed the facility identified Resident #3's rash on that date. The rash was noted on the left upper back side and hip. The rash was described as sparce and red and a treatment of [REDACTED]. Documentation revealed the resident complained of itching on 12/30/11. On 01/20/12 the weekly Non-Pressure Skin Condition Report revealed the resident had areas that were fading and new areas were noted and treatment was noted to be continued, with progress noted as no change noted through 02/26/12. Documentation revealed the resident complained of itching on 12/30/11, 01/27/12, 02/10/12. A review of the physician's orders [REDACTED]." A review of a pathology report dated 03/01/12 of a biopsy from Resident #3's left upper back revealed " the changes present in this biopsy specimen are consistent a hypersensitivity reaction to include drug eruption or arthropod (mite) assault. The specimen lacks the characteristic [MEDICATION NAME] changes to support a chronic [MEDICAL CONDITIONS]" Documentation revealed the resident complained of itching on 03/08/12, 03/22/12, 03/29/12. Review of a weekly skin check sheet dated 04/12/12 revealed "continued with rash to torso and extremities, also noted behind ears with treatment in place." The facility did not provide evidence of any further actions taken after the skin assessment showing signs and symptoms of the rash not improving and spread of the rash. An observation, on 04/13/12 at 10:05 AM, revealed Resident #3 received a bed bath. The resident was observed with an extensive rash over his/her trunk, front and back and upper and lower extremities. An interview with Resident #3, on 04/13/12 at 2:30 PM, revealed the rash was present for four to five months and "itched so bad" at night, he/she could not sleep. Resident #3 stated he/she was put on a "nerve pill" because the rash was getting on his/her "nerves." The resident stated he/she thought the rash was getting better, but yesterday it got worse again. An interview with Resident #3, on 04/17/12 at 5:00 PM, revealed staff never used any gowns while providing care for him/her. An interview with the Physician's Assistant (PA) at the Dermatology Clinic, on 04/18/12 at 1:39 PM, revealed she saw Resident #3 at the clinic on 03/01/12. She stated the pathology report of Resident #3's biopsy, completed on 03/01/12, was not conclusive due to the similarity in the pattern for mite reaction, as well as that of a drug reaction. She further stated, after conversations with nursing staff at the facility and being told there were no changes in the resident's medications, she ruled out a drug reaction and decided to treat Resident #3 for Scabies. The facility began treating Resident #3 for scabies on 04/18/12. An observation, on 04/19/12 at 10:25 AM, revealed three housekeeping staff deep cleaned Resident #3's room and reported the resident was being showered in the shower room. 4. A record review revealed the facility admitted Resident #4 on 06/26/06 with [DIAGNOSES REDACTED]. A review of the quarterly MDS, dated [DATE], revealed the facility assessed Resident #4 as moderately cognitively impaired and required extensive assistance of one staff for bed mobility, transfers, walking in room, eating, toileting, personal hygiene and bathing. An observation, on 04/13/12 at 10:50 AM, revealed Resident #4 was in his/her w/c propelling himself/herself in the hallway on wing #1. The resident was noted with a red rash on his/her bilateral hands and web spaces. The resident denied pain or discomfort from itching. The rash was noted to spread up the resident's forearms. An interview with Unit Manager (UM) for wing #1, on 04/17/12 at 4:45 PM, revealed she had just discovered the rash on Resident #4 and the Medical Director was notified, and a treatment of [REDACTED]. The UM stated Resident #4 was a wanderer and had a weekly skin assessment completed, on 04/13/12, and there was no mention of a rash. An interview with Certified Nurse Aide #8, on 04/17/12 at 4:50 PM, revealed she noticed the rash the previous night and notified Licensed Practical Nurse (LPN) #4. An interview with LPN #4, on 04/18/12 at 5:00 PM, revealed she was made aware of the rash on Resident #4 by the CNA the previous day. She stated the resident was not on contact precautions and the Medical Director was suppose to see her the next day, which was the usual day she made rounds. She stated all the residents on wing #1, including Resident #4's roommate, were to have skin audits every shift and several new rashes were identified. An observation, on 04/18/12 at 4:50 PM, revealed Resident #4 was awake and alert in the bed without any notice of contact precautions in place. 5. A record review revealed the facility admitted Resident #5 on 12/07/07 with [DIAGNOSES REDACTED].#5 as moderately cognitively impaired, and required extensive assistance of two staff members with all activities of daily living (ADLs). A review of the Resident Weekly Skin Check Sheets revealed the rash started, on approximately 02/12/12, with "red bumps on the bilateral arms, neck, upper back, abdomen and upper thighs." A physician's orders [REDACTED]. A Weekly Non-Pressure Skin Condition Report, dated 02/22/12, revealed the resident had a rash, "everywhere but on (his/her) head," and was "healed" on 03/13/12. On 04/08/12, red bumps were noted on his/her left upper back, breast and left side, and the resident's nails were trimmed. An observation of a skin assessment, on 04/27/12 at 9:55 AM and 10:55 AM, revealed the resident had a few scattered areas of a red, raised rash on the upper chest and left upper arm and was noted scratching his/her left arm area. 6. A record review revealed the facility admitted Resident #6 on 06/20/11 with [DIAGNOSES REDACTED]. A review of the quarterly MDS, dated [DATE], revealed the facility assessed Resident #6 as cognitively intact, requiring extensive assistance of one to two staff for all care except eating. A review of the Resident Progress notes, dated 03/23/12, revealed a condition change form with a new order related to itching and mild rash for [MEDICATION NAME] 25 mg at hour of sleep. A condition change form, dated 03/26/12, revealed to continue the [MEDICATION NAME] with [MEDICATION NAME] ointment due to complaint of itching. A review of the weekly skin audits, dated 03/27/12 through 04/22/12, revealed the resident continued to have the rash. On 04/09/12, documentation revealed large red "bumps" were noted on the abdomen and back, with the resident complaining of itching. Review of a Physician Telephone Order dated 04/20/12 revealed orders for [MEDICATION NAME] 5% cream (treatment for [REDACTED]. The treatment was done during a facility wide mass treatment. An observation of Resident #6 on 04/26/12 at 8:25 AM revealed contact precautions in place UM #1 stated the precautions were initiated "due to a reaction Resident #6 had to the treatment for [REDACTED]. On 04/26/12 at 9:30 AM, an observation of a skin assessment of Resident #6, performed by UM #1 revealed a red patchy rash covering the entire trunk, front and back, both arms and the left thigh. An interview with Resident #6, on 04/26/12 at 1:05 PM, revealed he/she had the rash for "some time," but could not remember how long. He/she stated the rash itched terribly and nothing had helped until the ointment was applied all over his/her body the other day, and now the itching was better. 7. A record review revealed the facility admitted Resident #8 on 07/10/09 with [DIAGNOSES REDACTED]. A review of the significant change MDS assessment, dated 04/04/12, revealed the facility assessed Resident #8 to be cognitively intact and able to make needs known, but required extensive assistance to perform Activities of Daily Living (ADLs). A review of a dermatology consult, dated 10/06/11, revealed the resident was diagnosed with [REDACTED]. A review of the Resident Weekly Skin Check Sheet, dated 10/11/11, revealed documentation "continues with scattered raised red areas"; however, the Weekly Non-pressure Skin Condition Report does not identify or track the rash. A review of the Resident Weekly Skin Check Sheet, dated 03/02/12, revealed documentation of red bumps/rash to the bilateral upper arms. Weekly Non-pressure Skin Condition Report for the same time frame did not identify or track the rash. Further review revealed the resident received treatment for [REDACTED]. An Interview with Registered Nurse (RN) #1, on 04/28/12 at 1:13 PM, revealed she expected the Weekly Non-pressure Skin Condition Report to be filled out whenever the rash was identified and used to track treatment and progress of the rash. Observation of a skin assessment, on 04/28/12 at 9:55 AM, revealed the rash on Resident #8's back to be concentrated to the lower posterior [MEDICATION NAME] region. Bruising was also noted to the posterior of the resident's upper arms. RN #1 stated the area was from scratching. 8. A record review revealed the facility admitted Resident #9 on 02/24/10, with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident was independent in cognition and decision-making and required the extensive assistance of two staff members with bed mobility and a sling and mechanical lift for transfers. An interview with RN #1, on 04/27/12 at 8:30 AM and 04/28/12 at 10:20 AM, revealed a rash was observed on Resident #9, since approximately 04/20/11. An interview with Licensed Practical Nurse (LPN) #1, on 04/26/12 at 3:00 PM, revealed the problem started last year for Resident #9, after another resident was admitted with a similar rash and staff members and their family members came down with the same type of rashes. The LPN stated "the one common denominator in all these rashes was this building." A review of the Weekly Non-Pressure Skin Condition Report, dated 12/08/11 through 12/29/11 revealed the resident experienced a rash to the anterior and posterior trunk areas, shoulders and to the top of the right thigh, that was first observed on 12/08/11, and the resident was never free of the condition. In addition, review of the assessments did not describe the actual locations of the rash. There was no evidence of an evaluation of the progression and/or improvement or decline of the status of the rash on the resident's body. For example, review of the skin assessment, anatomical drawings, the description of the rash varied from red, raised bumps to "continuing rash" and documentation in the nursing notes revealed no mention in the nursing notes other than an occasional mentions of a "rash continued." There was no evidence the facility conducted on-going assessments or documented the findings for the resident in order to identify the persistence and/or spread of the rash. A review of the physician orders, for 2011 through 2012, revealed the resident was treated with medications used to treat itching from parasites, under the skin, on 06/14/11, 09/07/11, 02/16/12 and on 04/19/12. The recommended guideline of treating the entire facility, residents and staff members was not followed to prevent reinfestation, based on the Centers for Disease Control (CDC) Guidelines, until 05/19/12. physician's orders [REDACTED]. On 06/14/11, there was a treatment administered, with a one time dose of a topical cream, Permethin, for a parasitic infestation. On 07/25/11, there was a treatment with another topical steroid and a pill for itching. On 08/03/11, there was a treatment with Vaseline Synalar ointment. On 09/07/11, an oral dose of a broad spectrum anti-parasitic agent was prescribed. On 12/17/11, the resident was referred to a dermatologist for a consult regarding a "red pruritic rash." On 12/28/11, the resident received treatment with a [MEDICATION NAME] Dose Pack, a prescription of oral steroids for "Multifactoral Pruritis." On 12/30/11, the resident was treated with equal parts of [MEDICATION NAME] and [MEDICATION NAME], topically, as needed for itching and the physician ordered the resident to wear mittens, at night, to prevent scratching. On 01/17/12, after a dermatology consult, the resident was administered [MEDICATION NAME], intramuscularly for a [DIAGNOSES REDACTED]." On 01/23/12, [MEDICATION NAME] powder was ordered topically, every shift, and A and D Ointment was ordered topically, as needed, "to sooth affected areas." On 01/25/12, the resident was treated with [MEDICATION NAME] Ointment topically, three times a day. On 01/29/12, [MEDICATION NAME] was discontinued and the resident was treated with [MEDICATION NAME] cream, three times a day. On 02/16/12, the resident was seen by a dermatologist who prescribed [MEDICATION NAME] and [MEDICATION NAME] Cream, which was to be repeated in one week. On 02/17/12, the resident was prescribed [MEDICATION NAME], three times a day, for itching. A review of the History and Profile, dated 02/28/12, revealed the physician's documentation indicated "apparently, there has been an outbreak of Scabies, at the nursing home." And the resident "had some [MEDICAL CONDITION] on his/her leg and has been scratching." On 03/05/12, the order for [MEDICATION NAME] was increased to four times a day. On 04/03/12, the resident was prescribed Sarna Lotion to the back, chest, abdomen, legs, neck and bilateral arms, every shift, as needed for a [DIAGNOSES REDACTED]." On 04/19/12, after another dermatology consult, the resident was again prescribed [MEDICATION NAME] Cream, to be repeated in one week. The recommended CDC guidelines were not followed until 05/19/12, when every resident and staff members and the facility environment was treated. While the facility continued to treat the rash, there was no evidence the facility ever evaluated the effectiveness of the treatment and failed to resolve the rash that continued to spread to several other residents in the facility. A review of the care plan for pain, dated 12/07/11, revealed "I have itching from my neck to my knees." The interventions were to apply skin lotions, as ordered. There were no updates or new interventions for the comprehensive care plan regarding the itching. The interventions of the Care Plan Update, which were generated with each order mentioned in the previous paragraph, were to administer the medication or topical ointment prescribed, with the goal of the resident having no rash or skin irritation. The goal was not met and was not reevaluated and the interventions were not evaluated for effectiveness. An interview with Resident #9, on 04/25/12 at 3:50 PM, revealed the resident complained of the development on an itchy rash on his/her body. An observation and interview with Resident #9, on 04/26/12 at 10:20 AM, revealed Resident #9 suffered with the symptoms related to a persistent rash, "for fourteen months." The resident stated he/she had "suffered and itched all over" and was "broke out with little bitty bumps that got bigger" and stated "now I've heard it was scabies." At first, the rash was confined to the scalp area and spread to his/her neck and then to the hands. The skin assessment revealed red, raised rashes, scattered over the back, torso, arms and wrists. 9. A record review revealed the facility Resident #25 on 09/15/10 with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment, dated 02/21/12, revealed the resident was cognitively independent with decision-making skills and independent with all activities of daily living except for bathing, which required the assistance of two staff members. A review of the Resident Weekly Skin Check Sheet, the Care Plan updates, and the progress notes revealed the resident was noted scratching and picking at the scabs since 03/21/12. The area was described as red bumps on the back side of the bilateral legs, a rash and red areas were noted to the chest, abdomen, trunk, bilateral legs and upper back. A review of the Weekly Non-Pressure Skin Condition Report revealed the rash and open sores were not monitored on this record. An observation of Resident #25, on 04/25/12 at 10:45 AM and on 04/27/12 at 10:05 AM, revealed the resident was scratching his/her legs and stated, "it itched until I could hardly bear it." A skin assessment revealed multiple areas of open sores on the upper and lower back, bilateral buttocks and both arms and legs. An area on the right lower leg had a scant amount of blood "oozing" from the wound area and dried blood was noted to the sheet below the resident's leg. The resident stated he/she had always picked at skin sores, yet stated the itching was "unrelenting." An interview with RN #1, on 04/27/12 at 3:10 PM, revealed the resident's rash and open sores were worse now than when she evaluated the resident on 04/26/12, and the resident had a history of [REDACTED]. The rash was first documented, on 03/21/12, and an order was received for a topical antifungal. The resident did have an order for [REDACTED]. 10. A record review revealed the facility admitted Resident #13 on 04/01/11 with [DIAGNOSES REDACTED]. A review of the Resident Weekly Skin Assessments, dated 01/22/12, revealed the resident experienced "a few scattered red bumps on the upper body, bilateral arms and chest," and the resident "complained of itching." A review of the quarterly MDS, dated [DATE], revealed the resident was moderately cognitively impaired and made few decisions. He/she required the extensive assistance of two staff members with ADLs. A review of the physician's orders [REDACTED]. An observation of a skin assessment, on 04/26/12 at 11:00 AM, revealed a slightly red raised rash on the resident's abdominal area. The resident stated she experienced "quite a bit of itching." An interview with the MDS Coordinator/RN, on 04/28/12 at 3:55 PM, revealed the problem noted on the change of condition form, would not be carried over to the comprehensive care plan, if it was a condition that would be expected to resolve within a two-week timeframe, such as a skin tear or a sore throat that was treated. The rash the resident experienced was treated and the coordinator stated she thought it would be resolved, and stated this resident's rash and resulting itching, "probably should be carried over to the comprehensive care plan for continued monitoring." An interview with Certified Nurse Aide #10, on 04/2

Based on observation, interview, record review and facility policy/procedure review, the facility failed to maintain an Infection Control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection for twelve residents, (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #13, and #25), in the selected sample of twenty-eight residents, who were identified as having rashes. Residents #1, #2, #3, #5, #9 and #10 were treated by the facility for Scabies (an infestation with mites). On 04/19/12 at approximately 3:56 PM, the facility ' s infection control nurse presented the survey agency surveyor a list of twenty-two residents in the facility currently identified with rashes; however, after immediate jeopardy was identified on this same date, the facility conducted a skin sweep and Symptom Screen of all residents in the building on 04/19/12 and identified 35 residents symptomatic of rashes out of the total census of 136, per the facility ' s Allegation of Compliance dated 04/26/12. Resident #9 was first identified with a rash on 04/20/11 and had experienced itching for 14 months, Resident #1 was first identified with a rash on 12/05/11 and developed cellulitis due to the rash. Resident #3 was first identified with a rash on 12/16/11 and was administered [MEDICATION NAME] because the itching was causing the resident to be anxious. Additionally, thirteen facility staff have presented with rashes for which eight staff reported being treated for [REDACTED]. The facility failed to implement the policy and procedure "Infection Control and Prevention Program" related to key surveillance activities, definition of the infection, calculation of the infection rates and data analysis. The facility failed to follow the "Infection Control, Infectious Disease, Scabies Management " policy as evidenced by the facility not implementing Contact precautions and observations of the Medical Director having direct contact with three resident ' s rashes (Resident ' s #25, 8, and 9), ungloved. This failure caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 04/19/12 and found to exist on 12/05/11 and was ongoing. Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care F309. The facility was notified on 04/19/12. It was determined the Immediate Jeopardy was removed on 04/22/12, non-compliance continued with the scope and severity of an "E," based on the facility's need to monitor for the on-going effectiveness of the corrective action taken and to ensure evaluation through the facility's Quality Assurance process. (Refer to F309 and F490) Findings include: A review of the facility's policy and procedure, "Infection Control and Prevention Program" dated 10/31/09, revealed the facility's infection control program included, but was not limited to the following components: (a) Key surveillance activities, (b) Definition of Infection, (C) Calculation of infection rates and (d) Data analysis. Essential elements of the surveillance system were to include, use of standardized definitions and listings of the symptoms of the infection and use of surveillance tools such as, (1) Infection surveys and data collection templates, (2) Walking rounds throughout the facility, (3) Identification of segment of the population at risk for the infection, (4) Identification of the processes or outcomes selected for surveillance, and (5) Statistical analysis of data that can uncover an outbreak, and feedback of the results to the primary caregivers so they can assess the residents for sign of infection. A review of the facility's policy and procedure, Infection Control, Infectious Diseases, Scabies Management, revised January 2007, revealed procedures that included Implementation of Contact Precautions (due the communicability of scabies) until a [DIAGNOSES REDACTED]. A private room is indicated but if not possible, obtain a physician's orders [REDACTED]. Cover wrist area by the gown and pull the gloves over the cuff of the gown. treatment of [REDACTED]. A review of the Center for Disease Control and Prevention (CDC), updated November 2, 2010, revealed for prevention, early detection, treatment, and implementation of appropriate isolation and infection control practices are essential in preventing scabies outbreaks. Institutions should maintain a high index of suspicion that undiagnosed skin rashes and conditions may be scabies, even if characteristic symptoms of scabies are absent (e.g. no itching). Also noted was Appropriate isolation and infection control practices (e.g. gloves gowns, avoidance of direct skin to skin contact, etc) should be used when providing hands-on care to patients who might have scabies. 1. A record review revealed the facility admitted Resident #1 on 05/13/09 with [DIAGNOSES REDACTED]. A review of the physician's progress notes, dated 12/05/11, revealed Resident #1 complained of a rash and the Advanced Practice Registered Nurse (APRN) documented observing small scabbed areas on the right upper chest. The APRN ordered [MEDICATION NAME] cream 0.1% (an anti-inflammatory cream) to be applied to the chest twice daily for ten days to treat the rash. A review of weekly skin assessments, dated 12/08/11 through 12/19/11, revealed a rash was present on the resident's right chest, right arm and left buttocks, then both arms, the trunk and back of the neck with some improvement noted on 12/19/11. The rash presented as pale pink on 12/23/11 through 12/26/11, and started to reappear on the chest, on 12/27/11, as red areas. There was no documented evidence of a change in treatment from 12/08/11 through 12/27/11. On 01/05/12, the facility treated Resident #1 for scabies per orders from the Dermatology Clinic. A rash was noted to spread to the left shoulder on 01/08/12, and by 01/15/12, the rash was documented as spreading to the upper torso. Documentation, on 01/21/12, revealed the resident continued to complain of itching. On 01/31/12, the rash was noted on the right side of the chest, as well as scratched areas on the left upper arm. Further review revealed, on 03/20/12, a rash was noted on the resident's neck and he/she complained of itching. Review of a pathology report of a punch biopsy from the right shoulder, dated 03/22/12, revealed a pattern that was mostly suggestive of scabies with an intense inflammatory reaction. The biopsy, dated 03/22/12, confirmed a [DIAGNOSES REDACTED]. An interview with the Physician's Assistant from the Dermatology Clinic, on 04/18/12 at 1:39 PM, revealed the pathology report of Resident #1's biopsy, dated 03/22/12, confirmed a [DIAGNOSES REDACTED]. Record review revealed, on 04/05/12, the resident was noted with multiple small to large sized red raised "bumps" around the neck, on the left arm, lower extremities, the abdomen, chest and left inner thigh. A review of the comprehensive care plan, updated 04/05/12, revealed a problem due to biopsy results with an approach "to apply [MEDICATION NAME] cream 5% (treatment for [REDACTED]." Record review revealed, on 04/13/12, the left side of Resident #1's face, ear lobe and throat were swollen and warm to touch, and the resident complained of pain upon touch. The facility treated Resident #1 a third time for scabies, and he/she received an antibiotic for a [DIAGNOSES REDACTED]. Another care plan update, on 04/13/12, related to the complaint of itching revealed an approach "to apply [MEDICATION NAME] cream 5% to the scalp only and wash off in the morning." An observation, on 04/13/12 at 10:30 AM, revealed Resident #1 was in his/her room sitting in a wheelchair (w/c) beside the bed. The (Lt) side of Resident #1's face and top lip was red and swollen. The resident pulled back his/her Lt ear to reveal the back of the ear and the hairline. Resident #1 stated there were "bugs" in his/her bed and he/she itched and clawed from head to toe. The resident stated he/she was "broke out all over" and cannot sleep at night. Resident #1 pulled up his/her pant leg and sleeves which revealed a rash over his/her arms and legs. Observation of the resident's room and outside the room in the hallway revealed no evidence contact precautions had been initiated as per the facility ' s " Infection Control, Infectious disease, Scabies management " which included implementation of contact precautions until a [DIAGNOSES REDACTED]. An interview with Resident #1's family member, on 04/14/12 at 5:00 PM, revealed the resident started to itch after his/her roommate developed a rash in November 2011. She stated she was told by a family member of the roommate that the resident had Scabies. She stated Resident #1 was seen by a physician who informed the family that the rash looked like scabies and treated the resident for it. She stated Resident #1 continued to complain of itching from January through April and she believed the resident has had scabies the entire time. 2. A record review revealed the facility admitted Resident #2 on 10/21/08 with [DIAGNOSES REDACTED]. Review of the comprehensive care plan, dated 05/18/11, revealed a goal for "bumps on my skin will heal by the next review," with an approach to "monitor the bumps on my skin and notify the MD if not healing." Review of weekly skin assessments, dated 10/24/11- 10/31/11, revealed Resident #2 was never free of the signs and symptoms of a skin rash during that period of time. A review of physician's orders [REDACTED]. There was no further documentation of a change in treatment; however, physician notification was noted. An interview with the Dermatologist, on 04/16/12 at 2:45 PM, revealed although it was difficult to [DIAGNOSES REDACTED]. Resident #2 presented to the clinic with all the clinical symptoms so he felt it was safe to treat him/her as such. Further review of the skin assessments, dated 10/31/11 through 03/18/12 revealed the resident was never free of the signs and symptoms of a skin rash during that time period. Review of the facility ' s Significant Change MDS Assessment, dated 03/19/12, revealed the facility assessed Resident #2 as cognitively intact. An interview with Resident #2, on 04/17/12 at 4:50 PM, revealed staff did not don gowns or any type of protective garment, other than gloves when providing care for him/her. Observation of the resident's room and outside the room in the hallway revealed no evidence contact precautions had been initiated. 3. A record review revealed the facility admitted Resident #3 on 06/25/11 with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment, dated 02/27/12, revealed the facility assessed Resident #3 as cognitively intact and requiring extensive assistance of one to two staff for all care. A review of the physician's orders [REDACTED]." An observation, on 04/13/12 at 10:05 AM, revealed Resident #3 receiving a bed bath. The resident was observed with an extensive rash over his/her trunk, front and back and upper and lower extremities. An interview with Resident #3, on 04/13/12 at 2:30 PM, revealed the rash was present for four to five months and "itched so bad" at night, he/she could not sleep. Resident #3 stated he/she was put on a "nerve pill" because the rash was getting on his/her "nerves." The resident stated he/she thought the rash was getting better, but yesterday it got worse again. An interview with Resident #3, on 04/17/12 at 5:00 PM, revealed staff never used any gowns while providing care for him/her. Observation of the resident's room and outside the room in the hallway revealed no evidence contact precautions had been initiated. An interview with the Physician's Assistant (PA) at the Dermatology Clinic, on 04/18/12 at 1:39 PM, revealed she saw Resident #3 at the clinic several times. She stated the pathology report of Resident #3's biopsy, completed on 03/01/12, was not conclusive due to the similarity in the pattern for mite reaction, as well as that of a drug reaction. She further stated, after conversations with nursing staff at the facility and being told there were no changes in the resident's medications, she ruled out a drug reaction and decided to treat Resident #3 for Scabies. The facility began treating Resident #3 for scabies on 04/18/12. 4. A record review revealed the facility admitted Resident #4 on 06/26/06 with [DIAGNOSES REDACTED]. A review of the quarterly MDS, dated [DATE], revealed the facility assessed Resident #4 as moderately cognitively impaired and required extensive assistance of one staff for bed mobility, transfers, walking in room, eating, toileting, personal hygiene and bathing. An observation, on 04/13/12 at 10:50 AM, revealed Resident #4 was in his/her w/c propelling him/herself in the hallway on wing #1. The resident was noted with a red rash on his/her bilateral hands and web spaces. The rash was noted to spread up the resident's forearms. Resident #4 denied any pain or discomfort from itching. An interview with Unit Manager (UM) for wing #1, on 04/17/12 at 4:45 PM, revealed she discovered the rash on Resident #4 on 04/17/12, the Medical Director was notified on 04/17/12, and a treatment of [REDACTED]. The UM stated Resident #4 was a wanderer and had a weekly skin assessment completed, on 04/13/12, and there was no mention of a rash. An interview with Certified Nurse Aide #8, on 04/17/12 at 4:50 PM, revealed she noticed the rash the previous night and notified Licensed Practical Nurse (LPN) #4. An interview with LPN #4, on 04/18/12 at 5:00 PM, revealed she was made aware of the rash on Resident #4 by the CNA the previous day. She stated the resident was not on contact precautions and the Medical Director was supposed to see her the next day, which was the usual day she made rounds. She stated all the residents on wing #1, including Resident #4's roommate, were to have skin audits every shift and several new rashes were identified. An observation, on 04/18/12 at 4:50 PM, revealed Resident #4 was awake and alert in the bed. Observation of the resident's room and outside the room in the hallway revealed no evidence contact precautions had been initiated. 5. A record review revealed the facility admitted Resident #5 on 12/07/07 with [DIAGNOSES REDACTED]. The quarterly MDS assessment, dated 02/02/12, revealed the facility assessed Resident #5 as moderately cognitively impaired, and required extensive assistance of two staff members with all activities of daily living (ADLs). A review of the Resident Weekly Skin Check Sheets revealed the rash started, on approximately 02/12/12, with "red bumps on the bilateral arms, neck, upper back, abdomen and upper thighs." A physician's orders [REDACTED]. A Weekly Non-Pressure Skin Condition Report, dated 02/22/12, revealed the resident had a rash, "everywhere but on (his/her) head," and was "healed" on 03/13/12. On 04/08/12, red bumps were noted on his/her left upper back, breast and left side, and the resident's nails were trimmed. An observation of a skin assessment, on 04/27/12 at 9:55 AM by UM #1, revealed the resident had a few scattered areas of a red, raised rash on the upper chest and left upper arm and was noted scratching his/her left arm area. Observation of the resident's room and outside the room in the hallway revealed no evidence contact precautions had been initiated. 6. A record review revealed the facility admitted Resident #6 on 06/20/11 with [DIAGNOSES REDACTED]. A review of the quarterly MDS, dated [DATE], revealed the facility assessed Resident #6 as cognitively intact, requiring extensive assistance of one to two staff for all care except eating. A review of the Resident Progress notes, dated 03/23/12, revealed a condition change form with a new order related to itching and mild rash for [MEDICATION NAME] 25 mg at hour of sleep. A condition change form, dated 03/26/12, revealed to continue the [MEDICATION NAME] with [MEDICATION NAME] ointment due to complaint of itching. On 04/09/12, documentation revealed large red "bumps" were noted on the abdomen and back, with the resident complaining of itching. A review of the weekly skin audits, dated 03/27/12 through 04/22/12, revealed the resident continued to have the rash and was treated for [REDACTED]. An observation, on 04/26/12 at 9:30 AM, during Resident #6's skin assessment revealed a red patchy rash covering the entire trunk, front and back, both arms and the left thigh. An interview with Resident #6, on 04/26/12 at 1:05 PM, revealed he/she had the rash for "some time," but could not remember how long. He/she stated the rash itched terribly and nothing had helped until the ointment was applied all over his/her body the other day, and now the itching was better. 7. A record review revealed the facility admitted Resident #7 on 02/28/08 with [DIAGNOSES REDACTED]. Review of the Infection Control Log submitted by the Infection Control Nurse revealed Resident #7 was identified by the facility as having a rash with an onset date of 04/09/12. Review of the Resident Progress notes dated 04/09/12 at 9:10 PM revealed the physician was notified of the rash on Resident #7's right leg. On 04/11/12 at 10:30 AM documentation revealed an order was received to monitor the rash every shift and notify of any changes. A condition change form, dated 04/12/12, revealed a rash on the back side of the right leg with an order for [REDACTED].#7's room and outside the room in the hallway revealed no evidence contact precautions had been initiated. On 04/15/12, a note was added at 6:10 PM, "continued with a rash to bilateral legs, treatment applied twice daily with no sign or symptoms of scratching. Review of the quarterly MDS, dated [DATE], revealed the facility assessed Resident #7 as severely cognitively impaired and totally dependent on the staff for all care. A review of the quarterly assessment notes, on 04/17/12, did not mention the rash on Resident #7's legs. Review of the weekly non-pressure skin condition report noted in the resident's record did not address a skin rash from the period of 04/09/12 through 04/28/12. Review of the care plan, updated 04/20/12, revealed "skin integrity impaired" after a physician's orders [REDACTED]. 8. A record review revealed the facility Resident #25 on 09/15/10 with [DIAGNOSES REDACTED]. Record review revealed on 02/17/12 the physician ordered Resident #25 [MEDICATION NAME], a medication prescribed for anxiety and itching. A review of the quarterly MDS assessment, dated 02/21/12, revealed the resident was cognitively independent with decision-making skills and independent with all activities of daily living except for bathing, which required the assistance of two staff members. A review of the Resident Weekly Skin Check Sheet, the Care Plan updates, and the progress notes revealed the resident was noted scratching and picking at the scabs since 03/21/12. The area was described as red bumps on the back side of the bilateral legs, a rash and red areas were noted to the chest, abdomen, trunk, bilateral legs and upper back. Record review revealed an order was received for a topical antifungal on 03/21/12. A review of the Weekly Non-Pressure Skin Condition Report revealed no evidence the rash and open sores were being monitored on this record. Observation of skin assessment rounds by two State Agency surveyors, on 04/18/12 at 5:50 PM, with the Facility ' s Medical Director and the Unit Coordinator, revealed the Medical Director washed her hands, then performed her assessment of the Resident #25 ' s rash areas; however, touched the rash areas ungloved, then washed her hands. However, review of the facility ' s " Infection Control, Infectious Diseases, Scabies Management " , revised January 2007, revealed procedures that included Implementation of Contact Precautions (due the communicability of scabies). Wear long sleeve gowns during close contact with the resident, their clothing or bed linens. Cover wrist area by the gown and pull the gloves over the cuff of the gown. treatment of [REDACTED]. An observation of Resident #25, on 04/25/12 at 10:45 AM and on 04/27/12 at 10:05 AM, revealed the resident was scratching his/her legs and complaining, "It itched until I could hardly bear it." A skin assessment by UM #1 revealed multiple areas of open sores on the upper and lower back, bilateral buttocks and both arms and legs. An area on the right lower leg had a scant amount of blood "oozing" from the wound area and dried blood was noted to the sheet below the resident's leg. The resident stated he/she had always picked at skin sores, yet stated the itching was "unrelenting." Observation of the resident ' s room and outside the room in the hallway revealed no evidence contact precautions had been initiated. An interview with RN #1, on 04/27/12 at 3:10 PM, revealed the resident's rash and open sores were worse now than when she evaluated the resident on 04/26/12, and the resident had a history of [REDACTED]. The rash was first documented, on 03/21/12, and an order was received for a topical antifungal. The resident did have an order for [REDACTED]. This medication was restarted on 04/27/12. 9. A record review revealed the facility admitted Resident #8 on 07/10/09 with [DIAGNOSES REDACTED]. A review of a dermatology consult, dated 10/06/11, revealed the resident was diagnosed with [REDACTED]. A review of the Resident Weekly Skin Check Sheet, dated 10/11/11, revealed documentation "continues with scattered raised red areas"; however, the Weekly Non-pressure Skin Condition Report showed no evidence the facility had identified or tracked the rash. A review of the Resident Weekly Skin Check Sheet, dated 03/02/12, revealed documentation of red bumps/rash to the bilateral upper arms. Weekly Non-pressure Skin Condition Report for the same time frame did not identify or track the rash. An Interview with Registered Nurse (RN) #1, on 04/28/12 at 1:13 PM, revealed she expected the Weekly Non-pressure Skin Condition Report to be filled out whenever the rash was identified and used to track treatment and progress of the rash. An interview with the Director of Nursing (DON,) on 04/28/12 at 3:45 PM, revealed the licensed staff should have utilized the "Weekly Non-Pressure Skin Condition Report" to track and trend the rash and to evaluate the progress or lack of progress weekly with prescribed treatment. A review of the significant change MDS assessment, dated 04/04/12, revealed the facility assessed Resident #8 to be cognitively intact and able to make needs known, but required extensive assistance to perform Activities of Daily Living (ADLs). Observation of skin assessment rounds by two State Agency surveyors, on 04/18/12 at 5:50 PM, with the Facility ' s Medical Director and the Unit Coordinator, revealed the Medical Director had assessed Resident #25 and was observed touching Resident #25 ' s rash areas ungloved. She then washed her hands and proceeded to go into Resident #8 ' s room to perform an assessment at 6:00 PM. An observation of Resident#8's room and outside the room in the hallway revealed no evidence contact precautions had been initiated. During the assessment, the two State Agency surveyors observed the Medical Director specifically; touch the rash areas on Resident #8 ' s chest, arms and shoulders without being gloved despite the facility ' s " Infection Control, Infectious Diseases, Scabies Management " , revised January 2007, revealed procedures that included Implementation of Contact Precautions. Wear long sleeve gowns during close contact with the resident, their clothing or bed linens. Cover wrist area by the gown and pull the gloves over the cuff of the gown. treatment of [REDACTED]. Further review revealed the facility treated Resident #8 for scabies, on 04/19/12. However there was still no notation related to the rash in the Weekly Non-pressure Skin Condition Report identifying or tracking progress of a treatment as of 04/27/12. Observation of a skin assessment, on 04/28/12 at 9:55 AM, revealed the rash on Resident #8's back to be concentrated to the lower posterior [MEDICATION NAME] region. Bruising was also noted to the posterior of the resident's upper arms. RN #1 stated the area was from scratching. An observation of Resident#8's room and outside the room in the hallway revealed no evidence contact precautions had been initiated. 10. A record review revealed the facility admitted Resident #9 on 02/24/10 with [DIAGNOSES REDACTED]. A review of the clinical record, dated 04/26/11 and 05/17/11 revealed prescriptions with topical steroidal creams and oral steroids. On 06/14/11, there was a treatment with a one time dose of a topical cream for parasitic infestation. On 06/23/11, the resident was treated again with topical steroidal creams and oral steroids. On 07/25/11, there was a treatment with another topical steroid and a pill for itching. On 08/03/11, there was a treatment with Vaseline Synalar ointment. On 09/07/11, there was a treatment with an oral dose of a broad spectrum anti-parasitic agent. A review of the skin assessment documentation for the period of December 2011 revealed a lack of detail and description to demonstrate the specific location and extent of the rash. A review of the care plan for pain, dated 12/07/11, revealed "I have itching from my neck to my knees." The interventions were to apply skin lotions, as ordered. There were no updates or new interventions for the comprehensive care plan regarding the itching. Further review of the skin assessment documentation, dated 12/08/11, revealed "a rash was noted to the anterior and posterior trunk, shoulder and top of the right thigh." Throughout December 2011 and January 2012, documentation revealed the rash lacked evidence of healing. On 01/31/12, there was no evidence of the rash and no further documentation of the rash on the "Weekly Non Pressure Skin Condition Report'. However, the "Resident Weekly Skin Check Sheet," dated 01/31/12, stated the rash continued on the resident's trunk, bilateral upper extremities and upper thighs. There was no evidence of evaluation of the progression and/or improvement or decline of the status of the rash on the resident's body. For example, review of the skin assessment documentation revealed the description of the rash varied from red, raised bumps to continuing rash, and on the anatomical drawings, there was no indication of the areas or the drawings being marked with dots, circles and some X's. Topical steroids and antifungals were prescribed. Steroid dose packs were ordered in December 2011 and January 2012 for a "Multifactorial Pruritis." On 02/16/12, the resident was treated with a topical cream for a parasitic infection. On 02/16/12, there was another oral dose of an anti-parasitic agent. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident was independent in cognition and decision-making and required the extensive assistance of two staff members with bed mobility and a sling and mechanical lift for transfers. Review of the February through April 2012 skin assessment documentation revealed a continued lack of detail and description to demonstrate the specific location and extent of the rash even though the resident continued to experience rashes and intense itching throughout March and April. Record review revealed Resident #9 experienced increased discomfort from the rash. The rash had spread to cover the resident's trunk, arms, legs and hands. Observation of skin assessment rounds by two State Agency surveyors, on 04/18/12 at 5:50 PM, with the Facility ' s Medical Director and the Unit Coordinator, revealed the Medical Director had assessed Resident #25 and was observed touching Resident #25 ' s rash areas ungloved. She then washed her hands and proceeded to go into Resident #8 ' s room to perform an assessment at 6:00 PM. During the assessment, the two State Agency surveyors observed the Medical Director specifically; touch the rash areas on Resident #8 ' s chest, arms and shoulders without being gloved. The Medical Director proceeded to an unsampled resident ' s room then arriving to Resident #9 ' s room at 6:07 PM and was observed to touch Resident #9 ' s rash areas ungloved; however, washing her hands before and after, despite the facility ' s " Infection Control, Infectious Diseases, Scabies Management " , revised January 2007, revealed procedures that included Implementation of Contact Precautions (due the communicability of scabies). Wear long sleeve gowns during close contact with the resident, their clothing or bed linens. Cover wrist area by the gown and pull the gloves over the cuff of the gown. treatment of [REDACTED]. Additionally, Resident #9 stated, during the assessment that he/she had been " itching for over a year, it ' s terrible. " The resident further stated that he/she got new ones in the creases of his/her left arm and on his/her back. An interview with Resident #9, on 04/25/12 at 3:50 PM, revealed the resident complained of the development on an itchy rash on his/her body. There was no evidence the facility had conducted on-going assessments or documented the findings for the resident in order to identify the persistence and spread of the rash. An observation and interview with Resident #9, on 04/26/12 at 10:20 AM, revealed Resident #9 suffered with the symptoms related to a persistent rash, "for fourteen months." The resident stated he/she had "suffered and itched all

Based on observation, interview, record review and review of the facility's policy and procedure, it was determined the facility failed to administer in a manner which enabled it to use it's resources effectively and efficiently to attain the highest practical, physical, mental and psychosocial well-being for twelve residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #13, and #25), that were identified with rashes, in a selected sample of twenty-eight residents. On 04/19/12, the facility presented a list of twenty-two residents in the facility currently identified with rashes; however, according to the AoC, the facility conducted a skin sweep and Symptom Screen of all residents in the building and identified 35 residents symptomatic of rashes out of the total census of 136. Resident #9 was first identified with a rash on 04/20/11 and has had itching for 14 months, Resident #1 was first identified with a rash on 12/05/11 and developed [MEDICAL CONDITION] due to the rash. Resident #3 was first identified with a rash on 12/16/11 and was administered [MEDICATION NAME] because the itching was causing the resident to be anxious. The facility failed to have an effective system in place to ensure it's Infection Control and Prevention Program was implemented related to providing a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection related to key surveillance activities, definition of the infection, calculation of the infection rates and data analysis. The facility failed to ensure an effective system was in place to ensure the "Infection Control, Infectious Disease, Scabies Management " policy was implemented for Residents #1, #2, #3, #5, #8, #9 and #10, who were treated by the facility for Scabies (an infestation with mites). The facility failed to have an effective system in place to identify quality care issues and to develop and implement appropriate plans of action to correct identified quality deficiencies related to ongoing rashes for twelve residents. This failure caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 04/19/12 and found to exist on 12/05/11 and was ongoing. Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care F309. The facility was notified on 04/19/12. It was determined the Immediate Jeopardy was removed on 04/22/12, non-compliance continued with the scope and severity of an "E," based on the facility's need to monitor for the on-going effectiveness of the corrective action taken and to ensure evaluation through the facility's Quality Assurance process. (Refer to F309 and F441) Findings include: A review of the facility's policy and procedure, "Infection Control and Prevention Program" dated 10/31/09, revealed the facility's infection control program included was not limited to the following components: (a) Key surveillance activities, (b) Definition of Infection, (C) Calculation of infection rates and (d) Data analysis. Essential elements of the surveillance system were to include, use of standardized definitions and listings of the symptoms of the infection and use of surveillance tools such as, (1) Infection surveys and data collection templates, (2) Walking rounds throughout the facility,(3) Identification of segment of the population at risk for the infection, (4) Identification of the processes or outcomes selected for surveillance, and (5) Statistical analysis of data that can uncover an outbreak, and feedback of the results to the primary caregivers so they can assess the residents for sign of infection. A review of the facility's policy and procedure, Infection Control, Infectious Diseases, Scabies Management with a revised date January 2007, revealed procedures that included Implementation of Contact Precautions (due the communicability of scabies) until a [DIAGNOSES REDACTED]. A private room is indicated but if not possible, obtain a physician's orders [REDACTED]. Cover wrist area by the gown and pull the gloves over the cuff of the gown. treatment of [REDACTED]. A review of the facility's policy and procedure, Performance Improvement, revised 03/05/08 revealed the facility met the Quality Assessment and Assurance requirement through the Performance Improvement (PI) Committee. The PI committee identified and responded to quality deficiencies related to the facility operations and practices that caused negative outcomes. The committee was to meet at least monthly to identify issues the necessitated quality assessment and assurance activities and develop and implement appropriate plans to correct the identified quality deficiencies. A review of the the facility's policy and procedure, Center's Administration, revised 04/28/09 revealed the facility was to be operated under the direction of the Executive Director(Administrator) in accordance with federal, state, and local laws and professional standards. The Executive Director/ designee notifies the appropriate local and state authorities of any unusual occurrences including but not limited to communicable diseases and outbreaks of infections. On 04/17/12 at 10:20 AM, an interview with the Infection Control Nurse (ICN) revealed tracking of the resident response to treatment would be completed in the residents' progress notes. She presented an Infection Control Log for the month of March 2012 which listed residents in the facility noted with rashes. Of the sixteen (16) residents listed only five (5) had a date of onset noted with little to no information related to the location, description, or the progression of the rash. She also presented an Infection Control Log for April 2012 which she stated was incomplete. She stated there was no tracking of the rashes in January and February 2012, because she was not aware she was suppose to be doing them. On 04/19/12 at 3:56 PM, the ICN stated employees do not report treatment of [REDACTED]. She presented Employee Incident Reports for three staff that were treated for [REDACTED]. She presented an updated list for April 2012 of twenty-two (22) residents in the facility that currently had rashes. She stated the facility has completed skin scrapings in the past to check for scabies, but none have been completed in the past six months. An interview with the Assistant Director of Nursing (ADON), on 04/17/12 at 5:00 PM, revealed the problem with rashes had been ongoing since 04/11/11. The physician usually ordered treatment for [REDACTED]. If the resident was not better, they notified the physician for orders. She stated the Medical Director followed the majority of the residents, but some have their own private physicians. They follow the physician's orders [REDACTED]. She stated the Medical Director does not want to treat residents with [MEDICATION NAME], because the cream was an insecticide. She does not treat the residents unless they have an outbreak. They monitor rashes by weekly body audits and the CNAs conduct body audits on bath days. Every resident with "other skin" has their name listed on a board in the conference room and they are discussed with the Unit Managers (UM) every Wednesday. She further stated there was no conclusive evidence the rashes were or were not Scabies. An interview with the Director of Nursing Services (DNS), on 04/13/12 at 6:30 PM, revealed the rashes were frequently discussed with the Medical Director who made the decision what to order as a treatment. The Medical Director's opinion about the treatment for [REDACTED]. The DNS stated the facility has completed a number of things to try and determine the cause of the rashes to include an environmental air study, spoke to the Health Department's Infection Control personal related to the rashes and was told the facility was doing everything they should be doing, and it was felt there was nothing else the facility could do. The DNS stated they also looked at the soap and laundry detergent used by the facility. She stated they have been unable to get a Dermatologist to come into the facility, so they have sent some residents out to see a dermatologist. When the rashes do not clear up, they refer the residents back to the Medical Director and she makes the decision for treatment. The DNS stated she has no documentation of the process. An interview with the Supervisor of Infection Control at the County Health Department on 04/17/12 at 10:45 AM, revealed she spoke to the DNS in January related to rashes in the facility. She stated they discussed control measures such as cleaning the linen and the use of a disinfectant detergent. She stated she was told that skin scrapings for Scabies came back negative and was unaware there were residents in the facility being treated for [REDACTED]. An interview with the Medical Director, on 04/13/12 at 5:50 PM, revealed, in her opinion, there have been no definitive confirmed [DIAGNOSES REDACTED]. She stated she felt the vast majority of the rashes were related to environmental geriatric skin rashes and hysteria that has been fanned by facility staff. She stated there was no way to confirm if the rashes were caused by scabies or by commonalities associated with the aging population, She stated the residents being treated for [REDACTED]. On 04/18/12 at 6:30 PM, an interview with the Medical Director revealed she felt some of the rashes were related to drug reactions and some were related to a [MEDICAL CONDITION] (chronic itching and scratching which eventually becomes a habit). The itching could be associated with staff entering the resident's room and asking them if they itch and if their "bugs" are back. She further stated the pattern of the rash was not consistent with scabies and the residents scratched where they can reach. The Medical Director revealed it was very difficult to [DIAGNOSES REDACTED]. She stated she has treated some residents in the facility for scabies but does not treat residents [MEDICATION NAME] because the treatment was toxic in the elderly. She stated most of the residents responded best to [MEDICATION NAME]. She did not believe the rash spread from one resident to another because there was no cause and effect that was identified. She stated each rash was different and not consistent with an endemic spread. She stated staff were being treated for [REDACTED]. An interview with the Executive Director (ED), on 04/19/12 at 2:50 PM, revealed she oversees the Quality Assurance Committee meeting held monthly. The ED stated her involvement was to ensure all the information gets to the meetings. She stated tracking of the rashes consisted of members of the IDT going to look at the rashes to determine if there were similarities and if the rashes reoccurred. She stated an individual [DIAGNOSES REDACTED]. The ICN kept a map of the rashes so they could determine if there were any clustering of the rashes. The ED stated the Medical Director says the rashes were caused by different types of skin conditions, and because the facility has not been able to determine that there was one single source, the rashes have been classified as "other skin." She stated tracking and trending of the rashes was completed mainly by discussion. A credible allegation of compliance for removal of the Immediate Jeopardy was received on 04/26/12. The Immediate Jeopardy was verified removed on 04/28/12, prior to exit. The alleged date of removal was 04/22/12. Based on observations, interviews and record reviews, verification was made the Immediate Jeopardy was removed on 04/22/12. Observations, interviews and record review revealed the facility had taken the following actions: Licensed Nurses conducted body audits on 04/19/12 for Residents #1- #10. A skin sweep and Symptom Screen was conducted by licensed staff on all residents in the facility on 04/19/12. Physicians were notified and orders were received for all residents for treatment for [REDACTED]. Mass treatment was completed on all residents on 04/20/12. Skin scrapings were conducted on four random residents. The care plans were updated for each resident. The executive Director and Director of Nursing consulted with the health department on 04/20/12. All staff were contacted and questioned regarding having a rash or itching. A symptom screen was completed on all staff members on 04/20/12 and 04/21/12. All residents clothing and linens were removed from rooms and bagged on 04/20/12. All laundry was washed and dried at a temperature of 140 degrees. All residents rooms were deep cleaned on 04/20/12 and 04/21/12. Privacy curtains were laundered. Items that could not be laundered were bagged for a period of 10 days before they will be returned to the residents. All common areas, offices and Rehab Gym were deep cleaned on 04/20/12 and 04/21/12. Physician orders [REDACTED]. All facility staff were educated related to infection control policies on scabies and recommendations from the Centers of Disease Control on 04/20/12, 04/21/12 and 04/22/12. Family members of all residents were called and made aware of the rash and scabies and given information on scabies on 04/19/12 and 04/20/12. Infection Control Rounds, Personal Protective Equipment and Hand Hygiene Surveillance Tools were implemented and conducted daily starting 04/21/12. The Performance Committee to include the Medical Director met on 04/19/12 and again on 04/20/12. Residents identified as symptomatic as well as those that were clinically contraindicated to receive treatment are receiving daily skin audits by the Licensed Nurse starting on 04/21/12. The Infection Control committee is meeting weekly to review Infection control case logs. The Staff Development Coordinator was tracking and trending findings and will report to the Performance Improvement Committee. An interview with the Administrator, on 04/28/12 at 2:25 PM, revealed the facility was continuing to monitor where they were in the action plan, if there were any new symptomatic residents and employees, verifying that Surveillance tools are conducted timely and identifying if any trends. She stated the results of the surveillance tools, monitoring and tracking of rashes would be reported at the next Performance Improvement Committee meeting. She revealed the Performance Improvement Committee meets the third Wednesday of every month. Although it was determined the Immediate Jeopardy was removed on 04/22/12, non-compliance continued with the scope and severity of an "E", based on the facility's need to monitor for the on-going effectiveness of the corrective action taken and to ensure evaluation through the facility's Quality Assurance process.

Based on interview, record review and review of the facility's policy and procedure, it was determined, the facility failed to review and revise the comprehensive care plan for two residents (#9 and #25), in the selected sample of twenty-eight residents, related to rashes. On 04/19/12, the facility presented a list of twenty-two residents in the facility currently identified with rashes; however, according to the Allegation of Compliance (AoC), the facility conducted a skin sweep and Symptom Screen of all residents in the building and identified 35 residents symptomatic of rashes out of the total census of 136. Resident #9 was first identified with a rash on 04/20/11 and has had itching for 14 months, while the care plan identified the resident was having pain from itching in 12/2011, there was no revisions made to the care plan related to the problem of the rash. The facility identified Resident #25 as having a rash; however, failed to revise the care plan related to the resident's skin condition to address the Resident's development of the rash and the Resident's "unrelenting" itching. This failure caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 04/19/12 and found to exist on 12/05/11 and was ongoing. Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care F309. The facility was notified on 04/19/12. It was determined the Immediate Jeopardy was removed on 04/22/12, non-compliance continued with the scope and severity of a "D," based on the facility's need to monitor for the on-going effectiveness of the corrective action taken and to ensure evaluation through the facility's Quality Assurance process. (Refer to F441 and F490) Findings include: A review of the facility's policy and procedure for the "Comprehensive Plan of Care," dated 05/28/08, revealed "A comprehensive plan of care is developed for each resident within seven (7) days after completing the comprehensive assessment. The care plan is re-evaluated and modified as necessary to reflect changes in care: quarterly with the assessment; and with a significant change of assessment. Update the care plan, during the course of delivery to reflect goals attained (resolve a problem), improvement (interventions modified or deleted), new problems (resultant of change of condition or resident event), or modified interventions (resultant change of condition or resident event)." 1. A record review revealed the facility admitted Resident #9 on 02/24/10 with [DIAGNOSES REDACTED]. Interview with Registered Nurse (RN) #1, on 04/27/12 at 8:30 AM and 04/28/12 at 10:20 AM, revealed a rash was observed on Resident #9 since approximately 04/20/11, when documentation on the resident "Weekly Skin Check Sheet" revealed the resident "continued to have a red, pimply, scattered rash to the abdomen." An interview with Licensed Practical Nurse (LPN) #1, on 04/26/12 at 3:00 PM, revealed the problem for Resident #9 started last year after another resident was admitted with a similar rash. A review of the clinical record revealed prescriptions, dated 04/26/11, 05/17/11 and 06/23/11, of topical steroidal creams and oral steroids. On 06/14/11, there was a treatment with a one-time dose of a topical cream for a parasitic infestation. On 07/25/11, there was another topical steroid and a pill for itching, and on 08/03/11, there was Vaseline Synalar ointment. On 09/07/11, there was an oral dose of a broad spectrum anti-parasitic agent. A review of the care plan for pain, dated 12/07/11, revealed the problem "I have itching from my neck to my knees." The interventions were to apply skin lotions, as ordered. Further record review revealed, on 02/16/12, the facility administered another oral dose of an anti-parasitic agent to Resident #9; however, there were no updates or new interventions for the comprehensive care plan, regarding the itching, or regarding the spread of the rash or treatments. There was no evidence of evaluations of the treatments for effectiveness in alleviating the itch or resolving the rash. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident was cognitively independent with decision-making skills and required the extensive assistance of two staff members with bed mobility, and a sling and a mechanical lift for transfers. An observation and interview with Resident #9, on 04/25/12 at 3:50 PM, revealed the resident suffered with symptoms, related to a persistent rash, "for fourteen months" and had "suffered and itched all over, was broke out with little bitty bumps that got bigger" and stated "now I've heard it was scabies." He/she also stated, at first, the rash was confined to the scalp area and then spread to his/her neck as well as to his/her hands. An observation during a skin assessment, on 04/26/12 at 10:20 AM, revealed red, raised and scattered areas of a rash on the resident's upper extremities. An interview with the MDS Coordinator/RN, on 04/28/12 at 3:55 PM, revealed the problem noted on the change of condition form, would not have been carried over to the comprehensive care plan, if it was a condition that was expected to resolve within a two-week timeframe, such as a skin tear or a sore throat, that was treated. The rash the resident experienced was treated and the coordinator stated she thought it was resolved and stated this resident's rash and resulting itching, "probably should have been carried over to the comprehensive care plan for continued monitoring." 2. A record review revealed the facility admitted Resident #25 on 09/15/10 with [DIAGNOSES REDACTED]. A review of the care plan for skin breakdown, dated 05/25/11, revealed the monitoring pressure sores on his/her feet and the problem of poor circulation and the need for weekly skin assessments. However, there was no mention of a rash or itching, documented since approximately 02/17/12, when the physician ordered medication for itching. A review of the quarterly MDS assessment, dated 02/21/12, revealed the resident was independent of cognitively independent with decision-making skills and independent with all activities of daily living except for bathing, which required the assistance of two staff members. A review of the Resident Weekly Skin Check Sheet, the Care Plan updates, and the progress notes revealed the resident was noted to scratch and pick at scabs since 03/21/12. The area was described as red bumps on the back side of his/her bilateral legs, a rash, and red areas to the chest, abdomen, trunk, bilateral legs and upper back. A review of the Weekly Non-Pressure Skin Condition Report revealed the rash and open sores were not monitored on this record. An observation of Resident #25, on 04/25/12 at 10:45 AM, and on 04/27/12 at 10:05 AM, revealed the resident scratching his/her legs and complaining "it itched until I could hardly bear it." A skin assessment revealed multiple areas of open sores on the upper and lower back, bilateral buttocks and both arms and legs. An area on the right lower leg had a scant amount of blood "oozing" from the wound area, and dried blood was noted on the sheet below the resident's leg. The resident stated he/she had always picked at skin sores, and stated the itching was "unrelenting." An interview with RN #1, on 04/27/12 at 3:10 PM, revealed the resident's rash and open sores were worse than when she evaluated the resident on 04/26/12, and the resident had a history of [REDACTED]. The resident did have an order for [REDACTED]. However, review of the comprehensive care plan revealed no documented evidence that the facility revised the care plan and established interventions to address the Resident's rash and itching since identified on 02/17/12. An interview with the Director of Nursing (DON), on 04/28/12 at 3:45 PM, revealed she expected the licensed staff to utilize the "Weekly Non- Pressure Skin Condition Report" and the policy to track and trend rashes, and re-evaluate the progress or lack of progress with the prescribed treatment. She stated the assessment and monitoring of the rashes should have been placed on the comprehensive care plans. She also stated the itching should have been carried over to the comprehensive care plans, if the itching was current at the time of the quarterly review. A credible allegation of compliance for removal of the Immediate Jeopardy was received on 04/26/12. The Immediate Jeopardy was verified removed on 04/28/12, prior to exit. The alleged date of removal was 04/22/12. Based on observations, interviews and record reviews, verification was made the Immediate Jeopardy was removed on 04/22/12. Observations, interviews and record review revealed the facility had taken the following actions: Licensed Nurses conducted body audits on 04/19/12 for Residents #1 through #10. A skin sweep and Symptom Screen was conducted by licensed staff on all residents in the facility on 04/19/12. Physicians were notified and orders were received for all residents for treatment for [REDACTED]. Mass treatment was completed on all residents on 04/20/12. Skin scrapings were conducted on four random residents. The care plans were updated for each resident. The executive Director and Director of Nursing consulted with the health department on 04/20/12. All staff were contacted and questioned regarding having a rash or itching. A symptom screen was completed on all staff members on 04/20/12 and 04/21/12. All residents' clothing and linens were removed from rooms and bagged on 04/20/12. All laundry was washed and dried at a temperature of 140 degrees. All residents' rooms were deep cleaned on 04/20/12 and 04/21/12. Privacy curtains were laundered. Items that could not be laundered were bagged for a period of 10 days before they will be returned to the residents. All common areas, offices and Rehab Gym were deep cleaned on 04/20/12 and 04/21/12. Physician orders [REDACTED]. All facility staff were educated related to infection control policies on scabies and recommendations from the Centers of Disease Control on 04/20/12, 04/21/12 and 04/22/12. Family members of all residents were called and made aware of the rash and scabies and were given information on scabies on 04/19/12 and 04/20/12. Infection Control Rounds, Personal Protective Equipment and Hand Hygiene Surveillance Tools were implemented and conducted daily starting 04/21/12. The Performance Committee to include the Medical Director met on 04/19/12 and again on 04/20/12. Residents identified as symptomatic as well as those that were clinically contraindicated to receive treatment are receiving daily skin audits by the Licensed Nurse starting on 04/21/12. The Infection Control committee is meeting weekly to review Infection control case logs. The Staff Development Coordinator was tracking and trending findings and will report to the Performance Improvement Committee. An interview with the Administrator, on 04/28/12 at 2:25 PM, revealed the facility was continuing to monitor where they were in the action plan, if there were any new symptomatic residents and employees, verifying that Surveillance tools are conducted timely and identifying if any trends. She stated the results of the surveillance tools, monitoring and tracking of rashes would be reported at the next Performance Improvement Committee meeting. She revealed the Performance Improvement Committee meets the third Wednesday of every month. Although it was determined the Immediate Jeopardy was removed on 04/22/12, non-compliance continued with the scope and severity of a "D," based on the facility's need to monitor for the on-going effectiveness of the corrective action taken and to ensure evaluation through the facility's Quality Assurance process.