Every finding on record at St Joseph Skilled Nursing and Rehabilitation

Based on interviews and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment, and to help prevent the development and transmission of communicable diseases and infections as evidenced by: 1) failure to effectively decontaminate the environment of residents on contact isolation with confirmed or suspected C. Difficile infection and 2) failure to properly identify possible communicable diseases or infections before they spread. This deficient practice had the potential to affect 85 residents in the facility. Findings:1. On 12/09/2025 at 9:24 a.m., S9Housekeeper reported one product was used in contact isolation rooms with confirmed or suspected C. Difficile infection and the product had to sit for 2-3 minutes on surfaces.On 12/09/2025 at 9:37 a.m., S10Housekeeper reported there were two products used in contact isolation rooms with confirmed or suspected C. Difficile infection and the product had to sit for 2-3 minutes.On 12/09/2025 at 10:34 a.m., S2DON reported that S8Housekeeping Supervisor was responsible for ensuring contact isolation rooms with confirmed or suspected C. Difficile were terminally cleaned and nursing staff were responsible for direct patient care equipment. S2DON reported it was unknown if the product used on direct patient care equipment was effective against C. Difficile. On 12/09/2025 at 11:55 a.m., S8Housekeeping Supervisor reported there were two products available to use for all isolation rooms. S8Housekeeping Supervisor reported one of the products had a 3-5 minute kill time and the alternative product had a 10 minute kill time. On 12/09/2025 at 12:28 p.m., S11LPN reported direct patient care equipment used on residents in contact isolation rooms with confirmed or suspected C. Difficile infection was treated with one product. S11LPN reported this product had a contact time of 2 minutes. Review of product labels revealed no documentation the products were effective against C. Difficile. On 12/10/2025 at 12:17 p.m., S1Administrator confirmed the products reported in use by facility staff were not effective against C. Difficile infection.2. Review of the facility's August 2025 Infection Surveillance Report revealed the report should have identified infections into nine categories: gastrointestinal, genital, MDRO, neurologic, other, parasitic, respiratory, skin and soft tissue, and urinary tract/kidney. Further review revealed one resident in the genital category and the other residents in the category of other. Further review revealed the signs and symptoms portion was left blank on numerous entries. Review of the medical record for Resident #106 revealed physician documentation of confirmed C.Difficile infection on 08/08/2025. On 12/09/2025 at 10:34 a.m., S2DON reported the facility did not have a documented infection surveillance plan. On 12/11/2025 at 8:40 a.m., S1Administrator confirmed the infection surveillance data available did not demonstrate that infection surveillance was performed effectively in the facility.On 12/11/2025 at 9:00 a.m., S3RN was unable to produce documentation to demonstrate that infection surveillance was performed effectively in the facility.

Based on interview and record review, the facility failed to implement policies and procedures for COVID-19 immunizations for 5 (#8, #20, #32, #92, & #106) of 5 residents reviewed for immunizations. The facility failed to ensure the residents' medical records included documentation that indicated the residents or resident representatives received education regarding the benefits and potential side effects of COVID-19 immunization. This deficient practice had the potential to affect 85 residents residing in facility. Findings:Review of the facility's Coronavirus-COVID-19 Protocols policy dated September 2024 revealed, in part:13) All facilities must educate residents and staff on the COVID-19 vaccine (including additional doses/boosters) and offer to help get them vaccinated.Review of the medical records for Resident #8, Resident #20, Resident #32, Resident #92 and Resident #106 revealed there was no documented evidence of education regarding the benefits and potential side effects related to the COVID-19 vaccine. On 12/10/2025 at 4:00 p.m., S4RN confirmed there was no documented evidence of education regarding the benefits and potential side effects related to the COVID-19 vaccine.

Based on observations, interviews, and record reviews, the facility failed to assess residents for self-administration of medications for 2 (#46 & #109) of 2 sampled residents observed for medications available at the bedside. Findings:Facility's Self-Administration Medications policy dated 06/14/2006 revealed, in part. Policy: A Patient may self-administer medications if the Patient is determined safe for the Patient and other Patients of the Facility by the Facility's Interdisciplinary Team. Procedure: An Assessment for Self-Administration of Medications) See [NAME] Form CFS 1-14HH) must be completed on each Patient requesting to self-administer medications and quarterly thereafter. An Assessment for Self-Administration of Medications is kept with the Patient's medical record under the Assessments tab. Resident #46 Record review revealed Resident #46 was admitted to the facility 11/10/2023 with diagnoses that included polyosteoarthritis, unspecified; morbid (severe) obesity due to excess calories; diabetes mellitus due to underlying condition with unspecified complications; chronic obstructive pulmonary disease, unspecified; and functional quadriplegia. Review of annual Minimal Data Set (MDS) assessment dated [DATE] revealed Resident #46 had a Brief Interview for Mental Status (BIMS) score of 15 indicating that Resident #46 was cognitively intact. On 12/08/2025 at 10:06 a.m., 12/09/2025 at 8:35 a.m. and 12/09/2025 at 12:45 p.m., observations revealed a Ventolin inhaler at the Resident's bedside. On 12/08/2025 at 8:35 a.m., an interview with Resident #46 revealed she self-administered the Ventolin inhaler. On 12/09/2025 at 12:45 a.m., an interview with Resident #46 revealed staff replaces her inhaler when she runs out. On 12/09/2025 a record review revealed an order for Proventil HFA inhalation aerosol solution 108 (90 Base) mcg/act (albuterol sulfate) 2 puffs inhale orally every 6 hours as needed for SOB. Further record review revealed no facility assessment for Resident #46 to self-administer medications. On 12/09/2025 at 1:00 p.m., an observation with S2Director of Nursing (DON) confirmed Resident #46 had a Ventolin inhaler at bedside and was self-administering the inhaler without a facility assessment for the self-administering of medications. Resident #109 Review of Resident #109's diagnoses revealed in part aggressive periodontitis, anemia, type 2 diabetes, with diabetic chronic kidney disease, need for assistance for personal care, and hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominate side. Review of Resident #109's admission MDS dated [DATE] revealed a BIMS score of 11, which indicated Resident #109 had moderate cognitive impairment. Review of Resident #109's record revealed no documented evidence Resident #109 had been assessed to be appropriate to self- administer medications. Observation on 12/08/2025 at 8:45 a.m. revealed Resident #109 lying in bed, while alone in her room with Chlorohexidine Gluconate oral rinse on her bedside table. The prescription label indicated the oral rinse had been prescribed for her. During an interview on 12/08/2025 at 8:45 a.m., Resident #109 stated she did use the mouthwash by herself. During an interview on 12/08/2025 at 8:49 a.m., S5LPN confirmed Resident #109 should not have the oral rinse in her room on the bedside table. During an interview on 12/10/2025 at 11:28 a.m., S2DON confirmed Resident #109 had not been assessed to self- administer medication and should not have the Chlorohexidine Gluconate oral rinse at bedside.

Based on record review and interview, the facility failed to ensure the SNF ABN Form, CMS-10055 was provided to the resident and/or the resident's responsible party prior to the discontinuation of Medicare Part A services for 2 (#116, #117) of 3 residents reviewed for Beneficiary Notification who required the notification.Findings: Resident #116Record review revealed Resident #116's Medicare Part A skilled services episode start date was 06/24/2025. The last covered day of Part A services was 07/21/2025. The facility initiated the discharge from Medicare Part A services with benefit days remaining. Resident #116 was discharged home. Further review revealed no documented evidence Resident #116 was provided the SNF ABN, Form CMS-10055 prior to being discharged from Medicare Part A Services. On 12/11/2025 at 8:45 a.m. an interview with S6SW and S7Business Office Manager, confirmed a SNF ABN, Form CMS-10055 was not provided to the resident or their responsible party as required prior to the resident's discharge from Medicare Part A Services. Resident #117Record review revealed Resident #117's Medicare Part A skilled services episode start date was 06/17/2025. The last covered day of Part A services was 08/01/2025. The facility initiated the discharge from Medicare Part A services with benefit days remaining. Resident #117 was discharged home. Further review revealed no documented evidence Resident #117 was provided the SNF ABN, Form CMS-10055 prior to the resident's discharge from Medicare Part A Services. On 12/11/2025 at 11:02 a.m. an interview with S6SW and S7Business Office Manager confirmed a SNF ABN, Form CMS-10055 was not provided to the resident or their responsible party prior to the resident's discharge from Medicare Part A Services.

Based on record reviews and interviews, the facility failed to ensure residents were free of chemical restraints for 1 (#38) of 5 residents reviewed for unnecessary medications.Findings: Review of Resident #38's record revealed an admission date of 07/18/2025 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, cerebral infarction due to embolism of right middle cerebral artery, bipolar disorder current episode depressed mild or moderate severity unspecified, generalized anxiety disorder, and depression. Review of Resident #38's current physician's orders revealed the following orders, in part: 11/12/2025- Aripiprazole (AP) oral tablet 10 mg give 10 mg po 1 time a day r/t bipolar disorder;11/12/2025- Fluoxetine Hydrochloride (AD) capsule 20 mg give 1 capsule po 1 time a day for depression; and 11/17/2025- monitor for behaviors q shift, antidepressant side effect monitoring, antipsychotic side effect monitoring every shift Review of Resident #38's End of Part A stay MDS assessment dated [DATE] revealed a BIMS score of 13 indicating no cognitive impairment. Further review of the MDS revealed resident received the following high risk drug class medications- antipsychotic and antidepressant.Review of Resident #38's current care plan revealed the resident had a behavior problem related to bipolar disorder, current episode depressed, mild or moderate severity unspecified. Interventions included to administer medications as ordered, monitor and document for side effects and effectiveness, monitor for the following behaviors: itching, picking at skin, restlessness, agitation, hitting, increase in complaints, biting, kicking, spitting, foul language, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusal of care, and to observe and report behavior episodes and attempt to determine underlying cause. Further review of the care plan revealed the resident used antidepressant medication related to depression. Interventions included to administer antidepressant medications as ordered by the physician, monitor/document side effects and effectiveness every shift, and observe/document/report as needed adverse reactions to antidepressant therapy.Review of Resident #38's November 2025 TAR revealed the facility failed to document antidepressant side effect monitoring and antipsychotic side effect monitoring 11 times, and behavior monitoring 10 times.Review of the November 2025 MAR revealed Resident #38 was administered Aripiprazole (AP) and Fluoxetine (AD) daily beginning on 11/12/2025. Review of the December 2025 TAR revealed the facility failed to document antidepressant side effect monitoring, antipsychotic side effect monitoring, and behavior monitoring for Resident #38 for 5 times during December 2025.Review of December 2025 MAR revealed resident #38 was administered Fluoxetine (AD), Aripiprazole (AP) daily from 12/01/2025 through 12/09/2025.An interview on 12/10/2025 at 2:50 p.m. with S3RN confirmed multiple omissions on Resident #38's November and December 2025 TAR for AD side effect monitoring, AP side effect monitoring, and behaviors monitoring every shift. An interview on 12/10/2025 at 4:15 p.m. with S4RN confirmed the facility failed to document as ordered the monitoring of antidepressant side effects, antipsychotic side effects, and behavior during November 2025 and December 2025. S4RN confirmed the facility failed to document the monitoring as ordered while Resident #38 was receiving Aripiprazole (AP) and Fluoxetine (AD).An interview on 12/11/2025 at 9:45 a.m. with S3RN confirmed that Resident #38 failed to have documented evidence of monitoring as ordered for antidepressant side effects, antipsychotic side effects, and behaviors every shift. S3RN confirmed Resident #38 should be monitored for AD side effects, AP side effects, and behaviors q shift while resident was taking Aripiprazole (AP) and Fluoxetine (AD).

Based on interview and record review, the facility failed to ensure a copy of the discharge notices were sent to the Office of the State Long-Term Care Ombudsman for 2 (#107, #108) of 2 residents sampled for discharges. Findings:Resident #108 Review of the MDS assessments revealed Resident #108 was admitted on [DATE] and the resident left the facility Against Medical Advice which was a voluntary discharge on [DATE]. Review of the monthly emergency transfer log revealed it only included notifications for the month of December 2025. On 12/20/2025 at 2:40 p.m., interview with S3RN revealed the facility did not have access to the monthly emergency transfer logs prior to December 2025. Resident #107 Review of the MDS assessments revealed Resident #107 was admitted on [DATE] and was discharged to the hospital on [DATE]. The MDS assessments also revealed resident #107 was readmitted to the nursing facility on 10/14/2025 and discharged home on [DATE]. Review of the monthly emergency transfer log revealed it only included the month of December 2025. On 12/20/2025 at 2:40 p.m., interview with S3RN revealed the facility did not have access to the monthly emergency transfer logs prior to December 2025.

Based on observation, interview and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice by failing to clean and store piston syringes in accordance with facility policy for 1 (# 74) of 1 residents reviewed for enteral feedings.Findings:Review of the medical record revealed resident #74 had an admission date of 10/22/2025 with diagnoses which included diabetes, encephalopathy, muscle weakness and communication deficits. Review of the December 2025 physician orders revealed the resident received medications and nutritional support by way of a PEG tube.On 12/08/2025 at 1:34 p.m., observation of Resident #74's syringe at the bedside revealed the tip was filled with a yellowish fluid. The syringe was capped and the plunger was in the syringe.Review of the facility policy on piston syringe use dated May 2012 read in part.syringes used for liquids other than clear water must be rinsed appropriately, dried, and replaced in a proper storage bag or other approved container. Store syringe and plunger separately in the bag.On 12/10/25 at 3:40 p.m., interview with S2DON confirmed staff should have cleaned and stored the syringe properly after use for Resident #74.

Based on observation, interviews, and record reviews, the facility failed to ensure residents were assessed for the risk of entrapment from bedrails prior to installation for 2 (#53 and #77) of 3 residents identified for having side rails in use.Findings:Review of the facility's Proper Use of Side Rails Policy and Procedure, revised December 2016, revealed the following, in part:General Guidelines3. An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's:c. Risk of entrapment from the use of side rails.Resident #77Review of Resident #77's record revealed an admission date of 09/11/2025 with diagnoses including acute and chronic respiratory failure with hypoxia, hypertension, heart failure, paroxysmal atrial fibrillation, chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypercapnia, depression, unspecified dementia, and metabolic encephalopathy. Review of Resident #77's current physician's orders revealed an order dated 10/07/2025 for quarter assist rails in place as an enabler as desired or needed, alert physician of any noted complications or quarter assist rail use, responsible party aware and in agreement of use.Observations on 12/08/2025 at 8:48 a.m. and 12/09/2025 at 9:45 a.m. revealed Resident #77 was lying in bed with bilateral quarter rails in the up position. Review of Resident #77's Medicare 5 day MDS assessment dated [DATE] revealed a BIMS score of 9 indicating moderate cognitive impairment. Further review of the MDS revealed bed rail marked as not used. Review of Resident #77's current care plan revealed use of assist rails-quarter rails required as an enabler in order to promote as much independence as possible. Further review revealed the interventions included the resident uses bilateral quarter assist rails(s) as enabler to assist with bed mobility and transfer.Review of Resident #77's record revealed no documented evidence of an assessment for the risk of entrapment prior to the installation of bed rails/side rails.An interview on 12/10/2025 at 3:35 p.m. with S1Administrator confirmed the facility was unable to provide documented evidence of an assessment for the risk of entrapment for Resident #77 prior to the installation of bed rails/side rails. Resident #53Review of Resident #53's record revealed an admission date of 08/20/2025 with diagnoses including in part, unspecified atrial fibrillation, muscle weakness (generalize), unsteadiness on feet, need for assistance with personal care, cognitive communication deficit, myocardial infarction, dementia and major depressive disorder. Review of Resident #53's current physician's orders revealed an order dated 08/20/2025 for quarter assist rails in place as an enabler as desired or needed. Alert physician of any noted complications of quarter assist rail use. RP aware of and in agreement with use. Observation on 12/09/2025 at 4:56 p.m. revealed Resident #53 was in her room lying in bed with quarter bed rails in an up position. Review of Resident #53's most recent quarterly MDS assessment dated [DATE] revealed a BIMS score of 12, indicating moderate cognitive impairment with daily decision-making skills. Further review of the MDS revealed bed rail marked as not used. Review of Resident #53's current care plan revealed use of assist rails-quarter rails required as an enabler in order to promote as much independence as possible. Review of Resident #53's record revealed no documented evidence of an assessment for the risk of entrapment prior to the installation of bed rails/side rails.An interview on 12/10/2025 at 3:35 p.m. with S1Administrator confirmed the facility was unable to provide documented evidence of an assessment for the risk of entrapment for Resident #53 prior to the installation of bed rails/side rails.

Based on record reviews and interviews, the facility failed to ensure residents were free from unnecessary medications for 1 (#38) of 5 residents sampled for medication review. Findings:Review of Resident #38's record revealed an admission date of 07/18/2025 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, cerebral infarction due to embolism of right middle cerebral artery, atrial fibrillation, atherosclerotic heart disease of native coronary artery without angina pectoris, hypertensive heart disease with heart failure, other seizures, and diabetes mellitus. Review of Resident #38's current physician's orders revealed the following orders, in part: 11/11/2025- Eliquis (anticoagulant) oral tablet 5 mg give 5 mg po 2 times a day;11/11/2025- Levetiracetam (anticonvulsant) oral tablet 500 mg give 500 mg po 2 times day; and 11/13/2025- anticoagulant side effect monitoring and anticonvulsant side effect monitoring every shift.Review of Resident #38's End of Part A stay MDS assessment dated [DATE] revealed a BIMS score of 13 indicating no cognitive impairment. Further review of the MDS revealed resident received the following high risk drug class medications- anticoagulant and anticonvulsant.Review of Resident #38's current care plan revealed the resident was on anticonvulsant therapy related to hemiparesis following cerebral infarction affecting left non-dominant side, bipolar disorder, other seizures, and seizure disorder. Interventions included to give medication as ordered, monitor for any adverse consequences, specifically increased confusion or over-sedation, observe and report any seizure activity, and monitor/document side effects and effectiveness. Review of the November 2025 TAR revealed the facility failed to have documented evidence of monitoring for anticonvulsant side effects and anticoagulation side effects 13 times beginning 11/12/2025 through 11/30/2025.Review of the November 2025 MAR revealed Resident #38 received Eliquis (anticoagulant) and Levetiracetam (anticonvulsant) beginning 11/11/2025.Review of the December 2025 TAR revealed the facility failed to document monitoring anticoagulant and anticonvulsant side effect monitoring 5 times during December 2025.Review of December 2025 MAR revealed resident #38 received Eliquis and Levetiracetam from 12/01/2025 through 12/09/2025. An interview on 12/10/2025 at 4:15 p.m. with S4RN confirmed the facility failed to document as ordered the monitoring of anticoagulant side effects and anticonvulsant side effects every shift. An interview on 12/11/2025 at 9:45 a.m. with S3RN confirmed the facility failed to document as ordered the monitoring of anticoagulant side effects and anticonvulsant side effects every shift for Resident #38 while he received Eliquis and Levetiracetam.

Based on record review and interview the facility failed to ensure grievances were investigated for 1 (#1) of 3 (#1, #2, #3) sampled residents. The facility failed to investigate a grievance by Resident #1's RP (responsible party) promptly.Findings:Review of the facility's grievance policy dated November 2017 revealed in part:The patient or patient representative has a right to voice grievances to the facility or other entity that hears grievances without fear of discrimination or reprisal. Grievances include those with respect to care and treatment, the behavior of staff and other concerns.Guidelines:3. When the facility is made aware of a problem or concern voiced by a Patient or on behalf of the Patient, the facility must make every effort for prompt resolution of all grievances regarding the residents' rights.4. The following steps should be taken for concern resolution:a. Attempt to solve the problem yourself and check back with the Patient to see if they are satisfied with the outcome.b. Involve your Executive Director or Director of Nursing Services.5. A grievance form must be completed and turned in to the department head supervisor.Review of Resident #1's medical record revealed an initial admit date of 06/17/2021 and a readmission date of 06/20/2024 with a diagnosis of but not limited to, schizophrenia, chronic kidney disease, depression, anxiety, dysphagia and schizoaffective disorder.Review of Resident #1's most recent quarterly MDS (Minimum Data Set) dated 07/05/2025 revealed Resident #1 had a BIMS (Brief Interview Mental Status) of 7 indicating severely impaired cognition. During a phone interview on 07/30/2025 at 10:00 a.m. Resident #1's responsible party stated he reported the theft of Resident #1's phone charger to S2 ADON (assistant director of nurses) when visiting about two weeks ago. Resident #1's RP further reported no one at the facility had followed-up with him about this theft. Review of the facility grievance and complaint logs failed to reveal an entry related to Resident #1.During an interview on 07/30/2025 at 10:30 a.m. S2 ADON confirmed Resident #1's RP had reported the theft of Resident #1's phone charger to her about a week ago S2 ADON also confirmed a grievance investigation was not done. S2 ADON stated, I did not follow up with Resident #1's RP and should have.

Based on observations, interview and record review the facility failed to use infection control standards of practice for 1(#2) of 3 (#1, #2 and #3) sampled residents by not properly storing a resident's Foley catheter bag preventing an increased risk of contamination and infection. Resident #2's Foley catheter bag was improperly stored on the floor. Findings:Review of the facility's Catheter Care, Urinary policy (revised September 2014) presented by S1 DON (Director of Nursing) revealed in part:Purpose: The purpose of this procedure is to prevent catheter-associated UTI (urinary tract infections).Infection Control: Be sure the catheter tubing and drainage bag is kept off the floorObservation on 7/29/2025 at 11:25 a.m. with S2 ADON (Assistant Director of Nursing) revealed resident #2's Foley catheter noted to be lying on the floor. Resident #2 noted to be on enhanced barrier precautions according to the sign on her door.Observation on 07/30/2025 at 10:30 a.m. revealed resident #2's Foley catheter bag positioned on the floor at the side of the bed. Review of resident #2's medical record revealed diagnoses including but not limited to unstable dementia, severe, with psychotic disturbance, posterior reversible encephalopathy, gastrostomy status, folate deficiency anemia, essential hypertension, cognitive communication deficit, and urinary tract infection.Review of resident #2's most recent Quarterly MDS (minimum data set) dated 06/11/2025 section H bladder and bowel, revealed the use of an indwelling catheter.Review of resident #2's Comprehensive Plan of Care revealed resident #2 had a Foley catheter. Some of the interventions was to position the Foley catheter bag and tubing below the level of the bladder and away from entrance room door. Check tubing for kinks each shift.Review of resident #2's Physician Progress notes dated 07/02/2025 revealed in part.Reason for visit:Follow up visit. Nursing request, familyAssessment and Plan: Urinary tract infection, site unspecified with E. coli. Augment 875/125 mg (milligram) BID (twice a day) times 10 days. Seen 06/13/2025 and evaluated. Nurse had reported some increased agitation, and a urinalysis obtained. Has urinary tract infection with E. coli and plan to start on Augmentin 875/125 mg BID times 10 days. Neuromuscular dysfunction of bladder, unspecified. Foley.During an interview on 7/29/2025 at 112:25 a.m. S2 ADON confirmed resident #2's Foley catheter bag was on the floor and should not have been. Reported residents' bed was in the lowest position and confirmed the catheter should not be on the floor. Further review of resident #2's records revealed she had received treatment for a urinary tract infection on 04/18/2025 and 07/15/2025.

Based on record reviews and interview the facility failed to ensure nurses started a medication that had been ordered by the physician for 1(#2) of 3 (#1, #2 and #3) sampled residents. The facility failed to start the medication Naltrexone for resident #2. Findings: Review of resident #2's record revealed in part, a Psych Evaluation, date of service July 3, 2025. Chief complaint and history of present illness, history of dementia and insomnia.Case Conceptualization: Speech unintelligible. Information obtained from staff. They describe resident #2 as being 'hypersexual' and gave examples on behavior. Resident #2 is not aggressive. Resident #2 has a PEG (percutaneous endoscopic gastrostomy) tube for nutrition. Resident #2 does sleep well. Will make recommendations below and will re-assess in 1 month, sooner if needed. -Recommendations: Start trial of Naltrexone 25 mg (milligram) daily. Rationale: Naltrexone shown to reduce inappropriate behavior.Review of resident #2's July 2025 MAR (medication administration record) failed to reveal the medication Naltrexone had been started as ordered.Review of resident #2's records revealed diagnoses that included but not limited to unstable dementia, severe, with psychotic disturbance, posterior reversible encephalopathy, acute neurologic view, gastrostomy status, essential hypertension, and cognitive communication deficit. During an interview on 07/30/2025 at 12:40 p.m. with S1 DON (Director of Nursing) reported the medication Naltrexone was never started and it should have been.

Based on record reviews and interviews, the facility failed to: 1) ensure a resident was permitted return to the facility after hospitalization for 3 (#1, #2, #3) of 3 (#1, #2, #3) residents reviewed for transfer and discharge and; 2) have documentation a resident or resident's responsible party and the Ombudsman being notified in writing of the transfer/discharge and appeals right for 3 (#1, #2, #3) of 3 (#1, #2, #3) residents reviewed for transfer and discharge. Review of the facility's Transfer or Discharge, Facility-Initiated policy dated 2022 revealed the following in-part: Transfer and discharge includes movement of a resident from a certified bed in the facility to a non-certified bed in another part of the facility, or to a non-certified bed outside the facility. Transfer and discharge does not refer to movement of a resident to a bed within the same certified facility. Specifically: a. transfer refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility when the resident expects to return to the original facility; and b. discharge refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility or other location in the community, when return to the original facility is not expected. Facility-Initiated Transfer or Discharge 1. Facility-initiated transfer or discharge means a transfer or discharge which the resident objects to, or did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences. Notice of Transfer or Discharge (Emergent or Therapeutic Leave) 1. When residents who are sent emergently to an acute care setting, these scenarios are considered facility-initiated transfers, NOT discharges, because the resident's return is generally expected. 2. Residents who are sent emergently to an acute care setting, such as a hospital, are permitted to return to the facility. Residents who are sent to the acute care setting for routine treatment/planned procedures are also allowed to return to the facility. 3. Under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge: a. The health and/or safety of individuals in the facility would be endangered due to the clinical or behavioral status of the resident; b. The resident's health improves sufficiently to allow a more immediate transfer or discharge; c. An immediate transfer or discharge is required by the resident's urgent medical needs; or d. A resident has not resided in the facility for 30 days. 4. Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable (e.g., in a monthly list of residents that includes all notice content requirements). 5. Notice of Facility Bed-Hold and Return policies are provided to the resident and representative within 24 hours of emergency transfer. Notice of Discharge after Transfer 1. If discharge is initiated by the facility after an emergency transfer to the hospital, the reason for discharge is based on the resident's status at the time the resident seeks return to the facility (not at the time the resident was transferred to acute care). 2. If the facility does not permit a resident's return to the facility (i.e., initiates a discharge) based on inability to meet the resident's needs, the facility will notify the resident, and/or his or her representative in writing of the discharge, including notification of appeal rights. 3. The facility will send a copy of the discharge notice to a representative of the Office of the State LTC Ombudsman. 4. Notice to the Office of the State LTC Ombudsman will occur at the same time the notice of discharge is provided to the resident and resident representative. Findings: Resident 1 Record review revealed resident #1 was admitted to the facility 02/04/2025 and was to receive skilled services. Resident #1 had diagnoses including acute kidney failure, altered mental status, essential hypertension, hypothyroidism, acute cystitis with hematuria, retention of urine, constipation, unspecified dementia severe with psychotic disturbance, insomnia, and diabetes mellitus. Further record review revealed resident #1 was transferred to an acute care hospital to receive a psychiatric evaluation on 03/13/2025 related to resident #1's behavior (refusing care, pulling out Foley catheter, crying, yelling and making suicidal threats. Resident #1 was discharged from the nursing facility on 03/13/2025. On 04/29/2025 at 10:45 a.m. an interview with the social worker at the local behavioral health inpatient facility revealed the facility would not accept resident #1 back after the doctor had deemed the resident was stable to be discharged and return to the facility. The social worker reported resident #1 was still admitted at the behavioral health facility because she had not been able to find an accepting long term care facility. 04/29/2025 at 1:25 p.m. an interview with S3Communications Relations Coordinator revealed she was responsible for resident admissions to the facility. S3Communications Relations Coordinator reported on 03/13/2025 resident #1 was sent out to the hospital was admitted to the behavioral health unit. S3Communications Relations Coordinator revealed resident #1 was discharged from nursing facility skilled services on 03/13/2025. Further interview with S3Communications Relations Coordinator revealed she received a call on 04/01/2025 from the social worker (from the local behavioral unit) informing that resident #1 was going to be discharged back to the facility on [DATE]. S3Communications Relations Coordinator reported she informed the social worker she needed progress notes, nurse's notes, occupational therapy evaluation, physical therapy evaluation and a physician's order for skilled services for resident #1 in order for insurance to authorize resident #1 to be re-admitted to skilled services. S3Communications Relations Coordinator revealed she received the progress notes and nurse's notes, but never received the occupational therapy evaluation, physical therapy evaluations, or the physician's order for skilled services. S3Communications Relations Coordinator revealed she had notified S1Administrator they were still waiting on an authorization for resident #1 for skilled services before she could be re-admitted the resident to the facility. Resident 2 Record review revealed resident #2 was admitted to the facility on [DATE] with diagnoses that included essential hypertension, unspecified convulsions, thyrotoxicosis without thyroid storm, depression, and schizophrenia. Further record review revealed resident #2 was transferred to an acute care hospital to receive a psychiatric evaluation on 01/23/2025 related to behaviors (refusing medications, hallucinating ,and post-traumatic stress disorder symptoms). Resident #2 was discharged from the nursing facility on 01/30/2025. On 04/29/2025 at 10:45 a.m. an interview with the social worker at the local behavioral health inpatient facility revealed the facility would not accept resident #2 back after the doctor had deemed the resident was stable to be discharged and return to the facility. The social worker reported resident #2 was finally transferred to another long term facility on 03/20/2025 because the facility would not take him back. Resident 3 Record review revealed resident #3 was admitted to the facility on [DATE] and was to receive skilled services. Resident #3's diagnoses included metabolic encephalopathy, essential hypertension, urinary tract infection, stage 2 sacral pressure ulcer, hypothyroidism, muscle weakness, difficulty in walking, need assistance with personal care, and cognitive communication deficit. Further record review revealed resident #3 was transferred to local acute care hospital for psychiatric evaluation on 02/07/2025 related to her behaviors (anxious, wandering, and confusion). Resident #3 was discharged from the nursing facility skilled services on 02/07/2025. On 04/29/2025 at 10:45 a.m. an interview with the social worker at the local behavioral health inpatient facility revealed the provider would not accept resident #3 back after the doctor had deemed the resident was stable to be discharged and return to the facility. The social worker reported resident #3 was finally transferred to another facility on 02/25/2025 because the facility would not take her back. On 04/30/2025 at 11:10 a.m. an interview with S2Director of Nursing (DON) with S1Administrator present. S2DON confirmed there was no documentation in resident #1, resident #2, and resident #3's medical records that the facility was not able to meet their needs. S2DON further revealed there was no documentation resident #1, resident #2, resident #3 or their responsible party, and the Ombudsman being notified in writing of their transfer/discharge including notification of the appeals rights. On 04/30/2025 at 11:18 a.m. an interview with S1Administrator revealed he was instructed by S4Vice President of Operations that they were not to re-admit skilled residents who were sent out to the hospital or behavioral health until they had an authorization from the insurance company.

Based on record review and interview, the facility failed to have documentation a resident received information on resident rights and the temporary leave-bed hold policy for 1 (#2) of 3 (#1, #2, #3) residents reviewed for resident rights. Findings: Record review revealed resident #2 was admitted to the facility on [DATE]. Further review of the medical records revealed there was no documentation resident #2 or his responsible party received information on resident rights and all regulations governing the resident conduct and responsibilities during his stay. On 04/30/2025 at 12:25 p.m. an interview with S1Administrator revealed he was not able to locate resident #2's admission packet. S1Administrator confirmed they did not have documentation resident #2 or his responsible party received information on resident rights and the temporary leave-bed hold policy.

Based on observations, record review and interviews the facility failed to assess a resident for self-administration of medications for 1 (#323) of 1 sampled residents. Findings: Review of the facility's Self -Administration of Medications policy and procedure dated 06/14/2006 revealed: A patient may self-administer medications if the patient is determined safe for the patient and other patients of the facility by the facility's interdisciplinary team. Procedure: An assessment for Self-Administration of Medications must be competed on each Patient requesting to self-administer medications and quarterly thereafter. An assessment for self-administration of Medications is kept with the Patient's medical record under the Assessment tab. If it has been determined the Patient is capable of self-administering his/her medications, a physician order must be obtained, a care plan formulated, and staff in-serviced. The nursing staff must interview the Patient on every shift to verify that all self-administered doses on the Patient's Medication Administration Record. If the shift interview indicates any question as to the continued safety of self-administration, then the nurse will initiate the re-assessment process outlined above. All medications for self-administration must be stored in a locked storage area in the Patients room. Narcotics must be under double lock. Review of the medical record for sampled resident #323 revealed an admitted [DATE] with diagnoses including acute respiratory failure, disorder of the lungs, hypertension and depression. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. On 09/30/2024 at 10:39 a.m., observation of resident #323's room revealed a bottle of Fluticasone Nasal (to treat allergies) spray 100 micrograms (mcg)/150 mcg in the room on the bedside table. Review of the label on the box revealed to administer 2 sprays. Resident #323 stated she sprays 2 in each nostril every day. On 10/01/2024 at 9:07 a.m., observation of resident #323's room revealed the Fluticasone nasal spray remained at the bedside. On 10/02/2024 at 7:54 a.m., observation of Resident #323's room revealed the Fluticasone nasal spray remained at the bedside. Review of the current physician orders for resident #323 revealed an order dated 09/19/2024 for Fluticasone Propionate 50 mcg/actuation nasal spray, suspension (2 sprays) both nostrils at bedtime. Further review of the record revealed there was no physician's order to allow resident #323 to keep the medication in the room at the bedside, and there was no assessment to determine if resident #323 was safe to have the medication in the room at the bedside to self administer. Observation of the bottle in the resident's room revealed the label from the pharmacy was from the hospital the resident was in prior to her admission to the nursing facility. Resident #323 said the hospital gave it to her and she actually took her own dose this morning. On 10/02/2024 at 11:20 a.m., an interview with S5Licensed Practical Nurse (LPN) revealed she was not aware resident #323 had the Fluticasone nasal spray in her room. S5LPN revealed there was a bottle on the mediation cart and she received the medication in the evening. S5LPN further revealed there was no order for resident #323 to have the medication at the bedside and there was no assessment for resident #323 to keep the medication at the bedside to self-administer the medication. On 10/02/2024 at 11:45 a.m., an interview with S2Director of Nursing (DON) revealed she was not aware the resident had the medication in her room. S2DON revealed if a resident had medications in their room and was self-administering the medication then they were supposed to have an assessment to self-administer medications.

Based on record reviews and interviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet the resident's needs by not 1) having documentation of meal percentage intakes for 1 (#62) of 4 (#37, #43, #62, and #321) residents reviewed for nutrition. Also the failed practice was evidenced by not developing a care plan for 1 (#16) of 10 (#3, #16, #37, #40, #41, #58, #62, #221, #223, and #324) residents reviewed for Activities of Daily Living (ADL), and for 1 (#324) resident observed to have medications at the bedside. Findings: Review of the Self - Administration of Medications policy and procedure dated 06/14/2006 revealed: A patient may self-administer medications if the patient is determined safe for the patient and other patients of the facility by the facility's interdisciplinary team. Procedure: An assessment for Self-Administration of Medications must be completed on each patient requesting to self-administer medications and quarterly thereafter. An assessment for self-administration of Medications is kept with the patient's medical record under the Assessment tab. If it has been determined the patient is capable of self-administering his/her medications, a physician order must be obtained, a care plan formulated, and staff in-serviced. The nursing staff must interview the patient on every shift to verify that all self-administered doses on the patient's medication administration record. If the shift interview indicates any question as to the continued safety of self-administration, then the nurse will initiate the re-assessment process outlined above. All medications for self-administration must be stored in a locked storage area in the patient's room. Narcotics must be under double lock. Resident #323 On 09/30/2024 at 10:39 a.m., observation of resident #323's room revealed a bottle of Fluticasone Nasal spray 100 micrograms (mcg)/150mcg in the room on the bedside table. Review of the label on the box revealed to administer 2 sprays. Resident stated she sprays 2 in each nostril every day. On 10/01/2024 at 7:54 a.m. and 9:07 a.m., observations of resident #323's room revealed the Fluticasone nasal spray remained at the bedside. Review of the current Physician orders for resident #323 revealed an order dated 09/19/2024 for Fluticasone Propionate 50 mcg/actuation nasal spray, suspension (2 sprays) both nostrils at bedtime. Further review of the record revealed no Physician's order to allow resident #323 to keep medication in the room at the bedside, and there was no assessment to determine if resident #323 was safe to have medication in the room at the bedside to self-administer. Further review of the record revealed there was no plan of care developed for the self-administration of medications for resident #323. On 10/02/2024 at 11:20 a.m., an interview with S5Licensed Practical Nurse (LPN) revealed she was not aware resident #323 had the Fluticasone nasal spray in her room. S5LPN said there was a bottle of the Fluticasone Nasal spray on the medication cart and resident #323 received the medication in the evening. Observation of the bottle of Fluticasone Nasal spray in the resident's room revealed the label from the pharmacy was from the hospital the resident was in prior to admission. Resident #323 said the hospital gave it to her and she actually took her own dose this morning. Interview on 10/02/2024 at 11:20 a.m. with S5LPN revealed she was not aware of the medication in resident #323's room. She confirmed there was no order for resident #323 to have the medication at the bedside and there was no assessment for resident #323 to keep the medication at bedside and self-administer the medication. On 10/02/2024 at 11:45 a.m., an interview with S2Director of Nursing (DON) revealed she was not aware the resident had the medication in her room. S2DON said if a resident has medications in their room and is self-administering the medication then they are supposed to have a self-medication assessment, a plan of care to self-administer medications and store the medications in a secured box. S2DON confirmed there was no plan of care developed for resident #323 to self- administer medications. 18118 Resident #62 Review of the medical record for resident #62 revealed an admitted [DATE] with diagnoses including encephalopathy, epilepsy, malignant neoplasm, protein calorie malnutrition, and dehydration. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed resident #62's Brief Interview for Mental Status (BIMS) score was 99 which indicated that the resident was unable to complete the interview. Resident #62 was dependent on staff for activities of daily living. Review of the current care plan revealed resident #62 required extensive assistance with eating. Further review of the care plan revealed interventions were to allow the resident adequate time to eat, monitor his food intake at each meal, and to document the meal percentage consumed. Review of the resident #62's Activities of Daily Living (ADL) Verification Worksheet for daily meal intake percentages revealed there was no documented evidence of the breakfast, lunch and dinner meal percentage intakes on 09/10/2024, 09/14/2024, 09/15/2024 and 09/26/2024. Further review of the worksheet revealed no documented evidence of the breakfast and lunch meal percentage intakes on 09/12/2024, 09/21/2024 and 09/27/2024. On 10/01/2024 at 12:45 p.m., an interview with S2DON confirmed the meal intake percentages were incomplete for the month of September 2024 for resident #62. 32231 Resident #16 Review of resident #16's medical record revealed she was admitted to the facility on [DATE] with diagnoses that included in part, obstructive sleep apnea, acute and chronic respiratory failure with hypoxia, insomnia, altered mental status, and obesity. Review of the admission minimum data set assessment dated [DATE] revealed resident #16 had a BIMS score of 15. A score of 13-15 revealed resident #16 was cognitively intact with daily decision making skills. On 09/30/2024 at 11:30 a.m., an observation revealed resident #16's fingernails were dirty with grime observed underneath the nail beds of both hands. An interview with resident #16 revealed that the staff had not offered to clean her fingernails. Further observations of resident #16 on 10/01/2024 at 12:40 p.m. and 5:00 p.m., the resident continued to have dirty fingernails. During an interview on 10/02/2024 at 11:43 a.m., S1Administrator and S2Director of Nursing were notified of the above findings. On 10/02/2024 at 11:51 a.m., an observation revealed resident #16's fingernails remained dirty. S8Assistant Director of Nursing and S4Regional Director of Clinical Services were present during the observation and interview with resident #16. After the observation and interview was finished, S8Assistant Director of Nursing and S4Regional Director of Clinical Services both confirmed that resident #16's fingernails needed to be cleaned. On 10/02/2024 at 11:55 a.m., S9Certified Nursing Assistant was notified of the above findings. She revealed that she had given resident #16 a bath earlier that morning and that she was aware of the resident's fingernails being dirty. Review of the medical record revealed there was no documented evidence of a care plan being developed to address nail care for resident #16. On 10/02/2024 at 12:00 p.m., an interview with S4Regional Director of Clinical Services reviewed the electronic health record for resident #16. She confirmed there was no documented evidence of a care plan being developed to address the cleaning of the resident's fingernails.

Based on observations, record reviews, and interviews the facility failed to ensure a resident who is unable to carry out activities of daily living (ADL) received the necessary services to maintain good personal hygiene for 7 (#3, #16, #41, #45,#58, #62 and #221) of 11 (#3, #16, #37, #40, #41, #45, #58, #62, 221, #223, and #324) residents reviewed for Activities of Daily Living (ADL) care. The facility failed to ensure 1) residents' fingernails were kept clean and/or trimmed for #16, #41, #58 and #62, and 2) residents #3, #45 and #221 received baths as scheduled. Findings: Resident #62 Review of the medical record for resident #62 revealed an admitted [DATE] with diagnoses including encephalopathy, hypertension, epilepsy, atrial fibrillation, malignant neoplasm, protein calorie malnutrition, dehydration and chronic pain. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed resident #62's Brief Interview for Mental Status (BIMS) score was 99 which indicated that the resident was unable to complete the interview. Resident #62 was dependent on staff for activities of daily living. On 09/30/2024 at 2:10 p.m., and 10/01/2024 at 9:52 a.m., observations of resident #62 revealed his fingernails were long and needed to be trimmed. On 10/01/2024 at 9:10 a.m., an interview with the S2Director of Nursing (DON) revealed the resident was dependent of staff for ADLs. On 10/01/2024 at 1:35 p.m. S2DON observed resident #62's fingernails, and S2DON confirmed resident #62's fingernails were long and needed to be trimmed. 19121 Resident #45 Review of resident #45's record revealed an admitted [DATE] with diagnosis of hypertension, heart disease, atrial fibrillation, urine retention, peripheral vascular disease, bilateral amputation of legs, sepsis, and neuropathic bladder. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS of 14 which indicates the resident is cognitively aware and able to make daily decisions. Further review of the MDS revealed the resident is dependent on staff for toileting, hygiene, shower/bathing, upper and lower body dressing, personal hygiene, and transfers. Interview on 09/30/2024 at 10:10 a.m. with resident #45 stated he does not get his baths three times a week and sometimes he goes a week without getting a bath. Review of the bath schedule effective 06/25/2024 revealed resident #45 should receive a bath on the evening shift on Tuesday, Thursday and Saturday. Review of the ADL verification worksheets dated 08/01/2024 through 09/30/2024 revealed no documented evidence that resident #45 received baths as scheduled for 13 days in August 2024 and 11 days in September 2024. Interview on 10/02/2024 at 7:20 a.m. with S12Certified Nursing Assistant (CNA) that works with resident #45 stated he was to receive baths on the evening shift on Tuesday, Thursday and Saturdays and she stated the resident does not refuse bathing. Interview on 10/02/2024 at 3:00 p.m. with S2DON confirmed that resident #45's documentation did not reflect him receiving baths on Tuesday, Thursdays and Saturdays in August and September 2024. 32231 Resident #16 Review of the resident #16's medical record revealed she was admitted to the facility on [DATE] with diagnoses that included in part, obstructive sleep apnea, acute and chronic respiratory failure with hypoxia, insomnia, altered mental status, and obesity. Review of the admission minimum data set assessment dated [DATE] revealed resident #16 had a brief interview for mental score of 15. A score of 13-15 revealed resident #16 was cognitively intact with daily decision making skills. On 09/30/2024 at 11:30 a.m., an observation revealed resident #16 in her room, sitting up in her wheelchair, and visiting with her family member. Further observation revealed resident #16's fingernails were dirty with grime observed underneath the nail beds of both hands. An interview with resident #16 revealed that the staff had not offered to clean her fingernails. Further observations of resident #16 on 10/01/2024 at 12:40 p.m. and 5:00 p.m., the resident continued to have dirty fingernails. During an interview on 10/02/2024 at 11:43 a.m., S1Administrator and S2Director of Nursing were notified of the above findings. On 10/02/2024 at 11:51 a.m., an observation revealed resident #16 in her room, sitting up in her wheelchair positioned close to her bedside table where the resident's meal tray had been placed. Further observation revealed the resident's fingernails remained dirty. S8Assistant Director of Nursing and S4Regional Director of Clinical Services were present during the observation and interview with resident #16. After the observation and interview was finished, S8Assistant Director of Nursing and S4Regional Director of Clinical Services both confirmed that resident #16's fingernails needed to be cleaned. On 10/02/2024 at 11:55 a.m., S9Certified Nursing Assistant was notified of the above findings. She revealed that she had given resident #16 a bath earlier that morning and that she was aware of the resident's fingernails being dirty. Resident #221 Review of the medical record revealed resident #221 was admitted to the facility on [DATE] and was discharged home on 07/30/2024. Resident #221's diagnoses included in part, cerebral infarction, essential (primary) hypertension, systolic and diastolic congestive heart failure, pain, dizziness, chronic obstructive pulmonary disease, hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, facial weakness following cerebral infarction, encounter for surgical aftercare following surgery on the circulatory system, chronic pulmonary embolism, and chronic pulmonary embolism. Review of the discharge minimum data set assessment dated [DATE] revealed the resident required partial to moderate assistant with showering and bathing. Review of the medical record revealed resident #221 had a baseline care plan that revealed she required bathing support. Review of the Activities of Daily Living Verification Worksheet revealed there was no documented evidence of resident #221 having received a bath a total of twenty-two times from the dates of 07/08/2024 - 07/30/2024. On 10/02/2024 at 3:20 p.m., S1Administrator and S2Director of Nursing were notified of the findings noted above. S2Director of Nursing confirmed there was no documented evidence of resident #221 having received a bath for the 22 days. She further confirmed that there was no documented reason as to why the resident had not received a bath on those dates. 41829 Resident #58 Record review revealed resident #58 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia, dysphagia, essential hypertension, insomnia, anemia, constipation, chronic pain syndrome, and major depressive disorder. Review of quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 7 which indicated severe cognitive impairment. Further review revealed resident #58 required substantial/maximal assistance with eating, oral hygiene, toileting hygiene, shower/bathing, dressing upper and lower body, and personal hygiene. Review of active care plans revealed resident #58 had a self-care deficit and required extensive assistance with bathing, hygiene, dressing, grooming. An intervention listed was to clean and manicure fingernails as needed. Observations of resident #58, on 09/30/2024 at 10:00 a.m. and on 10/01/2024 at 8:35 a.m., revealed his fingernails on both hands were very long with a dark brown grimy substance under the fingernails on both hands. On 10/01/2024 at 12:05 p.m., an observation of resident #58 with S2Director of Nursing revealed resident #58's fingernails on both hands were very long with a dark brown grimy substance under the fingernails on both hands. S2DON confirmed resident #58's fingernails needed to be cleaned and trimmed. 43405 Resident #3 Review of resident #3's record revealed an admitted [DATE] with diagnoses including anxiety disorder, chronic kidney disease, other schizoaffective disorders, pain unspecified, unspecified dementia with behavioral disturbance, unstageable pressure ulcer of right heel, dysphagia, and long term use of opiate analgesics. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 14 indicating cognitively intact. Further review of the MDS revealed resident #3 dependent on staff for toileting hygiene, shower/bathing, upper and lower body dressing, personal hygiene, bed mobility, and transfers. Review of the Bath Schedule effective 06/25/2024 revealed resident #3 should be getting a bath on Monday, Wednesday, and Fridays on the evening shift. Review of the Activities of Daily Living Verification Worksheet for 08/01/2024-09/30/2024 revealed no documented evidence that resident #3 received baths as scheduled for 5 days in August 2024 and 8 days in September 2024. An interview on 10/02/2024 at 2:15 p.m. with S2DON confirmed that resident #3 did not have documentation of baths for 5 days in August 2024 and 8 days in September 2024. Resident #41 Review of resident #41's record revealed an admitted [DATE] with diagnoses including cerebral infarction, transient ischemic attack, unspecified convulsions, age related physical debility, chronic obstructive pulmonary disease, lobar pneumonia, and peripheral vascular disease. Review of resident #41's quarterly MDS dated [DATE] revealed a BIMS of 11 indicating moderate cognitive impairment. Further review of the MDS revealed resident #41 was dependent on staff for toileting, bathing, dressing, transfers, and personal hygiene. Observations of resident #41 on 09/30/2024 at 9:05 a.m. and 10/01/2024 at 4:25 p.m. revealed resident's fingernails on bilateral hands were long. An interview on 09/30/2024 at 9:05 a.m. with resident #41 revealed he's unable to trim his own fingernails. An interview on 10/01/2024 at 4:25 p.m. with resident #41 revealed he does not like his fingernails to be this long. Review of resident #41's careplan dated 11/22/2023 revealed ADL functions for resident included nail care. An interview on 10/02/2024 at 9:45 a.m. with S3Licensed Practical Nurse (LPN) revealed Certified Nurse Aids (CNA) on the hall are responsible for trimming resident #41's fingernails, and confirmed resident #41's were long and needed to be trimmed.

Based on record review and interview, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible by not completing an Accident/Incident report when a resident was found sitting on the floor for 1 (#62) of 3 (#51, #62, and #222) residents reviewed for falls. Findings: Review of the facility's Accident/Incidents Policy dated May 2016 revealed: 1 An Accident/Incident Report must be completed immediately upon facility staff becoming aware of the occurrence of an accident/incident (to include medication errors) involving a Patient and, if necessary, the Patient's Care Plan must be updated. Review of the facility's Fall Management Guidelines policy dated November 2022 revealed: 1. Definition Unintentional change in position coming to rest on the ground, floor or onto the next lower surface. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. Review of the medical record for resident #62 revealed an admitted [DATE] with diagnoses including encephalopathy, hypertension, epilepsy, atrial fibrillation, malignant neoplasm, dehydration and chronic pain. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed resident #62's Brief Interview for Mental Status (BIMS) score was 99 which indicated that the resident was unable to complete the interview. Review of the careplan with an effective date of 06/14/2024 revealed resident #62 was at risk for falls related to weakness. Review of the nurses' notes dated 06/27/2024 at 11:47 a.m. revealed resident #62 was sitting on the floor in his bedroom urinating. The nurse assisted the resident with getting dressed and cleaned his room. Review of the record revealed an Accident/Incident Report was not completed on 06/27/2024 when resident #62 was sitting on the floor. On 10/01/2024 at 12:45 p.m., an interview with S2Director of Nursing (DON) confirmed on 06/27/2024 at 11:47 a.m., when resident #62 was found sitting on the floor, the nurse should have completed an Accident/Incident report.

Based on observations, record review and interviews the facility failed to provide respiratory care consistent with professional standards of practice for 3 (#2, #323, and #325) of 3 (#2, #323, #325) residents sampled for respiratory care. The facility failed to ensure 1) Resident's oxygen concentrator filters were clean for (#2, #323) and 2) The resident's nebulizer equipment and tubing were dated and stored appropriately for (#323, #325). Findings: Resident #2 On 09/30/2024 at 3:16 p.m. observation of resident #2's oxygen concentrator revealed the filter on the back of the machine was dirty. Further observation of the oxygen administration revealed resident #2 received 2 liters per minute (lpm) per nasal cannula. Observation of the oxygen tubing revealed there was no date or initial on the humidification bottle or the oxygen tubing. On 10/01/2024 at 8:57 a.m. observation of the oxygen concentrator revealed the filter remained dirty. On 10/01/2024 at 11:58 a.m. observation of the oxygen concentrator with S2Director of Nursing (DON) confirmed the filter on the back of the machine was dirty. Resident #323 On 09/30/2024 at 10:33 a.m. observation of the oxygen concentrator for resident #323 revealed the filter on the back of the machine was dirty with dust and debris. Further observation of resident #323's room revealed the nebulizer mask and tubing was not dated or covered. On 10/01/2024 at 9:06 a.m. observation of the oxygen concentrator revealed the filter remained dirty with dust and debris and the nebulizer mask remained uncovered and was not dated. On 10/01/2024 11:30 a.m. observation of the oxygen concentrator revealed it remained dirty with dust and debris and the nebulizer mask remained uncovered and not dated. On 10/01/2024 11:35 a.m., an interview with S2DON confirmed the oxygen concentrator filter needed cleaning and the nebulizer mask should have been dated and covered. Resident #325 On 09/30/2024 at 12:07 p.m. observation of resident #325's room revealed the nebulizer pipe was not dated or covered. On 10/01/2024 at 12:08 p.m. observation of resident #325's room revealed the nebulizer pipe was not dated or covered. On 10/1/2024 at 12:10p.m., an interview with S2DON confirmed the nebulizer pipe was not dated or covered.

Based on record reviews, observations, and interviews, the facility failed to ensure residents were assessed for the risk of entrapment from bed rails and/or reviewed the risks and benefits of bed rails with the resident or resident's representative and/or obtain an informed consent prior to installation of bed rails for 5 (#9, #16, #31, #40, and #62) of 6 (#9, #16, #31, #40, #51, and #62) residents reviewed for accident hazards. Findings: Review of the facility's policy for Bed Safety and Bed Rails dated August 2022 revealed in part: Policy Statement Resident beds meet the safety specifications established by the Hospital Bed Safety Workgroup. The use of bed rails is prohibited unless the criteria for use of bed rails have been met. 7. The resident assessment also determines potential risks to the resident associated with the use of bed rails, including the following: a. Accident hazards: (1) The resident could attempt to climb over, around, between, or through the rails. Or over the foot board; and/or (2) A resident or part of his/her body could be caught between rails, the openings of the rails, or between the bed rails and mattress. 8. Before using bed rails for any reason, the staff shall inform the resident or resident's representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The following information will be included in the consent. a. The assessed medical needs that will be addressed with the use of bed rails; b. The resident's risks from the use of bed rails and how these will be mitigated; c. The alternatives that were attempted but failed to meet the resident's needs; and d. The alternatives that were considered but not attempted and the reasons. Resident #62 Review of the medical record for resident #62 revealed an admitted [DATE] with diagnoses including encephalopathy, epilepsy, atrial fibrillation, malignant neoplasm, protein calorie malnutrition, dehydration and chronic pain. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed resident #62's Brief Interview for Mental Status (BIMS) score was 99 which indicated that the resident was unable to complete the interview. Resident #62 was dependent on staff for activities of daily living (ADLs). Review of the Assist Rail/Enabler Device informed consent dated 06/14/2024 revealed the consent was not signed by the resident or the resident's representative. On 09/30/2024 at 7:50 a.m.,10/01/2024 at 7:45 a.m., and on 10/02/2024 at 7:30 a.m., resident #62 was observed lying in the bed with quarter bed rails raised and locked on both sides of the bed. On 10/01/2024 at 12:45 p.m., an interview with S2Director of Nursing (DON) revealed the Assist Rail/Enabler Device informed consent for resident #62 was not signed by the resident or the resident's representative. Resident #31 Review of the medical record for resident #31 revealed an admitted [DATE] with diagnoses including acute and chronic respiratory failure with hypoxia, emphysema, cachexia, malformations of cerebral vessels, and anxiety. Review of the quarterly MDS assessment dated [DATE] revealed resident #31's BIMS score was 10 which indicated the resident had moderate cognitive impairment and required assistance with ADLs. Observations of resident #31 on 09/30/2024 at 10:27 a.m., 10/01/2024 at 9:00 a.m. and 3:20 p.m., and on 10/02/2024 at 9:15 a.m. revealed he was lying in the bed with quarter bed rails raised and locked on both sides of the bed. Review of the Assist Rail/Enabler Device informed consent dated 11/22/2023 revealed the consent was not signed by the resident or the resident's representative. On 10/01/2024 at 12:45 p.m., an interview with S2DON confirmed the Assist Rail/Enabler Device informed consent for resident #31 was not signed by the resident or the resident's representative. 32231 Resident #16 Review of the resident #16's medical record revealed she was admitted to the facility on [DATE] with diagnoses that included in part, obstructive sleep apnea, acute and chronic respiratory failure with hypoxia, insomnia, altered mental status, and obesity. Review of the admission minimum data set assessment dated [DATE] revealed resident #16 had a Brief Interview for Mental Status (BIMS) score of 15. A score of 13-15 revealed resident #16 was cognitively intact with daily decision making skills. On 09/30/2024 at 11:30 a.m., an observation revealed resident #16 in her room, sitting up in her wheelchair, and visiting with her family member. Further observation revealed resident #16 had one quarter bedrails, one to each side of her bed. Both bed rails were up and in a locked position. Further observations revealed that on 10/01/2024 at 12:40 p.m., 10/01/2024 at 5:00 p.m., and 10/02/2024 at 11:51 a.m., the bed rails remained up and in a locked position. Review of the Assist Rail/Enabler device informed consent document dated 09/20/2024 revealed the name of the device as an Assist Rail x1. Further review revealed there was no documented evidence of the consent form being signed by resident #16 and /or the resident's representative. On 10/01/2024 at approximately 3:15 p.m., S2DON was notified of the above findings. S2DON reviewed resident #16's medical record and confirmed the resident should have been assessed for having two bed rails and the consent was not signed by resident #16 and /or the resident's representative prior to the bed rails being place on the bed. Resident #40 Review of resident #40's medical record revealed she was admitted to the facility on [DATE] with diagnoses including in part, acute combined systolic (congestive) and diastolic (congestive) heart failure, chronic obstructive pulmonary disease, morbid (severe) obesity, functional quadriplegia, weakness, fall from bed, and pain in joints of left hand. Review of the annual minimum data set assessment dated [DATE] revealed resident #40 had a BIMS score of 15. A score of 13-15 revealed resident #40 was cognitively intact with daily decision making skills. On 09/30/24 12:13 p.m., an observation of resident #40 revealed the resident lying in bed. Further observation revealed one-half bed rails intact to each side of the resident's bed. Both bed rails were up and in a locked position. Further observation revealed that on 10/01/2024 at 12:25 p.m., resident #40 was lying in her bed with both of the bed rails up and in a locked position. Review of the medical record revealed there was no documented evidence of resident #40 being assessed for having two, one-half bed rails and no signed consent by resident #40/ representative prior to the bed rails being placed on the bed. On 10/03/2024 at approximately 3:20 p.m., S2DON was notified of the observations of resident #40 having one-half bed rails intact, one to each side of her bed and no documented evidence of resident #40 of a signed consent for the use of the bed rails. After a review of resident #40's medical record with S2Director of Nursing, she confirmed there was no documented evidence of an assessment being completed or a signed consent being obtained prior to the use of one-half bed rails for resident #40. 41829 Resident #9 Record review revealed resident # 9 was admitted to the facility 09/07/2012 with diagnoses that included gastrostomy status, unspecified intellectual disabilities, unspecified dementia, encephalopathy, angina pectoris unspecified, chronic pain syndrome, hyperlipidemia, gastro-esophageal reflux disease without esophagitis, constipation, unspecified glaucoma, and mild protein-calorie malnutrition. Review of quarterly MDS assessment dated [DATE] revealed a BIMS score of 13 which indicated resident #9 was cognitively intact. Resident #9 was dependent on staff for assistance with all Activities of Daily Living. On 09/30/2024 at 10:26 a.m., an observation of resident #9 revealed she was lying bed. The quarter bed rails on each side of the bed were in the upright position. On 10/01/2024 at 11:52 a.m., an observation of resident #9 revealed she was lying in bed. The quarter bed rails on each side of the bed were in the upright position. On 10/02/2024 at 9:10 a.m., an observation of resident #9 revealed she was lying in bed with the quarter bed rails on each side of the bed in the upright position. Review of active care plans revealed resident #9 required one person assistance with turning and repositioning in bed. An intervention listed included resident #9 used quarter assist rails x2 to assist with bed mobility and transfers. Further review of resident #9's medical record revealed there was no documented evidence of resident #9 being assessed for the use of bed rails or a consent for bed rails to be used. During an interview on 10/01/2024 at 3:08 p.m., with S2DON revealed there was no documentation that resident #9 was assessed for the use of bed rails. S2DON further revealed there was no documentation of a consent for bed rails to be used. S2DON confirmed resident #9 should have been assessed for bed rail use and a consent should have been obtained prior to the use of bedrails.

Based on observation, record review, and interview the facility failed to establish and maintain an Infection Control Program designed to provide a sanitary environment and to help prevent the development and transmission of disease and infection by not ensuring the whirlpool aides were following the manufacturer's guidelines for disinfecting the whirlpool tubs between residents in a high risk population for 43 (#'s 120, 141, 100, 31, 47, 48, 30, 17, 80, 23, 35, 49, 28, 94, 67, 134, 72, 4, 115, 42, 25, 62, 85, 107, 142, 19, 16, 55, 109, 106, 22, 14, 44, 7, 8, 65, 114, 124, 29, 68, 5, 36, 104) residents that received a whirlpool bath out of a total sample of 89 (#'s 120, 143, 112, 141, 139, 100, 31, 89, 47, 45, 117, 38, 102, 48, 30, 17, 80, 23, 35, 49, 28, 135, 94, 144, 98, 67, 134, 72, 4, 115, 137, 131, 42, 66, 6, 140, 99, 25, 12, 27, 57, 24, 126, 95, 79, 77, 62, 85, 107, 64, 142, 74, 92, 19, 10, 130, 18, 63, 3, 16, 127, 55, 109, 46, 41, 52, 106, 22, 14, 44, 7, 8, 65, 103, 114, 70, 124, 29, 68, 61, 5, 1, 59, 36, 104, 32, 71, 51, 15) residents listed on the bath day report roster dated 03/09/15 to 03/11/15. There were a total of 91 residents in the facility according to the Resident Census and Conditions of Residents form (CMS 672). Findings: An observation of the North end 200 hall whirlpool room on 03/09/15 at 8:55AM revealed that 6 (#65, #16, #31, #68, #5, and an unknown resident who was asleep in her wheelchair) residents were in the holding area of the whirlpool room. An interview with Resident #65 revealed that they had been there since 8:30AM waiting for a whirlpool. An observation of the North end, 200 hall holding area for the whirlpool room on 03/09/15 at 9:58AM revealed that one resident of the six was no longer in the holding area and one additional resident was now in the holding area. A total of six residents remained in the area. An interview with S4Whirlpool Aide on the North end of the 200 hall was conducted on 03/11/15 at 8:20AM. When asked how she cleaned the whirlpool, she stated that when the resident is finished and water is out of the whirlpool the whirlpool is sprayed down with the disinfectant and rinsed with water. When asked if there was a wait time after spraying the disinfectant on the whirlpool, she stated, No, no one has told me that. She further stated that at the end of the day when they have completed all whirlpool baths, she will use the sprayer to apply the cleaner to the tub, fill it with water and remove parts to conduct a thorough cleaning. An observation on 03/11/15 at 8:30AM revealed that S5Whirlpool Aide was assisting residents in the whirlpool room on the North end of the 100 hall. Resident #107 had just finished his whirlpool and was exiting the whirlpool room; the room had a strong smell of cleaner. An interview with S5Whirlpool Aide at this time revealed that Resident #107 had a bowel movement and she removed the feces from the whirlpool. When asked how she normally cleans the whirlpool she stated that she was about to clean the whirlpool as she normally does. An observation of S5Whirlpool Aide disinfecting the whirlpool revealed that she used the shower handle that had a direct link to the disinfectant bottle to spray the inside of the whirlpool with the disinfectant and immediately began to wipe down the area around the water line of the whirlpool with a washcloth. She then rinsed the whirlpool with water and stated that was how she cleaned the whirlpool between residents. When asked about wiping down the other parts of the whirlpool, the S5Whirlpool Aide stated that at the end of the day, she takes the seat and other pieces off to disinfect them. She further stated that she assists about 10-15 residents each day in the whirlpool. An observation revealed that the whirlpool did not have the capability of automatically diluting the disinfectant cleaner. S5Whirlpool Aide confirmed that the disinfectant was coming straight from the bottle and no water was being added to the disinfectant. The cleaning process was observed to take a total of about 5 minutes. As the surveyor was leaving, S5Whirlpool Aide assisted Resident #142 into the whirlpool room. A review of an in-service held on 08/26/14 and 08/27/14 titled Bath: Bathtub and Whirlpool Disinfecting revealed the following procedure for bathtub disinfecting (whirlpool tubs were the only tubs offered in the facility): 1. After each bath, spray approved disinfectant over entire side of tub and faucet fixtures, 2. Wipe entire inside of tub and faucet fixtures with a sponge, 3. Rinse thoroughly with clean water, and 4. At the end of each day, the inside of the tubs must be thoroughly scoured with disinfectant and rinsed thoroughly. The procedure for whirlpool disinfecting was as follows: 1. Due to many different models of whirlpool tubs, please see manufacturer's guidelines for precise cleaning and disinfecting instructions. A review of the sign in sheet revealed that S4Whirlpool Aide had not signed in attendance. An interview with S20ADON on 03/11/15 at 11:45AM revealed that she and S19CNA Supervisor monitors the whirlpool cleaning process. She confirmed that there is no documentation of monitoring of the CNA staff disinfecting of the whirlpools. When asked why S4WhirlPool aide was not on the in-service sign-in sheet 08/26/14, she stated that S4WhirlPool Aide had not been employed by the facility that long. When asked about new hire training, she stated that the new hires are trained on the use and cleaning of the whirlpool by the whirlpool aide that currently works in the whirlpool room or the CNA Supervisor. She further confirmed that no documentation of training on hire for the use or disinfecting of the whirlpool is maintained. S20ADON stated that she observed a whirlpool given by S21CNA in mid-January 2015 where she saw the S21CNA use a spray bottle to apply the disinfectant to the whirlpool, use a washcloth to wipe it down, and then rinse with water. She further stated that the entire process from start to finish took about 3 minutes. She confirmed that no annual skills/performance check-off evaluations were done. As she was interviewed and realized they were not cleaning the whirlpool per the manufacturer's guidelines she stated, Ya'll need to tell us what we need to do. An interview with S19CNA Supervisor on 03/11/15 at 12:15PM revealed that she and S20ADON monitor the use and disinfecting of the whirlpool. She stated that the whirlpool aide that currently works in the whirlpool room on each floor trains the new hires on the use and disinfecting of the whirlpool. When ask if she had observed at any time the process of cleaning the whirlpool, she stated that she had assisted last week with Resident #55, because the resident had a loose stool during her whirlpool bath. She stated that after getting the resident out of the whirlpool they let out the water, sprayed the whirlpool with disinfectant all over the inside surface, and used a brush to clean all areas of the whirlpool. She further stated that the whirlpool was then rinsed with water and was then ready for use by the next resident. She stated that the entire process took 5-6 minutes from start to finish. When asked if the disinfectant was diluted in any way she stated No. S19CNA Supervisor also stated that she was trained by a CNA Supervisor at the time of her hire. When shown the facility policy that stated to check the manufacturer's guidelines for cleaning the whirlpool, which was included in the in-service she had given on 08/26/14 and 08/27/14, she stated that she was not aware of the manufacturer's guidelines and the facility had not provided her with a copy of the manufacturer's guidelines. When asked if she had ever read the manufacturer's guidelines printed on the label of the disinfectant bottle, she stated, No, I have not. S19CNA Supervisor confirmed that she does not keep documentation when she observes the use and disinfecting of the whirlpool. An interview with S2DON on 03/11/15 at 9:45AM revealed that the facility uses Classic whirlpool disinfectant cleaner to disinfect the facility's whirlpool. An interview with S1Administrator on 03/11/15 at 2:10PM confirmed that no annual skills/performance evaluations or return demonstrations have been conducted for CNA staff. A review of the Operating Instructions for the MasterCare Integrity Bath Model MB-80-R provided by the facility on 03/11/15 revealed a topic titled Cleaning and Disinfecting the Tub and Chair which, in part, stated to remove the pads from the chair and lay them in the well of the tub, rinse tub and chair with hot water before disinfecting, close the drain, use the wand to spray the inside of the tub, chair, and the pads, scrub all areas with the long handled brush. Continued review of the Operating Instructions revealed a topic titled Rinsing the Residual Cleaner Disinfectant off of the tub. The instructions were as follows: open the drain, after standard contact time per label directions on disinfectant container, rinse thoroughly all areas that were in contact with the disinfectant cleaner. If bathing another patient, dry the chair and pads with a towel. A review of the labeling found on a bottle of Classic whirlpool disinfectant cleaner revealed in part; to remove heavy soil or gross filth from surface, dilute 2 ounces of Classic disinfectant per gallon of water, and allow to remain in contact for a time of 10 minutes for use as a disinfectant, then let air dry. The bottle was clearly labeled with the following statement: It is a violation of Federal Law to use this product in a manner inconsistent with its labeling. A review of the Answers to Frequently Asked Questions found on Central Solutions (product manufacturer) website provided by the facility on 03/11/15 revealed the question, How long does it take Classic Disinfectant to work? The answer was noted that a ten minute contact time is required for disinfection. It denoted that using an antimicrobial product in its proper concentration for a time less than 10 minutes changes its efficacy from a disinfectant level to a sanitizer level of kill. Additionally, the website revealed that Classic disinfectant cleaner has a 100% kill of organisms when allowed a contact time of 10 minutes with the exception of spores. A review of the CDC's (Center for Disease Control and Prevention) Guidelines for Environmental Infection Control in Health-Care Facilities: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC) revealed that under the section titled, Hydrotherapy Tanks and Pools it directed to drain and clean hydrotherapy equipment after each patient's use, and disinfect equipment surfaces and components by using an EPA-registered product in accordance with the manufacturer's instructions. Examples of hydrotherapy tanks included tubs, whirlpools, and whirlpool spas. A review of the cumulative [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. with an Open Wound of the Leg, 2 with a Pressure Ulcer, Debility 4, Diabetes Mellitus 19, Anemia 16, and Malnutrition/Weight Loss 6. On 03/11/15 at 11:40AM, an interview with S19CNA Supervisor revealed a list is maintained and revised by the treatment nurse and unit nurses identifying which residents with open wounds should not receive whirlpool baths. On 03/11/15 at 11:45AM, an interview with S5Whirlpool Aide for the first floor revealed that residents #94 and #14 should not be bathed, because they had open wounds. Review of the list compiled by the treatment nurse of those residents on the first floor with open wounds who should not receive a whirlpool bath included residents #94 and #14. Review of the Bath Day Report Roster revealed resident #94 received a whirlpool bath on 3/11/15. Resident #14 received a whirlpool bath on 3/10/15. Review of the list compiled by the treatment nurse for residents on the second floor with open wounds who should not receive baths in the whirlpool included resident #106 and resident #22. Review of the Bath Day Report Roster confirmed that resident #106 received a whirlpool bath on 03/09/15 and resident #22 received a whirlpool bath on 03/10/15. Review of the current Physician order [REDACTED]. Resident #62 had an abrasion to the left stump obtained 02/26/15. Review of the Bath Day Report Roster revealed resident #62 received a whirlpool bath on 03/10/15 and on 03/11/15. Resident #106 had a deep tissue injury to the right heel obtained 03/05/15. Review of the Bath Day Report Roster revealed resident 106 received a whirlpool bath on 03/09/15. An interview with S1Administrator and S22Corporate Vice President on 03/12/15 at 10:10AM confirmed that the whirlpool cleaning process was deficient and did not follow the manufacturer's guidelines.

Based on observation, record review, and interview the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being, by not ensuring the whirlpool aides were following the manufacturer's guidelines for disinfecting the whirlpool tubs between residents in a high risk population for 43 (#'s 120, 141, 100, 31, 47, 48, 30, 17, 80, 23, 35, 49, 28, 94, 67, 134, 72, 4, 115, 42, 25, 62, 85, 107, 142, 19, 16, 55, 109, 106, 22, 14, 44, 7, 8, 65, 114, 124, 29, 68, 5, 36, 104) residents that received a whirlpool bath out of a total sample of 89 (#'s 120, 143, 112, 141, 139, 100, 31, 89, 47, 45, 117, 38, 102, 48, 30, 17, 80, 23, 35, 49, 28, 135, 94, 144, 98, 67, 134, 72, 4, 115, 137, 131, 42, 66, 6, 140, 99, 25, 12, 27, 57, 24, 126, 95, 79, 77, 62, 85, 107, 64, 142, 74, 92, 19, 10, 130, 18, 63, 3, 16, 127, 55, 109, 46, 41, 52, 106, 22, 14, 44, 7, 8, 65, 103, 114, 70, 124, 29, 68, 61, 5, 1, 59, 36, 104, 32, 71, 51, 15) residents listed on the bath day report roster dated 03/09/15 to 03/11/15. There were a total of 91 residents in the facility according to the Resident Census and Conditions of Residents form (CMS 672). The facility failed to: 1. Establish and maintain an Infection Control Program designed to provide a sanitary environment and to help prevent the development and transmission of disease and infection, 2. Ensure staff were trained according to the manufacturer's guidelines of the disinfectant for disinfection of the whirlpools, 3. Ensure a system was in place to monitor the disinfecting of the whirlpools, 4. Establish an effective Quality Assurance committee. Findings: 1. Cross refer to finding at Tag F441 2. Cross refer to finding at Tag F498 3. Cross refer to finding at Tag F520 An observation of the North end, 200 hall whirlpool room on 03/09/15 at 8:55AM revealed that 6 (#65, #16, #31, #68, #5, and an unknown resident who was asleep in her wheelchair) residents were in the holding area of the whirlpool room. An interview with Resident #65 revealed that they had been there since 8:30AM waiting for a whirlpool. An observation of the North end, 200 hall holding area for the whirlpool room on 03/09/15 at 9:58AM revealed that one resident of the six was no longer in the holding area and one additional resident was now in the holding area. A total of six residents remained in the area. A review of an in-service held on 08/26/14 and 08/27/14 titled Bath: Bathtub and Whirlpool Disinfecting revealed the following procedure for bathtub disinfecting (whirlpool tubs were the only tubs offered in the facility): 1. After each bath, spray approved disinfectant over entire side of tub and faucet fixtures, 2. Wipe entire inside of tub and faucet fixtures with a sponge, 3. Rinse thoroughly with clean water, and 4. At the end of each day, the inside of the tubs must be thoroughly scoured with disinfectant and rinsed thoroughly. The procedure for whirlpool disinfecting was as follows: 1. Due to many different models of whirlpool tubs, please see manufacturer's guidelines for precise cleaning and disinfecting instructions. A review of the sign in sheet revealed that S4Whirlpool Aide (works the North end of the 200 hall whirlpool room) had not signed in attendance. An interview with S20ADON on 03/11/15 at 11:45AM revealed that she and S19CNA Supervisor monitors the whirlpool cleaning process. She confirmed that there is no documentation of monitoring of the CNA staff disinfecting of the whirlpools. When asked why S4WhirlPool Aide was not on the in-service sign-in sheet 08/26/14, she stated that S4WhirlPool Aide had not been employed by the facility that long. When asked about new hire training, she stated that the new hires are trained on the use and cleaning of the whirlpool, by the whirlpool aide that currently works in the whirlpool room or the CNA Supervisor. She further confirmed that no documentation of training on hire for the use or disinfecting of the whirlpool is maintained. S20ADON stated that she observed a whirlpool given by S21CNA in mid-January 2015 where she saw the S21CNA use a spray bottle to apply the disinfectant to the whirlpool, use a washcloth to wipe it down, and then rinse with water. She further stated that the entire process from start to finish took about 3 minutes. She confirmed that no annual skills/performance check-off evaluations were done. When asked how they determine the topics for the 12 hours of yearly in-services if they do not have any evaluation measures in place, she stated she was not sure of that. As S20ADON was interviewed and realized they were not cleaning the whirlpool per the manufacturer's guidelines she stated, Ya'll need to tell us what we need to do. An interview with S19CNA Supervisor on 03/11/15 at 12:15PM revealed that she and S20ADON monitor the use and disinfecting of the whirlpool. She stated that the whirlpool aide that currently works in the whirlpool room on each floor trains the new hires on the use and disinfecting of the whirlpool. When ask if she had observed at any time the process of cleaning the whirlpool, she stated that she had assisted last week with Resident #55 because the resident had a loose stool during her whirlpool bath. She stated that after getting the resident out of the whirlpool they let out the water, sprayed the whirlpool with disinfectant all over the inside surface, and used a brush to clean all areas of the whirlpool. She further stated that the whirlpool was then rinsed with water and was then ready for use by the next resident. She stated that the entire process took 5-6 minutes from start to finish. When asked if the disinfectant was diluted in any way she stated No. S19CNA Supervisor also stated that she was trained by a CNA Supervisor at the time of her hire. When shown the facility policy that stated to check the manufacturer's guidelines for cleaning the whirlpool, which was included in the in-service she had given on 08/26/14 and 08/27/14, she stated that she was not aware of the manufacturer's guidelines and the facility had not provided her with a copy of the manufacturer's guidelines. When asked if she had ever read the manufacturer's guidelines printed on the label of the disinfectant bottle, she stated, No, I have not. S19CNA Supervisor confirmed that she does not keep documentation when she observes the use and disinfecting of the whirlpool. A review of the labeling found on a bottle of Classic whirlpool disinfectant cleaner revealed in part; to remove heavy soil or gross filth from surface, dilute 2 ounces of Classic disinfectant per gallon of water, and allow to remain in contact for a time of 10 minutes for use as a disinfectant, then let air dry. The bottle was clearly labeled with the following statement: It is a violation of Federal Law to use this product in a manner inconsistent with its labeling. A review of the CDC's (Center for Disease Control and Prevention) Guidelines for Environmental Infection Control in Health-Care Facilities: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC) revealed that under the section titled, Hydrotherapy Tanks and Pools it directed to drain and clean hydrotherapy equipment after each patient's use, and disinfect equipment surfaces and components by using an EPA-registered product in accordance with the manufacturer's instructions. Examples of hydrotherapy tanks included tubs, whirlpools, and whirlpool spas. An interview with S1Administrator and S22CorporateVP on 03/12/15 at 10:10AM confirmed that the whirlpool cleaning process was deficient and did not follow the manufacturer's guidelines.

Based on interview and record review the facility failed to ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. The facility failed by not ensuring the whirlpool aides were following the manufacturer's guidelines for disinfecting the whirlpool tubs between residents in a high risk population for 43 (#'s 120, 141, 100, 31, 47, 48, 30, 17, 80, 23, 35, 49, 28, 94, 67, 134, 72, 4, 115, 42, 25, 62, 85, 107, 142, 19, 16, 55, 109, 106, 22, 14, 44, 7, 8, 65, 114, 124, 29, 68, 5, 36, 104) residents that received a whirlpool bath out of a total sample of 89 (#'s 120, 143, 112, 141, 139, 100, 31, 89, 47, 45, 117, 38, 102, 48, 30, 17, 80, 23, 35, 49, 28, 135, 94, 144, 98, 67, 134, 72, 4, 115, 137, 131, 42, 66, 6, 140, 99, 25, 12, 27, 57, 24, 126, 95, 79, 77, 62, 85, 107, 64, 142, 74, 92, 19, 10, 130, 18, 63, 3, 16, 127, 55, 109, 46, 41, 52, 106, 22, 14, 44, 7, 8, 65, 103, 114, 70, 124, 29, 68, 61, 5, 1, 59, 36, 104, 32, 71, 51, 15) residents listed on the Bath Day Report Roster dated 03/09/15 to 03/11/15. There were a total of 91 residents in the facility according to the resident census and conditions report (CMS 672). Findings: An observation of the North end, 200 hall whirlpool room on 03/09/15 at 8:55AM revealed that 6 (#65, #16, #31, #68, #5, and an unknown resident who was asleep in her wheelchair) residents were in the holding area of the whirlpool room. An interview with Resident #65 revealed that they had been there since 8:30AM waiting for a whirlpool. An observation of the North end 200 hall holding area for the whirlpool room on 03/09/15 at 9:58AM revealed that one resident of the six was no longer in the holding area and one additional resident was now in the holding area. A total of six residents remained in the area. An interview with S4Whirlpool Aide on the North end of the 200 hall was conducted on 03/11/15 at 8:20AM. When asked how she cleaned the whirlpool, she stated that when the resident is finished and water is out of the whirlpool the whirlpool is sprayed down with the disinfectant and rinsed with water. When asked if there was a wait time after spraying the disinfectant on the whirlpool, she stated, No, no one has told me that. She further stated that at the end of the day when they have completed all whirlpool baths, she will use the sprayer to apply the cleaner to the tub, fill it with water and remove parts to conduct a thorough cleaning. An observation on 03/11/15 at 8:30AM revealed that S5Whirlpool Aide was assisting residents in the whirlpool room on the North end of the 100 hall. Resident #107 had just finished his whirlpool and was exiting the whirlpool room; the room had a strong smell of cleaner. An interview with S5Whirlpool Aide at this time revealed that Resident #107 had a bowel movement and she removed the feces from the whirlpool. When asked how she normally cleans the whirlpool she stated that she was about to clean the whirlpool as she normally does. An observation of S5Whirlpool Aide disinfecting the whirlpool revealed that she used the shower handle that had a direct link to the disinfectant bottle to spray the inside of the whirlpool with the disinfectant and immediately began to wipe down the area around the water line of the whirlpool with a washcloth. She then rinsed the whirlpool with water and stated that was how she cleaned the whirlpool between residents. When asked about wiping down the other parts of the whirlpool, the S5Whirlpool Aide stated that at the end of the day she takes the seat and other pieces off to disinfect them. She further stated that she assists about 10-15 residents each day in the whirlpool. An observation revealed that the whirlpool did not have the capability of automatically diluting the disinfectant cleaner. S5Whirlpool Aide confirmed that the disinfectant was coming straight from the bottle and no water was being added to the disinfectant. The cleaning process took a total of about 5 minutes while the surveyor interviewed her. As the surveyor was leaving, S5Whirlpool aide assisted Resident #142 into the whirlpool room. A review of an in-service held on 08/26/14 and 08/27/14 titled Bath: Bathtub and Whirlpool Disinfecting revealed the following procedure for bathtub disinfecting (whirlpool tubs were the only tubs offered in the facility): 1. After each bath, spray approved disinfectant over entire side of tub and faucet fixtures, 2. Wipe entire inside of tub and faucet fixtures with a sponge, 3. Rinse thoroughly with clean water, and 4. At the end of each day, the inside of the tubs must be thoroughly scoured with disinfectant and rinsed thoroughly. The procedure for whirlpool disinfecting was as follows: 1. Due to many different models of whirlpool tubs, please see manufacturer's guidelines for precise cleaning and disinfecting instructions. A review of the sign in sheet revealed that S4Whirlpool Aide (works the North end of the 200 hall whirlpool room) had not signed in attendance. An interview with S20ADON on 03/11/15 at 11:45AM revealed that she and S19CNA Supervisor monitors the whirlpool cleaning process. She confirmed that there is no documentation of monitoring of the CNA staff disinfecting of the whirlpools. When asked why S4Whirlpool aide was not on the in-service sign-in sheet 08/26/14, she stated that S4Whirlpool Aide had not been employed by the facility that long. When asked about new hire training, she stated that the new hires are trained on the use and cleaning of the whirlpool by the whirlpool aide that currently works in the whirlpool room or the CNA Supervisor. She further confirmed that no documentation of training on hire for the use or disinfecting of the whirlpool is maintained. S20ADON stated that she observed a whirlpool given by S21CNA in mid-January 2015 where she saw the S21CNA use a spray bottle to apply the disinfectant to the whirlpool, use a washcloth to wipe it down, and then rinse with water. She further stated that the entire process from start to finish took about 3 minutes. She confirmed that no annual skills/performance check-off evaluations were done. When asked how they determine the topics for the 12 hours of yearly in-services if they do not have any evaluation measures in place, she stated she was not sure of that. As she was interviewed and realized they were not cleaning the whirlpool per the manufacturer's guidelines she stated, Y'all need to tell us what we need to do. An interview with S19CNA Supervisor on 03/11/15 at 12:15PM revealed that she and S20ADON monitor the use and disinfecting of the whirlpool. She stated that the whirlpool Aide that currently works in the whirlpool room on each floor trains the new hires on the use and disinfecting of the whirlpool. When ask if she had observed at any time the process of cleaning the whirlpool, she stated that she had assisted last week with Resident #55 because the resident had a loose stool during her whirlpool bath. She stated that after getting the resident out of the whirlpool they let out the water, sprayed the whirlpool with disinfectant all over the inside surface, and used a brush to clean all areas of the whirlpool. She further stated that the whirlpool was then rinsed with water and was then ready for use by the next resident. She stated that the entire process took 5-6 minutes from start to finish. When asked if the disinfectant was diluted in any way she stated No. S19CNA Supervisor also stated that she was trained by a CNA Supervisor at the time of her hire. When shown the facility policy that stated to check the manufacturer's guidelines for cleaning the whirlpool, which was included in the in-service she had given on 08/26/14 and 08/27/14, she stated that she was not aware of the manufacturer's guidelines and the facility had not provided her with a copy of the manufacturer's guidelines. When asked if she had ever read the manufacturer's guidelines printed on the label of the disinfectant bottle, she stated, No, I have not. S19CNA Supervisor confirmed that she does not keep documentation when she observes the use and disinfecting of the whirlpool. An interview with S1Administrator on 03/11/15 at 2:10PM confirmed that no annual skills/performance evaluations or return demonstrations have been conducted for CNA staff who perform the whirlpool baths on the 100 and 200 halls.

Based on observation, record review, and interview, the facility failed to identify and / or implement plans of action to correct quality deficiencies through the QAA (Quality Assessment and Assurance) Committee. The deficient practice involved infection control issues regarding the facility not disinfecting the 2 whirlpool tubs in the facility according to the manufacturer's guidelines. The deficient practice resulted in a situation involving 43 (#'s 120, 141, 100, 31, 47, 48, 30, 17, 80, 23, 35, 49, 28, 94, 67, 134, 72, 4, 115, 42, 25, 62, 85, 107, 142, 19, 16, 55, 109, 106, 22, 14, 44, 7, 8, 65, 114, 124, 29, 68, 5, 36, 104) residents that received a whirlpool bath out of a total sample of 89 (#'s 120, 143, 112, 141, 139, 100, 31, 89, 47, 45, 117, 38, 102, 48, 30, 17, 80, 23, 35, 49, 28, 135, 94, 144, 98, 67, 134, 72, 4, 115, 137, 131, 42, 66, 6, 140, 99, 25, 12, 27, 57, 24, 126, 95, 79, 77, 62, 85, 107, 64, 142, 74, 92, 19, 10, 130, 18, 63, 3, 16, 127, 55, 109, 46, 41, 52, 106, 22, 14, 44, 7, 8, 65, 103, 114, 70, 124, 29, 68, 61, 5, 1, 59, 36, 104, 32, 71, 51, 15) residents listed on the bath day report roster dated 03/09/15 to 03/11/15. There were a total of 91 residents in the facility according to the Resident Census and Conditions of Residents form (CMS 672). Findings: Cross refer to finding at Tag F441 Cross refer to finding at Tag F490 Cross refer to finding at Tag F498 An interview with S20ADON on 03/11/15 at 11:45AM revealed that she and S19CNA Supervisor monitors the whirlpool cleaning process. She confirmed that there is no documentation of monitoring of the CNA staff disinfecting of the whirlpools. When asked why S4Whirlpool aide was not on the in-service sign-in sheet 08/26/14, she stated that S4Whirlpool Aide had not been employed by the facility that long. When asked about new hire training, she stated that the new hires are trained on the use and cleaning of the whirlpool by the whirlpool aide that currently works in the whirlpool room or the CNA Supervisor. She further confirmed that no documentation of training on hire for the use or disinfecting of the whirlpool is maintained. S20ADON stated that she observed a whirlpool given by S21CNA in mid-January 2015 where she saw the S21CNA use a spray bottle to apply the disinfectant to the whirlpool, use a washcloth to wipe it down, and then rinse with water. She further stated that the entire process from start to finish took about 3 minutes. She confirmed that no annual skills/performance check-off evaluations were done. When asked how they determine the topics for the 12 hours of yearly in-services if they do not have any evaluation measures in place, she stated she was not sure of that. As she was interviewed and realized they were not cleaning the whirlpool per the manufacturer's guidelines she stated, Y'all need to tell us what we need to do. An interview with S19CNA Supervisor on 03/11/15 at 12:15PM revealed that she and S20ADON monitor the use and disinfecting of the whirlpool. She stated that the whirlpool Aide that currently works in the whirlpool room on each floor trains the new hires on the use and disinfecting of the whirlpool. When ask if she had observed at any time the process of cleaning the whirlpool, she stated that she had assisted last week with Resident #55 because the resident had a loose stool during her whirlpool bath. She stated that after getting the resident out of the whirlpool they let out the water, sprayed the whirlpool with disinfectant all over the inside surface, and used a brush to clean all areas of the whirlpool. She further stated that the whirlpool was then rinsed with water and was then ready for use by the next resident. She stated that the entire process took 5-6 minutes from start to finish. When asked if the disinfectant was diluted in any way she stated No. S19CNA Supervisor also stated that she was trained by a CNA Supervisor at the time of her hire. When shown the facility policy that stated to check the manufacturer's guidelines for cleaning the whirlpool, which was included in the in-service she had given on 08/26/14 and 08/27/14, she stated that she was not aware of the manufacturer's guidelines and the facility had not provided her with a copy of the manufacturer's guidelines. When asked if she had ever read the manufacturer's guidelines printed on the label of the disinfectant bottle, she stated, No, I have not. S19CNA Supervisor confirmed that she does not keep documentation when she observes the use and disinfecting of the whirlpool. On 03/13/15 at 4:00PM, an interview S1Administrator who was also the QAA committee person, confirmed that the QAA committee had not identified any issues and /or concerns regarding the disinfection of the facility's whirlpools. A review of the cumulative [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. with an Open Wound of the Leg, 2 with a Pressure Ulcer, Debility 4, Diabetes Mellitus 19, [MEDICAL CONDITION] 16, and Malnutrition/Weight Loss 6. An interview with S1Administrator and S22Corporate Vice President on 03/12/15 at 10:10AM confirmed that the whirlpool cleaning process was deficient and did not follow the manufacturer's guidelines.