Every finding on record at Southridge Rehab & Living Ctr

Based on interview and record review, the facility failed to implement and maintain an effective training program which includes, at a minimum, training on abuse, neglect, exploitation and misappropriation of resident property by failing to ensure that 2 of 5 Certified Nursing Assistants (CNAs) reviewed for in-service training completed the required training (#1 , #2 & #3). Findings: On 4/29/26 during a review of facility staff education records the following were noted: CNA #1 was hired on 6/20/25. Review of the employee record lacked evidence CNA #1 completed mandatory abuse neglect and dementia training upon hire. CNA #2 was hired on 10/14/25. Review of the employee record lacked evidence CNA #2 completed mandatory dementia training upon hire. CNA #3 was hired on 10/16/24. The last abuse neglect and dementia training received by CNA #3 was completed in 2024. The employee record lacks evidence of mandatory abuse & neglect and dementia training in 2025. On 4/30/26 at 1:05 p.m., the surveyor confirmed the above finding with the Senior [NAME] President of Development and Operations.

Based on record reviews, observation, and interviews, the facility failed to ensure that care plans were developed in the area of comfort care for 1 of 2 reviewed for hospice care (Resident #22), in the area of wandering for 1 of 1 reviewed for elopement (Resident #4), in the area of dialysis for 1 of 1 reviewed for dialysis needs (Resident #6), and in the area of pain for 1 of 1 resident reviewed for pain management (Resident #25). Findings: 1.Review of Resident #22's medical record stated they were admitted to the facility in November of 2021. A review of a hospice follow-up noted dated 12/29/25 states, Problem 1Hospice care Z51.5, Continue comfort-focused hospice management, Respect patient preference for minimal intervention. On 4/29/26 at 12:50 p.m., a surveyor reviewed resident #22's current care plan which lacked identification of comfort care with interventions. On 4/29/26 at 12:55 p.m RN #1 confirmed with surveyor that the resident does not have Hospice (comfort measures) listed on their care plan. 2. Review of the orders for Resident #25 show: 04/23/2026 oxycodone 5 mg tablet 1.5 Tablet Oral 2 Times Daily and 04/23/2026 oxycodone 5 mg tablet 1 Tablet Oral PRN Every 4 Hours for 30 Days. Record review of Resident #25's care plan there is no documentation addressing pain. The charge nurse stated that the nurses on the unit do not create the care plan, that is done by the MDS coordinator and she has only been here a short while. 3. Resident #4 was admitted to the facility on [DATE] with a diagnosis of Dementia. Review of the admission MDS dated [DATE], Section E (Behavior), revealed the resident was coded for wandering behavior. The MDS further indicated the residents wandering placed the resident at risk of entering a potentially dangerous area, including outside the facility. Resident #4's admission assessment indicated the resident was at risk for elopement, and a wander bracelet was applied. Additional nursing progress notes dated 4/1/26 through 4/26/26 documented repeated wandering and exit seeking behaviors including attempts to leave the unit through secured doors. Residents #4's care plan lacked evidence of a wander/elopement risk and/or safety issues with intervention and goals. On 4/30/26 at 1:05 p.m., the surveyor confirmed the above finding with the Senior [NAME] President of Development and Operations 4. On 4/27/26 at 1:37 p.m., during an interview with Resident #6, a surveyor observed a double lumen, central line catheter at the right chest area with a dressing covering the insertion site. Clinical record review revealed Resident #6 was admitted in March, 2026. Diagnoses included End Stage Renal Disease (ESRD) and hemodialysis. The Minimum Data Set (MDS) 3.0, admission assessment, dated 3/16/26, noted in Section O, Special Treatments and Procedures, that Resident #6 receives dialysis and has IV (intravenous) access. A review of Resident #6's current care plan, initiated on 3/11/26, and revised 3/19/26, includes the following focus area and interventions: Dialysis: Risk of fluid volume excess/deficit and risk for infection related to End-Stage Renal Failure. Interventions: Fistula site will remain free of infection and will be patent for use at dialysis over the next 90 days. Dialysis per physician orders and dialysis center schedule. Daily fluid restriction. Monitor and report weight gain/loss as ordered by physician. Weights and vital signs as ordered. Consult with dietitian as needed. Monitor and report labs per physician orders. Inspect fistula site daily for thrill/bruit and signs of infection. Monitor for extremity pain, numbness/tingling, or swelling distal to access site. Observe for bleeding at dialysis site and for free bleeding (nose bleeds, frequent bruising) and report to MD. Review of the admission progress note, completed by nursing and dated 3/10/26, noted left arm has AV (arteriovenous) fistula, thrill and bruit positive, right chest has a central line. Review of an inpatient hospital note from nephrology, dated 2/23/26, stated Access: TDC (tunneled dialysis catheter), placed by interventional radiology 1/23/26. Has AVG (arteriovenous graft) but avoiding use given pseudoaneurysm close to site of prior cannulation. Review of a provider's note, dated 4/9/26, stated Labs are managed by the dialysis team, and he/she is currently receiving dialysis Monday-Wednesday-Friday.at [NAME] County Dialysis. On 4/29/26 at 2:50 p.m., in an interview with the Director of Nursing, the Infection Preventionist and the Assistant Director of Nursing, a surveyor discussed that Resident #6's care plan did not include the days he/she goes to dialysis or the location of the dialysis center. In addition, the care plan did not include the presence of a central line for dialysis access and did not include instructions for monitoring the site before and after dialysis, or address emergency procedures. A review of the facility's Dialysis Care Policy, dated 2/28/23, noted in the section Procedure. 6. Care plan should include access site inspections, fluid restrictions, dialysis schedule, and Dialysis Center and contact number.

Based on observations and interviews, the facility failed to follow professional standards of practice with usage of Personal Protective Equipment (PPE) (Resident #39). Findings: On 4/27/26 at 10:41 a.m., a surveyor observed a Contact Precautions sign and Personal Protective Equipment (PPE) caddy posted on the door of room [ROOM NUMBER]. The Contact Precautions sign instructed staff to wear gloves and gown for all care and resident contact and to remove PPE prior to exiting the residents room. The surveyor observed RN #2 carrying a supply caddy containing diabetic testing supplies. RN #2 donned gloves upon entering the room, greeted the resident, and placed the supply caddy on the bed next to Resident #39's legs while obtaining the resident's blood glucose. Following the blood glucose check, RN #2 exited the room and removed his/her gloves. During an interview following the observation, RN #2 stated the Resident #39 is on Contact Precautions for Extended-Spectrum Beta-Lactamase (ESBL) in the urine. When asked about the protocol for contact precautions. RN #2 stated gowns and gloves were to be worn during personal care; however, she was not providing personal care at the time. On 4/27/26 at 10:48 a.m., the surveyor discussed the observation of RN #2 and interview findings with the Unit Manager. The Unit Manager stated staff were required to wear appropriate PPE when providing care to any resident on Contact Precautions, including while obtaining a blood glucose reading The Unit Manager confirmed RN #2 should not have placed the diabetic testing supply caddy on the residents bed, as the caddy would require disinfection due to the potential for contamination and additional staff education regarding Contact Precautions was needed. On 4/27/26 at 3:00 p.m., a surveyor discussed the above finding with the Administrator.

Based on record review, interview, and facility policy, the facility failed to ensure current provider orders reflected a resident's self-administration of respiratory medication, and failed to complete an assessment of a resident's ability to safely self-administer medication for 1 of 1 residents reviewed for tracheostomy care (R3).Findings: Review of the clinical record for R3 noted diagnoses which included: Chronic Obstructive Respiratory Disease (COPD), Chronic respiratory failure, and Tracheostomy. Review of R3's current provider orders, signed 4/24/26, included the following:An order originally written 6/12/25, for ipratropium 0.5 mg (milligrams) (2.5 mg base)/3 ml (milliliter) nebulization solution, (1) ampule for nebulization two times daily for COPD.An order originally written 12/18/25, for sodium chloride 3% for nebulization (1 unit) inhalation administer 1-3 ml every 4 hours via tracheostomy to help clear tracheal secretions. Review of R3's current care plan, with a revision date of 3/30/26, included the following focus areas and interventions: Respiratory: (R3) is unable to maintain oxygen saturation secondary to Chronic Respiratory Failure and COPD as evidenced by tracheostomy, need for respiratory medications/treatments, and supplemental oxygen. Interventions: (R3) is able to self-administer medications/treatments, nebulizer treatment as ordered by the Provider.And, R3 self-administers respiratory medications, i.e., nebulizers, etc. Medications will be stored in the Nurse Treatment Cart. Interventions: Ask (R3) if all medications are needed and document when they have been taken.Review appropriateness of continuing self-administration of medications. A review of R3's clinical record did not contain evidence that the facility had completed an assessment for R3's ability to safely self-administer medications. On 4/29/26 at 1:25 p.m., in an interview with a surveyor, the Assistant Director of Nursing (ADON) confirmed R3 self-administers nebulizer treatments. The ADON reviewed the provider orders and confirmed there was no current order for R3 to self-administer medications. The surveyor asked if staff had completed an assessment for the resident's ability to safely self-administer medications. The ADON stated yes, that the staff and physician meet with the resident and a form is completed. At the time of the interview, the ADON stated she was unable to locate evidence that an annual assessment for safe self-administration of medication had been completed. On 4/29/26 at 1:45 p.m., the ADON provided the surveyor a copy of the last assessment for R3's ability to safely self-administer medications, dated 3/22/24. The ADON also provided copies of provider orders, dated 2/23/24, which stated R3 could self-administer budesonide and ipratropium/albuterol via nebulizer. The ADON stated the order for R3 to self-administer nebulizer treatments had been dropped off when the orders were last changed. The ADON confirmed the current orders do not specify the resident may self-administer nebulizer treatments, and that the last assessment for safe self-administration of medication had been completed 2 years ago. A review of the facility's policy for Self-Administration of Medications, stated in Section II. Procedure. G. If resident is self-administering his/her own medications, completion of the self-administration screen will be completed initially, quarterly, and with a change in resident's medical condition.

Based on record reviews and interview, the facility failed to ensure the Minimum Data Set (MDS) Version 3.0 assessments were accurately coded in the areas of Hospice for 1 of 2 sampled residents (Resident #48).Finding:A review of Resident #22's clinical record revealed a physician's order dated 8/27/25 Admit the resident to hospice if appropriate due to suspected 6 months or less .Resident #22's quarterly MDS Version 3.0 assessment dated [DATE], Section O - Special Treatments, Procedures, Programs, was incomplete in the section for Hospice.On 4/29/26 at 3:30 p.m MDS coordinator confirmed the above finding with 3 surveyors.

Based on policy review, observation, and interview, the facility failed to provide appropriate treatment to prevent the risk of complications related to enteral feeding for 1 of 1 resident reviewed for tube feeding (Resident #8).Finding:Enteral Tube Policy last revised 7/22 states, enteral feeding tube placement will be verified prior to the initiation of feeding and/or medication administration. X-ray's is the only way to verify placement.On 4/28/26 at 11:05 a.m., a surveyor observed Registered Nurse (RN) #1 administer medications via a gastrostomy tube for Resident #8 without checking tube placement.On 4/28/26 at 2:13 p.m in an interview with a surveyor, RN #1 confirmed they only check the tube placement if I feel something is wrong and they also confirmed that the order states to check placement each shift.

Based on interviews, the facility failed to ensure that mail was delivered to all residents on 1 of 6 days, Monday through Saturday. (Saturday) Finding: During a group interview on 4/27/26 at 2:15 p.m., four residents voiced concerns regarding not receiving mail on Saturdays.On 4/30/26 at 1:05 p.m., during an interview, the Senior [NAME] President of Development and Operations confirmed mail was not routinely delivered on Saturdays because mail had previously been lost. The Senior [NAME] President of Development and Operations stated the weekend supervisor will be delivering the mail as needed on Saturdays.

Based on clinical record review, review of the facility's transport policy and interviews, a facility Transportation Aid failed to follow the transport a resident to an appointment safely by not attaching the shoulder harness strap and seat belt resulting in resident sliding from wheelchair during a transport and sustaining a fracture of the left femur for 1 of 3 residents reviewed for facility transports. (#1)Resident #1 was admitted to the facility in March of 2025 following a fall, for rehabilitation and treatment of a fracture of the resident's left distal femur, right proximal humerus, Type 2 Diabetes Mellitus, Atrial Fibrillation, and depression. The fracture of the left distal femur was not healing well, and the resident had an appointment with the Orthopedic Surgeon.During a review of the facility investigation, on 6/26/25, at approximately 8:30 a.m. the facility Transportation Aid (TA) loaded the resident into the van and secured the wheelchair. The Transportation Aid did not fasten the shoulder harness/seat belt combination because it was not working. She then got into the van and started to pull away from the facility and she heard the resident fall out of her chair onto the floor of the van. She stopped the van and immediately called 911. The rescue team came and transported the resident to the hospital. Transport Aside knew the safety belts were not working properly and did not report the issue.Hospital Discharge summary dated [DATE] stated recent right proximal humerus fracture s/p ORIF(Open Reduction and Internal Fixation) on 3/26/25 complicated by left distal radius fracture and left distal femur fracture who presents with left thigh pain after a fall in wheelchair van and admitted for comminuted left femur fracture.On 7/7/25 at approximately 10:00 a.m. in an interview with a surveyor, the Transportation Aid stated that she has been with the facility since 2013 but has only been driving the van for the last 2 weeks. When asked what education she had received, she stated she had watched the training videos and had been given an orientation to the van by the Maintenance Director. When asked about the day of the transport she stated that she had loaded the resident into the van and locked the wheels in place. When I went to fasten the shoulder strap it would not move, and I could not get it buckled. I thought that because the distance to the appointment was close and I could drop off the resident and come back and report it to Maintenance. When asked if the Maintenance staff was at the facility at the time she found the issue with the shoulder strap? She said, Yes they were. When asked why she did not have them look at it at that time? She stated, I thought it would be OK.On 7/7/25, at approximately 11:15 a.m., in an interview with the Administrator she stated, When the incident happened, the van was removed from service immediately. It was due for normal maintenance, so we had that done and also an inspection of the safety straps was done by the Maintenance Director. On 6/26/25, during the inspection, it was discovered that the seatbelt straps were not attached properly, and the issue was fixed. The Maintenance Director was designated to be the van driver trainer.On 7/7/25, during a review of the facility's policy for Motor Vehicle Rules & Requirements, dated 3/1/25, the policy states that there is A notification sign must be visibly placed in the vehicle that reads. 'SAFETY BELTS MUST BE WORN'. The driver and all passengers must properly wear seat/safety belts at all times during operation of the motor vehicle.On 7/7/25, at approximately 8:55 a.m. during an observation of the transport van, no signs requiring the use of seat belts were found. This was reported to the Administrator at that time.As a result of the facility's investigation, the following corrective actions were initiated:- 0n 6/26/25, Van was placed out of commission until its safety was confirmed- On 6/26/25, the Maintenance Director inspected the inside of van completely to include all the equipment to ensure proper functionality. Specifically focusing on the seatbelt and tie downs.- On 6/26/25, the Maintenance Director was designated to be Van Transport Trainer.- On 6/26/25 Education provided to staff how to secure a passenger was placed in van for reference.- On 6/27/25 Involved staff were retrained on van safety with return demonstration.- On 6/30/25 Passenger Loading Instructions Audit tool developed for random audit to be done by the Maintenance Director.- On 6/30/25 Daily Wheelchair Van Safety Checklist developed for transport aid to complete before using the van.- On 6/30/25 current Van Driver completed training.

Based on review of the complaint report, facility internal investigation, clinical record review, facility General Dose Preparation and Medication Administration Policy and Procedure, and interviews, the facility failed to identify the resident prior to administering medications, failed to follow the facilities policy on resident identification resulting in Resident #1 being given another's residents medication resulting in the need for a hospital evaluation for 1 of 1 residents reviewed (Resident #1) Findings: The Division of Licensing and Certification received a complaint that indicated on the morning of 5/20/25, Resident #1 received another resident's medications which resulted in lethargy and poor oxygen profusion. Resident #1 was transported to the emergency room for further evaluation. On 6/2/25, a review of the facility's internal investigation was completed. The investigation indicated that on 5/20/25, during morning medication pass, Certified Nurse Assistant-Medication (C.N.A.-M #1) administered the wrong medications (Eliquis - an anticoagulant medication used to prevent blood clots, Metformin used to treat type 2 diabetes; Flexeril used to treat muscle spasms; Lyrica used to treat nerve pain; Furosemide used to treat fluid retention; Potassium chloride a supplement to treat low potassium; Risperidone a antipsychotic medication used to treat a variety of mental health conditions; and Vitamin B) to Resident #1. C.N.A.-M #1 administered Resident #2's medications to Resident #1 in error. The physician' s noted dated 5/20/25 stated, Medication error: Patient inadvertently received another resident's medications (metformin, furosemide, risperidone, paroxetine, Eliquis, pregabalin, cyclobenzaprine). Based on the medication types and estimated dosages given, current presentation is not consistent with a toxic overdose. Poison Control was not contacted at this time, though the situation will continue to be monitored closely given the potential for delayed adverse effects. Patient remains clinically stable at time of evaluation, with only mild drowsiness noted. No signs of respiratory distress, hemodynamic instability, or neurologic changes . if any changes in mental status, vital signs, or neurologic function occur, the patient is to be transferred to the ED for further evaluation. Review of the nursing documentation, dated 5/20/25 at 4:10 p.m. stated, resident was given another resident medication. Provider notified and POA (Power of Attorney) notified as well. Monitoring vitals Q6 (every 6 hours) per doctor and monitoring sugars. Resident has been stable so far, only side effect was being a little drowsy, B/P (blood pressure) and Pulse continues to be WNL (with in normal limits). BS(blood sugars) has also been WNL. The nursing note, dated 5/20/25 at 8:03 p.m., stated, around 4:30 p.m. MedTech entered room to give evening medications and found resident to be unresponsive to voice and touch but breathing. Nurse attempted to get resident to respond but was unsuccessful . immediately 911 was called. EMS arrived and took patient to the hospital. Report given to hospital, all medications given in error told to hospital. Call received around 8:00 p.m. stating resident would be returning to facility sometime this evening. Nursing note, dated 5/20/25 at 11:08 p.m. stated, Resident returned to facility around 9:30 p.m., via stretcher transport . resident still lethargic and according to the hospital physician it is expected. Hospital reached out to poison control who told them to monitor [him/her] for 2 hours at the hospital and then send [him/her] back if stable. Reporting nurse stated all labs were WNL and BS (blood sugar) was 103, 10 minutes before return to facility. On 6/2/25 at 11:42 a.m., during an interview, the Registered Nurse (RN) manager for B2 unit stated she was working that day as the charge nurse and notified the doctor immediately of the medication error. The doctor gave orders to check vitals every 6 hours and blood sugars. The incident happened around 11:30-12pm and the residents vitals were stable, but [he/she] was not talking and sleeping very heavy, not responding with touch and it was then when she was sent to the hospital. On 6/2/25 at 11:59 a.m., during an interview, The Director of Nursing (DON) stated education on medication administration has been started and currently in place for nursing staff who administer medications. Education should be completed by 6/9/25. The facilities General Dose Preparation and Medication Administration policy and procedure, revised 11/15/24, under procedure 3.1 states, Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time for the correct resident. On 6/2/25 at 2:15 p.m., during the exit interview with the Administrator and the DON, the above failure to identify the resident prior to administering medications, failure to follow facility policy on resident identification resulting in Resident #1 being given another's residents medication and the need for a hospital evaluation was confirmed.

Based on interviews, observations and record reviews, the facility failed to provide supervision to a resident after staff found resident in closet in another resident room, with an open window. Resident was previously identified as an elopement risk and had previous exit seeking attempts for 1 of 2 residents identified for elopement risk. Shortly after, the resident was found outside in a snowbank with a second story window open. This failure created an immediate jeopardy situation. (Resident #1) Findings: On 2/17/25 the Department of Licensing and Certification received a facility reported incident indicating [Resident #1] fell into snow from second floor on 2/17/24. [Resident #1] found in snowbank at approximately 1:00 a.m. Medical record indicated that on 2/12/25, Resident #1 was transferred from the facility residential care unit to a secured long term care unit(B1 Unit). The transfer was related to safety due to increased dementia behaviors including exit seeking and recent elopements from the residential care facility. Resident #1 is [AGE] years old with a diagnosis of dementia. On 2/12/25 the facility completed elopement assessment and determined Resident #1 was a High Risk for elopement. Resident#1 was wearing a Secure Care anklet (monitor for wandering residents). On 2/19/25, during review of Resident #1's nursing progress notes, stated on 2/14/25 at 11:51 a.m., a nurse administered as needed medication for anxiety and initiated a 1:1 for safety from staff due to wandering, exit seeking and refusal of care. Documentation states that medication was effective and daughter visiting. Resident #1's Medication Administration Record (MAR), stated on 2/15/25 at 1:29 p.m., and on 2/15/25 at 7:34 p.m., a nurse administered as needed medication for anxiety and both times the response was not effective. Resident #1's nursing progress notes stated on the night of 2/16/25 and into the early morning of 2/17/25, Resident #1 exhibited exit seeking behaviors, pacing, not responding to redirection and medications were not effective. On 2/28/25 at 9:49 a.m., during an phone interview with CNA#1, stated resident was last seen in bed on 2/17/25 around 12:20 a.m. Earlier that evening resident was found missing. The staff searched and found Resident #1 in the closet of another resident room. The window in that room was also found open. The residents in that room were both asleep when Resident #1 was found. CNA #1 stated that neither resident sleeping in that room would have been able to exit their bed independently to open the windows. On 2/28/25 at 11:41 a.m., during an interview with PSS #1 stated that at on 2/17/25 1:00 a.m. he/she was taking a break outside with another staff member from Residential Care and found Resident #1 on a snowbank underneath an open second floor window. Resident #1 was assessed by a facility nurse and found to be alert, tearful, oriented to self, scrapes on knees and a bump on his/her head. PSS#1 called 911 and went to alert the facility staff that resident was outside. The long-term care unit staff were unaware Resident #1 had gone missing again. Resident #1 was transferred by Emergency Medical Services (EMS) to the emergency room . During review of Residents #1 Hospital Discharge Summary, dated 2/20/25, stated that Resident #1 was diagnosed with hypothermia, metabolic encephalopathy secondary to hypothermia and hypoxia and frostbite. Resident discharged back to facility on 2/2025 with orders by facility provider included comfort measures only and hospice. According to the archived records from the National Weather Service, the temperature range on 2/16/25 was 17-23 degrees Fahrenheit with light snow. On 2/19/25 at 10:00 a.m., during an interview with the facility Maintenance Director, all facility windows on B2 and A1 units had been assessed and retrofitted with window blockers that limited opening windows to 6 inches. Prior to this, according to the Maintenance Director, the windows could be easily opened. Some of the facility windows had very low sills and could be easily accessed. This was completed by 2/18/25 around 11:00 a.m. Resident Elopement policy last revised 9/2023 and found under section II (Procedure), Item G. The resident's plan of care is to be updated with appropriate interventions to meet resident's current needs. And under section II, Item H. Document in medical record. Indicate time the search began and the time the search ended. There is no documentation to support that staff followed the facility's policy when Resident #1 went missing the first time on the night of 2/17/25. Based on the above information, IJ was called on 3/4/25 for the facility's failure to provide adequate supervision to a resident with a history of exit seeking and elopement that resulted in a fall from a second story window into a snowbank. Staff on B2 were unaware the resident had been missing a second time until alerted by residential care staff after the fall. The facility's failure to provide these services constituted an immediate jeopardy situation. Please see F-0000 Initial Comments related to the IJ removal plan.

Based on record review and interviews, the facility failed to monitor targeted behaviors to support the use of antipsychotic and antianxiety medications for 1 resident reviewed for unnecessary medications and behavior monitoring. Findings: Review of Resident #1's Physician Order Sheet has the following orders for Psychotropic Medications: -Sertraline 100 mg(milligram) tablet one time daily oral for Unspecified dementia, Moderate, with mood disturabance. -Clonazepam 0.5 mg tablet two times daily oral for Generalized Anxiety disorder -Lorazepam 100 % power (0.25 ml) topical As needed Every Four Hours for Ninety Days for Generalized Anxiety Disorder Review of Resident #1's Physician Order Sheet order, dated 2/12/25 that states: Behavioral/Psychotropic Medication Monitor Notes: Behavior monitoring for psychotropic medications below: Antipsychotics, Antianxiety, Antidepressants, Sedative/hypnotics *Please document ALL behaviors including those Normal for the resident. Physical Monitors: 1. Behavioral Symptoms/Effective?/Non-Pharmacological Interventions/Number of Episodes/Psychoactive Side Effects Frequency: Three Times Daily (Nurse Day Shift, Nurse Evening Shift, Nurse Night Shift). Review of Resident #1's Care plan included under interventions Monitor, report and document changes in mentation and If [Resident #1] is agitated or restless, provide distration Resident #1 was admitted to Long Term Care Unit from Residential Care with diagnosis of dementia due to with exit seeking and wandering behaviors. On 2/19/25, during review of the Treatment Administration Record (TAR) for Resident #1, between the dates of 2/12/25 and 2/17/25 there is no documentation on the TAR that nursing followed this monitoring behaviors ad physician order directed. The Medication Administration Record (MAR) showed 4 documented times that an as needed psychotropic medication was given between 2/12/25 and 2/17/25. There is no documentation as to why this drug was administered for 3 of 4 times it was administered to Resident #1. During review of progress notes for Resident #1, between the dates of 2/12/25 and 2/17/25, the nursing notes failed that supported the ordered behavior monitoring for psychotropic medications. In addition, nursing notes do not explain why an as needed medication was administered or what nonpharmacological interventions were attempted prior to administering an as needed medication. On 2/19/25 at 12:15 p.m., during an interview with the Administrator and the Director of Nursing and discussed the above findings.

Based on record reviews and interviews, the facility failed to follow the baseline care plan implemented for Resident #1 in the area of Behaviors for 5 of 5 days that resident was in the facility. Findings: On 2/19/25, during review of Resident #1's baseline care plan, dated 2/12/25, stated in the area for Behaviors: Document behaviors in Treatment Administration Record (TAR) or on behavior monitoring form every shift. A review of Resident #1's Electronic Medical record (EMR) under TAR and Clinical Notes, failed to show documented behaviors for every shift between 2/12/25 and 2/17/25. On 2/28/25 at 8:51a.m., during an interview with CNA #1, who worked shifts with Resident #1 on 2/12/25, 2/13/25, 2/14/25, 2/15/25 and 2/16/25. CNA #1 stated that Resident #1 was wandering, exit seeking, refusing care, distressed frequently since arrival on B2 Unit. CNA #1 states that he/she was not told Resident #1 had eloped several times in Residential Care. On 2/28/25 at 9:49 a.m., during an interview with CNA #2, who worked shifts with Resident #1 on 2/12/25, 2/13/25, 2/15/25 and 2/16/25. CNA #2, confirmed that Resident #1 had been experiencing frequent wandering and exit seeking behaviors and was very difficult to manage when his/her family was not present. On 2/19/25 at 12:15 p.m., during an interview with the Administrator and the Director of Nursing, were unable to provide additional evidence or an explanation for not following the care plan for montoring behaviors.

Based on record reviews and interviews, the facility failed to notify the physician when interventions were ineffective in relieving resident's distress. In addition, the facility failed to notify the physician after the resident was missing and required a search to locate or when the resident experienced a life-threatening elopement. Findings: On 2/17/25 the Division of Licensing and Certification received a facility reported incident, which indicated Resident #1 was found outside in a snowbank having fallen from a second story window. Review of facility policy Resident Elopement Policy last revised 9/23 states under: II. PROCEDURE -Section D vii - The physician and resident's responsible party will be notified. -Section G. The resident's plan of care is to be updated with appropriate interventions to meet the resident's current needs -Section H Document in medical record. Indicate time the search began and the time the search ended. On 2/19/25, druing review of Resident #1's the Medication Administration Record, stated a PRN (as needed) medication for anxiety was given with no effect on 2/15/25 at 7:34 p.m. and 2/16/25 at 6:00 p.m There is no evidence to support that other interventions were tried and effective/ineffective or that a physician was notified. On 2/19/25, during review of Resident #1's electronic medical record (EMR), Clinical notes stated that Resident#1 had been found missing from his/her bed on 2/16/25 and located in the closet of another room where a window had also been found open. The notes lacked evidence the time the search began and time when resident was found. The notes also stated that interventions and medications had been unsuccessful to relieve resident's agitation. There is no evidence that a provider was notified. On 2/17/25 at approximately 1:00 a.m., Resident #1 was found outside in a snowbank underneath an open second story window. Resident #1 was transferred to the hospital and diagnosed with hypothermia and frostbite. The medical record lacked evidence that the facility physician was notified. On 2/19/25 at 12:15 p.m., a surveyor discussed the above findings with the Administrator and Director of Nursing and confirmed that physician was not notified of resdient behaviors and elopement.

Based on observations and interviews, the facility failed to adequately maintain maintenance services necessary to maintain in good repair and in sanitary condition for 2 of 2 units. Findings: On 6/26/2024 at 2:00p.m. during an environmental tour with a Cooperate Quality Improvement Nurse, the following were observed: On the Second Floor - B-2 Unit Resident room [ROOM NUMBER] - Window curtain stained, Resident room [ROOM NUMBER] - Window curtain off track, Resident room [ROOM NUMBER] - Stained ceiling tile above bed A Resident room [ROOM NUMBER] - Large chip out of the laminate on the front of the sink creating an uncleanable surface, Laminate on the left side of the sink is loose and could break creating a hazard. Resident room [ROOM NUMBER] - Window curtain stained, Resident room [ROOM NUMBER] - Resident bathroom toilet will not stop running. Next to Second floor Nurses' station hand sanitizer dispenser has had the drip catch cup torn away leaving screw holes in the wall that are rough and could be an injury hazard; and it is an uncleanable surface. Second floor hallway ceiling tile has several hanging bits of dirt and debris all down the hallway. First Floor - B-1 Unit Resident room [ROOM NUMBER] - Both resident's bed curtains have missing hooks and chipped paint in the middle of the ceiling, Resident room [ROOM NUMBER] - Left lower drawer under sink has chip in the laminate, creating a hazard and an uncleanable surface. Resident room [ROOM NUMBER] - Cob Webs along the wall on the left as you enter the room. All the above items were confirmed with Cooperate Quality Improvement Nurse at the time.

Based on record reviews and interviews, the facility failed to perform adequate screening and documentation for coronavirus (Covid-19) as required for 2 out of 5 residents screened for Covid-19 vaccinations. (Resident #1, Resident #6) Findings: 1. On 6/25/24, a surveyor reviewed Resident #1's Electronic Medical Record (EMR) and found no coronavirus (Covid-19) vaccinations recorded. Resident #1 was admitted to the facility on [DATE]. A surveyor reviewed the physical medical record and did not locate any documentation that Resident #1 had received, been offered, or refused the Covid-19 vaccination. 2. On 6/25/24, a surveyor reviewed Resident #6's EMR and found no coronavirus (Covid-19) vaccinations recorded. Resident #6 was admitted to facility on 10/26/23. A surveyor reviewed the physical medical record and did not locate any documentation that Resident #6 had received, been offered, or refused the Covid-19 vaccinations. Review of Centers for Disease Control (CDC) guidelines for Covid-19 vaccinations for Long Term Care (LTC) residents is as follows: Consent or assent for a COVID-19 vaccine is given by LTC residents (or people appointed to make medical decisions on their behalf called a medical proxy) and documented in their charts per the provider's standard practice. On 6/26/24 at 10:30 a.m., a surveyor interviewed the facility Infection Preventionist and confirmed the CDC is consulted for standard practice in Infection Control at the facility. On 6/26/24 at 10:10 am, in a discussion with the facility Infection Preventionist and the Corporate QUality Improvement Nurse, it was confirmed the facility did not have a Resident Immunization policy for Covid-19 nor did the facility follow the CDC recommendations for screening LTC residents for Covid-19 Vaccinations.

Based on record reviews and interviews, the facility failed to perform adequate screening and documentation for Pneumococcal and/or Influenza vaccination as required for 2 out of 5 residents screened for vaccinations. (Resident #1, Resident #6) Findings: 1. On 6/25/24, a surveyor reviewed Resident #1's Electronic Medical Record (EMR) and found no Pneumococcal vaccinations recorded under Immunizations. Resident #1 was admitted to the facility on [DATE]. A surveyor reviewed the physical medical record and did not locate any documentation that Resident #1 had received, been offered, or refused the Pneumococcal vaccination. 2. On 6/25/24, a surveyor reviewed Resident #6's EMR and found no Pneumococcal or Influenza vaccinations were recorded. Resident #6 was admitted to facility on 10/26/23. A surveyor reviewed the physical medical record and did not locate any documentation that Resident #6 had received, been offered, or refused the Pneumococcal or Influenza vaccinations. A surveyor reviewed the facility policy titled Infection Control Immunizations-Influenza, Pneumococcal Policy- last revised 3/22: Each resident will be offered an Influenza Vaccine October 1 through March 31 annually, unless the immunization is medically contraindicated, or the resident has already been immunized during this time period. Each Resident will be offered a Pneumococcal Vaccine, upon admission unless the immunization is medically contraindicated or the resident has already been immunized. Proof the resident either received the Influenza and/or Pneumococcal vaccine, the vaccine(s) was contraindicated for medical reasons, or the resident refused the vaccine(s). On 6/26/24 at 10:30 a.m., a surveyor interviewed the facility Infection Preventionist and the Corporate Quality Improvement Nurse and confirmed the above findings.

Based on observations and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for 2 of 2 initial kitchen observations completed on 6/24/24 and 6/25/24. Additionally, the facility failed to ensure that food temperatures were recorded. Findings: 1- On 6/24/24 at 8:50a.m. - Initial observation of the Kitchen: Observed two unlabeled and undated pans of deserts in the fridge - The Food Service Director (FSD) stated, That is today's desert. Observed soiled ceiling tiles - The FSD stated that the ceiling was last cleaned a couple of months ago. Observed a wall mounted fan with light to moderate dirt blowing on the cooking area. Observed a cart mounted fan with moderate to heavy dirt blowing on the cooking area When the cook was asked for the temperature log while cooking today's breakfast she stated, I did not get them on here. She showed the surveyor the log pages and it was noted that documentation of temperature while cooking was lacking since last Friday 6/21/2024. She stated that she was not here over the weekend, but that they have been out straight. Upon closer examination of the log sheets, it was discovered that there were no temperatures recorded for all meals on 6/16/24, Supper meal on 6/17/24, Supper meal on 6/18/24, Supper meal on 6/19/24, Supper meal on 6/20/24, Supper meal on 6/21/24, All meals on 6/22/24, All meals on 6/23/24, and Breakfast on 6/24/24. There was no log sheet even available for week of 6/23/24. 2. On 6/25/24 at 8:03 a.m., observed refrigerator in the B-2 Unit Common Dining area to have a heavy layer of dust on the top. In both the freezer compartment and the refrigerator there was a light to moderate amount of dirt and dried food. This was confirmed with the unit charge nurse at that time. 3. On 6/25/24 at 8:45a.m,. a surveyor observed the resident refrigerator on B-1 Unit. The base plate is covered with a heavy amount of dirt and rust. This was confirmed with the charge nurse at that time. 4. Additional findings during the 6/25/24 return observation of the Kitchen were: 3 employee drinks discovered in the 2 reach-in fridges in the Kitchen, and a half-eaten ice cream sandwich was found in walk-in freezer. This was called to the attention of the Cooperate Food Service Consultant at that time.

Based on record reviews and interviews, the facility failed to follow the facility Falls Management Policy for 8 of 8 residents reviewed for falls thus far in 2024. Resident (#1,#6, #13,#30, #35, #36, #39 #41,) Findings: 1. On 6/25/24, a surveyor reviewed the Electronic Medical Record (EMR) for Resident #13 who was admitted on [DATE], for Long Term Care and found that Resident #13 had fallen six times (1/7/24, 2/29/24, 3/1/24, 3/19/24, 4/12/24, and 5/20/24). The falls lacked complete documentation per facility's Fall Management Policy, including updated Fall prevention interventions in the care plan. Review of Resident #13's Progress Notes dated 1/7/24, 2/29/24, 3/1/24, 3/19/24, 4/12/24, and 5/20/24 shows that Post Fall Observations were done but all other required documentation is lacking, i.e. documentation for three shifts post fall and documentation of the Director of Nursing (DON) follow-up as stated in the facility's policy. 2. On 6/25/24, a surveyor reviewed the Electronic Medical Record (EMR) for Resident #30 who was admitted on [DATE], for Long Term Care and found that Resident #30 had fallen one time (2/16/24). The fall lacked complete documentation per facility's Fall Management Policy, including updated Fall prevention interventions in the care plan. Review of Resident #30's Progress Notes dated 2/16/24, Review of Resident #30's Progress Notes dated 2/16/24 shows that Post Fall Observations were done but all other required documentation is lacking, i.e. documentation for three shifts post fall and documentation of the Director of Nursing (DON) follow-up as stated in the facility's policy. 3. On 6/25/24, a surveyor reviewed the Electronic Medical Record (EMR) for Resident #35 who was admitted on [DATE], for Long Term Care and found that Resident #35 had fallen one time (6/16/24). The fall lacked complete documentation per facility's Fall Management Policy, including updated Fall prevention interventions in the care plan. Review of Resident #35's Progress Notes dated 6/16/24, Review of Resident #35's Progress Notes dated 6/16/24 shows that Post Fall Observations were done but all other required documentation is lacking, i.e. documentation for three shifts post fall and documentation of the Director of Nursing (DON) follow-up as stated in the facility's policy. 4. On 6/25/24, a surveyor reviewed the Electronic Medical Record (EMR) for Resident #36 who was admitted on [DATE], for Long Term care and found that Resident #36 had 2 falls (2/16/2024 and 4/30/24). Each fall lacked complete documentation per facility's Fall Management Policy, including updated Fall prevention interventions in the care plan. Review of Resident 36daTED's Progress Notes dated 2/16/2024 and 4/30/24. Review of Resident 36's Progress Notes dated 2/16/24 and 4/30/24 shows that Post Fall Observations were done but all other required documentation is lacking, i.e. documentation for three shifts post fall and documentation of the Director of Nursing (DON) follow-up as stated in the facility's policy. 5. On 6/25/24, a surveyor reviewed the Electronic Medical Record (EMR) for Resident #39 who was admitted on [DATE], for Long Term Care and found that Resident 39 had 3 falls (4/10/24, 5/14/24, and 6/17/24). Each fall lacked complete documentation per facility's Fall Management Policy, including updated Fall prevention interventions in the care plan. Review of Resident 39's Progress Notes dated 4/10/23, 5/14/24, and 6/17/24 shows that Post Fall Observations were done but all other required documentation is lacking, i.e. documentation for three shifts post fall and documentation of the Director of Nursing (DON) follow-up as stated in the facility's policy. 48648 Based on record reviews and interviews, the facility failed to follow the facility Falls Management Policy for 8 of 8 residents reviewed for falls thus far in 2024. Resident (#1,#6, #13,#30, #35, #36, #39 #41,) Findings: North County Associates, Falls Management Policy, last revised 7/2019 IV. Fall Reduction Actions A. DNS or designee will review fall incident reports regularly and identify potential patterns or trends. B. Quality Measures will be reviewed monthly and residents who triggers for falls and/or falls with major injury will have a completed record review by the DNS and/or designee. C. All falls will be reviewed at Quality Assurance or Fall Committee meetings on a quarterly basis, at a minimum. V. Procedure A. Complete Fall Risk Screen upon admission, quarterly, and as needed. B. Determine Risk Level and care plan according to risk level. C. When a fall has occurred the charge nurse will be notified in order to appropriately assess the resident and determine their medical status. D. A fall incident report will be completed after a resident has had a fall, whether it is witnessed or not. E. Complete Post Fall Observation Tool, following a fall, to help identify if the cause of the fall is related to mental status changes, physical limitations or environmental factors. F. Documentation must be completed in the nurse's note on each shift x3 following the fall. Residents' care plan will be updated with all new interventions. 1. On 6/25/24, a surveyor reviewed the Electronic Medical Record (EMR) for Resident #1 who was admitted on [DATE] for Long Term Care and found that Resident #1 had 8 falls (1/29/24, 1/31/24, 2/2/24, 2/2/24, 2/9/24, 2/27/24, 3/22/24, 4/7/24). Each fall lacked complete documentation per facility's Fall Management Policy; including updated Fall prevention interventions in the care plan which failed to show any updates in this area since 1/26/2024. Review of Resident #1's Progress Notes dated 2/20/24, 3/22/24, 4/11/24, 4/15/24 show increased pain due to injuries sustained from falls. 2. On 6/25/24 a surveyor reviewed the EMR for Resident #41 and found that Resident #41 admitted to the facility on [DATE] had 9 falls (2/17/24, 2/20/24, 3/1/24, 3/4/24, 3/7/24, 4/13, 24, 5/24/24, 5/27/24, 6/16/24. Each fall lacked complete documentation per facility's Fall Management Policy including revision of Fall Prevention Interventions in Resident #1's care plan. 3. 06/25/24 at 02:22 p.m. a surveyor spoke with ([NAME]) to request additional documentation on the facility follow up to resident falls. One undated monthly fall summary template was located and provided. 4. On 6/26/24 at 9:15a.m. surveyors met with Director of Nursing to discuss the monthly review for Quality Measures for falls and lack of consistent documentation following falls. The Director of Nursing stated they talk about falls all the time, but the documentation is not there.

Based on record reviews and interviews, the facility failed to provide a call bell to obtain assistance while on the bedside commode for 1 of 3 residents assessed to be a high risk for falls (Resident #1) Findings: On 6/25/24 a surveyor reviewed Resident #1's Electronic Medical Record and found that Resident #1 was admitted to facility on 1/26/24 with respiratory failure with hypoxia and since has had 8 unwitnessed falls. Resident #1 was rated upon admission as being a high risk for falls. On 6/25/24 a surveyor reviewed the progress notes in Resident #1's Electronic Medical Record (EMR) dated 3/22/24 and found a nurse's note that stated Resident was assisted to bed-side commode, CNA left her with call-bell not within reach. She then called out and fell to knees then onto her back (per resident). On 6/25/24, a surveyor reviewed the facility's Resident Incident Reporting Form, dated 3/23/24, for an incident that occurred 3/22/24 at 5:00a.m. that states (Resident #1 was assisted to bedside commode, then reaching for call bell fell on to floor mat and was found lying on her back. On 6/25/24 at 9:15 a.m. surveyors interviewed the Director of Nursing who agreed that a resident assessed to be at high risk for falls should have had their call bell when using the commode.

Based on observations and interviews, the facility failed to provide a sanitary, orderly, and comfortable environment on 1 of 2 units (Oakridge - B2) for 1 of 1 days of survey. Findings; On 5/31/2023 between the hours of 8:55 a.m. and 9:30 a.m., two surveyors observed the following during an environmental tour of Oakridge B-2 unit. -room [ROOM NUMBER] had crumpled tissues, a medication cup and smeared dried footprints on the floor. -room [ROOM NUMBER] bedroom floor had dried footprints, a purple glove near the trash can and a packet of syrup. Under the bed was a pile of debris that included a fork, napkins, a wrapper, and a plastic cup. -room [ROOM NUMBER] bedroom floor had multiple sticky areas of dried liquid near Bed C. The shared bathroom had a strong urine odor and the floor had visible dirt and debris around the trash can with a sticky dried substance and footprints. -room [ROOM NUMBER] bedroom had dried liquid on the floor, a pile of debris under the bed that included an opened coke can, a full butter packet, pile of white powder, tissues and a plastic lid such as would cover a bowl. The shared bathroom had a strong urine odor, the floor was dirty, tissues or toilet paper on the floor, a red substance dried on the floor and an unlabeled urinal stored on the back of toilet. -room [ROOM NUMBER] bedroom floor dirty with dust and debris. -room [ROOM NUMBER] bedroom had hair in sink, floor dirty with footprints, Dust coated windowsill. The shared bathroom had a dried brown substance on the floor near toilet and smears of light brown visible on floor and a strong odor of urine. -room [ROOM NUMBER] bedroom floor had areas of both dried gray liquid and dried white liquid with debris under the sink and a dust coated windowsill. -room [ROOM NUMBER] bedroom had dried liquid on side of bed and debris/trash under the head of the bed. The bathroom had a pungent odor and a dried sticky substance on floor. -room [ROOM NUMBER] bedroom wall scraped up behind Bed A with white visible under the paper surface, floor is visibly dirty with footprints, debris, food and dried brown liquid. Sink dirty with hair and debris. -room [ROOM NUMBER] bedroom had trash on the floor, sink was visibly dirty with gray liquid spots, floor was dirty with smeared dried brown footprints. -room [ROOM NUMBER] bedroom floor soiled with debris and dried footprints. Black liquid had spilled and dried near Bed B. Shared bathroom had a strong urine odor, sticky floor, visibly dirty toilet, trash on floor around trashcan, and dried liquid substance on floor. -room [ROOM NUMBER] shared bathroom with strong odor. Floor was visibly soiled with footprints. Sanitizing wipes container on floor. -Floor in nursing station was visibly dirty with dried, smeared footprints, dust and debris. -Unit shower room was visibly dirty with dust, footprints, and crumpled toilet paper on the floor near the toilet base. No hand soap in the soap dispenser for hand hygiene. -Employee bathroom across from the nursing desk had no hand soap available for hand hygiene. -Hoyer in hallway had built up black substance and lint substance in edges and horizonal surfaces. -Linen closet, near room [ROOM NUMBER], had dried brown footprints with visible debris along edges of floor. On 5/31/2023 from 1:50 p.m., to 2:00 p.m., two surveyors again observed the above concerns with the addition of the dining room with food crumbs and debris on the tables and under the tables. On 5/31/2023 during an environment tour with the Administrator the above findings were shared and confirmed.

Based on interview, observation, and record review, the facility failed to ensure resident's exhibiting symptoms of gastroenteritis were on contact precautions; failed to ensure Personal Protective Equipment (PPE) supplies were available for use (gowns); failed to disinfect resident rooms and common areas with the appropriate (Environmental Protection Agency) EPA cleaner; and failed to educate and reeducate staff on contact precautions and appropriate disinfection resulting in spread of gastroenteritis creating an immediate jeopardy situation to 9 out of 34 Resident's, as of 3/6/2023, on the B2 Unit. (Resident #41, #29, #28, #32, #13, #27, #26, #35, #4). In addition to the immediate jeopardy, the facility failed to have a risk assessment and have water management policies and procedures in place to reduce the risk of growth and spread of Legionella and other opportunistic waterborne pathogens in the facility water system resulting in potential harm that is not immediate jeopardy to 52 residents in the facility. Findings: According to the Centers for Medicare and Medicaid Services, State Operations Manual Appendix PP Guidance to Surveyors for Long Term Care Facilities rev. 211 dated 2/03/2023, page 778, Contact Precautions: Contact precautions are intended to prevent transmission of pathogens that are spread by direct (e.g., person-to-person) or indirect contact with the resident or environment (e.g., C. difficile, norovirus, scabies), and requires the use of appropriate PPE, including a gown and gloves before or upon entering (i.e., before making contact with the resident or resident's environment) the room or cubicle. Prior to leaving the resident's room or cubicle, the PPE is removed and hand hygiene is performed. On 3/6/23 at 9:21 a.m., the Acting Director of Nursing (ADON) stated, to the survey team, words to the effect of: at the end of last week we had some type of Norovirus type thing in the building on B2, now we have more residents that are not doing well. A surveyor asked what type of precautions the residents on B2 are on, and the ADON stated, standard precautions. On 3/6/23 at 9:32 a.m., in an interview with a surveyor, Licensed Practical Nurse (LPN)1 stated, on the evening shift last night [Resident #30] was nauseous, [Resident #13] had loose stool x(times) three, [Resident #21] had nausea this morning, [Resident #35] had vomiting, [Resident #50] had a loose stool and one episode of vomiting, and [Resident #4] had extra-large loose stool. On 3/6/23 at 10:38 a.m., in an interview with a surveyor, LPN2 indicated that there were three residents with diarrhea and vomiting. [Resident #4] started last night, vomiting and diarrhea; [Resident #35] started yesterday, and overnight vomiting and diarrhea, and vomiting right now; [Resident #13] started overnight, and the evening shift yesterday, diarrhea. This surveyor asked what type of precautions the residents are on. She stated, everyone is on contact, wash hands, and wash hands after gloves. The LPN did not indicate what contact precautions meant. On 3/6/23 at 11:03 a.m., a surveyor observed Resident #35 seated in a wheelchair, vomiting into a basin. Certified Nursing Assistant-Medication Technician (CNA-M)1 was holding the basin with ungloved hands. In an interview with a surveyor, CNA-M1 stated, she was off the weekend, and if there are bins (precaution supply carts) outside the room, she would have known to wear gloves into the room, the facility is not doing that. The facility has not identified it as Norovirus, they identified it as a stomach flu. The CNA-M1 stated she was given a list of people not to give laxatives to due to loose stool. At this time a surveyor requested to see the list, Residents #4, #34, #50, #27, #3, #29, #21, #35, and #13 were highlighted on the list to Please hold laxatives. On 3/6/23 at 11:07 a.m., in an interview with a surveyor, CNA3 indicated she came on shift at approximately 6:45 a.m. this morning and she said, some residents have symptoms of Norovirus, who had bowel movememt(BM ) over the last evening shift. CNA3 stated she did not write the residents down, but [Resident #4] and [Resident #30] were not feeling well. [Resident #35], [Resident #7], and [Resident #13] were not feeling well. CNA3 stated, I go between floors(works different floors/units and goes back and forth between units). When a surveyor asked what PPE the CNA should use, she stated masks and gloves on, no gown precautions. If full precautions would have gowns available. On 3/6/23 at 11:24 a.m., a surveyor observed Physical Therapy (PT) going into room [ROOM NUMBER] with no gloves on, she leaned on the bedside table, hands resting on her face and spoke with Resident #30 before taking Resident #30 into the hallway for therapy services. In an interview with a surveyor, the Physical Therapist indicated that her Rehab Manager, and LPN1 said [Resident #30] was clear (not having symptoms of nausea/vomiting). On 3/6/23 at 11:38 a.m., a surveyor observed the Rehab Manager in room [ROOM NUMBER], she was walking around the bedside of Resident #4, picking up items next to the bed, counting repetitions for Resident #4 while the resident was lifting and lowering a physical therapy long stick (piece of exercise equipment). The Rehab Manager did not have a gown, or gloves on. In an interview with a surveyor, the Rehab Manager indicated she was not aware that [Resident #4] was on contact precautions, and that [Resident #4] complains of nausea all the time. In an interview with a surveyor, at this time, the Rehab Manager indicated she was unaware that [Resident #4] had vomiting and diarrhea today. On 3/6/23 at 1:37 p.m., in an interview with a surveyor regarding gastrointestinal symptoms, LPN2 stated, it started with [Resident #29] on the 27th (2/27/23), and next day [Resident #28] was vomiting, now we've got several people with diarrhea and vomiting. On 3/6/23 at 2:23 p.m., in an interview with a surveyor, LPN2 indicated, the facility started contact precautions this morning, but had no gowns. When asked by a surveyor how staff know what type of precautions, LPN2 stated, As soon as cards (precaution signs that get posted on or near a resident room that describes what type of transmission based precautions to use when entering a room) get up here. Waiting for maintenance, the cards are in a different building The LPN2 also indicated the gowns are kept in a different building (therefore precaution indication cards and gowns were not available for staff) and she was waiting for maintenance to bring them to B2 Unit. On 3/6/23 at 1:57 p.m., in an interview with a surveyor, CNA2 was asked how she knows what type of precautions and personal protective equipment (PPE) she must wear when entering a resident room, she stated, usually, a sign and a cart outside the door. When report exchange. I know there are a lot of people sick right now, cautious, no signs up. Just make sure we wash hands before entering and leaving rooms. Some residents are having loose stool. Always glove. Not told to wear a gown. This surveyor asked if any residents are on contact precautions right now, and CNA2 stated, No. On 3/6/23 at 2:11 p.m., in an interview with a surveyor, CNA-M1 stated she was not wearing gloves when she was holding a basin that [Resident #35] was vomiting into on 3/6/23 at 11:03 a.m. CNA-M1 also stated that she cleaned up the vomit and floor area with the purple top disinfectant wipes (Super Sani-Cloth Germicidal disposable wipes (cleanser was not an EPA approved for norovirus disinfection)). She stated, Usually, housekeeping will clean it thoroughly, but I couldn't find anybody. CNA-M1 didn't disinfect the floor with an EPA approved disinfectant On 3/6/23 at 2:14 p.m., in an interview with a surveyor, LPN1 stated, regarding how to disinfect an area that a resident vomited, he said, have housekeeping come in and clean it up with chlorine concentration. I suppose we should be using gowns, but I haven't seen any up here. On 3/6/23 at 2:26 p.m., in an interview with a surveyor, CNA2 stated, no one is on precautions, and that usually, all the precaution stuff is hanging on the doors, or the nurse tells us. There is definitely something going on, residents are vomiting and pooping. [Resident #39] has very loose stool, and the facility is aware of [Resident #4]. I mentioned to LPN1 about the loose stool. On 3/6/23 at 2:29 p.m., in an interview with a surveyor, the Rehab Manager indicated that she wiped down an exercise device that [Resident #4] was using earlier with a purple top wipe (Super Sani-Cloth Germicidal disposable wipe(cleanser was not an EPA approved for norovirus disinfection)) before she left the B2 unit Resident #4 was having gastrointestinal symptoms. The Rehab Manager didn't disinfect the exercise device with an EPA approved disinfectant. On 3/6/23 at 2:35 p.m., a surveyor observed no signage on B2 unit to indicate that there is gastrointestinal illness on the unit or any directions for a visitor to the unit. During a medical record review, Resident #41's clinical note, dated 2/26/23 at 4:06 a.m. indicated, resident was vomiting during the prior shift. On 3/8/23 at 8:37 a.m., during observation of B2 unit, surveyor observed CNA-M2 don additional PPE (gown/gloves) then grab a medicine cup and a cloth wrist blood pressure (BP) cuff and enter room [ROOM NUMBER] (Resident #30), which was posted as contact precautions for GI symptoms. CNA-M2 applied the BP cuff to the resident's wrist, obtained the reading then removed the cuff and placed it in her scrub pocket, then administered the medications to the resident. Upon leaving the room, the CNA-M2 doffed the PPE and washed her hands. The surveyor requested the BP reading, the CNA-M2 removed the contaminated BP cuff from her scrub pocket. At this time, the surveyor confirmed the BP cuff was not cleaned after coming in contact with a resident who was on contact precautions prior to being placed in the CNA-M2 pocket. During a medical record review, Resident #29's clinical note, dated 2/27/23 at 11:40 a.m. indicated, has vomited several times this morning, can't hold down fluids . one diarrhea episode this morning. During a medical record review, Resident 28's clinical note, dated 2/28/23 9:19 a.m. indicated, Resident reportedly vomited several times early this morning. No diarrhea. During a medical record review, Resident #32's clinical note, dated 2/28/23 at 2:36 p.m. indicated, admits to mild nausea, no vomiting or diarrhea, on 3/1/23 at 8:47 a.m. indicated, several bouts of diarrhea during the night .Had another large diarrhea this morning. On 3/1/23 at 12:40 p.m. indicated, had large diarrhea stool in bed. During a medical record review, Resident #13's clinical note , dated 3/4/23 at 9:15 a.m. indicated, doesn't feel good because he/she has been having diarrhea. During a medical record review, Resident #27's clinical note, dated 3/4/23 at 5:47 p.m. indicated, acute episode of nausea with vomiting, diarrhea, on 3/6/23 at 4:57 a.m. late entry, had multiple episodes of vomiting and diarrhea during the NOC (night) shift., on 3/5/23 at 2:30 p.m. indicated, had another diarrhea stool, no further vomiting. During a medical record review, Resident #26's clinical note, dated 3/1/23 10:12 a.m. indicated, provider visit, type of visit: N/V (nausea/vomiting) occasionally last 5-7 days, on 3/5/23 at 9:06 a.m. indicated, feels nauseated, just vomited yellow bile in his/her waste basket. States that he/she feels awful. During a medical record review, Resident #35's clinical note, dated 3/6/23 at 4:54 a.m. indicated, Resident has been experiencing nausea and vomiting. During a medical record review, Resident #4's clinical note, dated 3/6/23 at 1:18 a.m. indicated, Resident had x-large loose BM. Currently complaining of nausea. A review of North Country Associates Infection Control Management of Norovirus Outbreak Policy, developed: April 2007, and revised on 9/18 indicated, Noroviruses are a group of viruses that cause gastroenteritis in people infected with the virus. Symptoms of gastroenteritis include nausea, vomiting, abdominal cramping, and diarrhea. The primary mode of transmission is via poor hand washing and/or unsanitary conditions. Any surface, device, or material (e.g., commodes, bathing tubs, electronic rectal thermometers, and portable phones) that becomes contaminated with feces may serve as a reservoir for the Norovirus. Notify Maine CDC (Centers for Disease Control) to report outbreak of Norovirus like illness, follow Maine CDC recommendations, Notify resident's physician and family of Norovirus like illness. Prevention: Immediately implement Contact Precautions for residents with symptoms consistent with Norovirus. Do not wait for culture results. Re-educate staff on Standard and Contact Precautions. Thoroughly clean and disinfect contaminated surfaces immediately after an episode of illness by using an EPA registered disinfectant effective against Norovirus. Can norovirus infections be prevented? Yes .thoroughly clean and disinfect contaminated surfaces immediately after an episode of illness by using a bleach-based household cleaner. Based on the above information, IJ was called on 3/6/23 at 3:19 p.m. for the facility's failure to provide adequate infection prevention measures to mitigate the spread of infection in a timely manner. The facility's failure to provide these services constituted an immediate jeopardy situation. Please see F-0000 Initial comments related to the IJ removal plan. On 3/9/23 at 1:12 p.m., during an interview with the Administrator, he stated the facility does not have a Legionella or other opportunistic waterborne pathogen management and prevention program in place. 33639