Every finding on record at The Oaks

Based on record review and interviews, the facility failed to ensure all allegations of injuries of unknown source with serious bodily injury was reported immediately, or within 2 hours of the allegation to the Administrator for 1 (#1) of 4 sampled residents.Findings:Review of the facility's Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating Policy and Procedure, revision date [DATE], revealed the following, in part:Policy StatementAll reports of resident abuse (including injuries of unknown origin), neglect/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.Policy Interpretation and ImplementationReporting Allegations to the Administrator and Authorities1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies:a. The state licensing/certification agency responsible for surveying/licensing the facility.3. Immediately is defined as:a. Within two hours of the allegation involving abuse or result in serious bodily injury.Review of Resident #1's record revealed an admission date of [DATE] with diagnoses including unspecified atrial fibrillation, unspecified fractures of ribs right side, type 2 diabetes mellitus without complications, stroke, hypertension, and age related osteoporosis without current pathological fracture.Review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 13 indicating no cognitive impairment. Further review of MDS revealed resident required supervision or touching assistance with bed mobility, transfers, and toileting, and partial/moderate assistance with bathing. Resident had no functional limitations in ROM to upper and lower extremities and no falls since her last MDS assessment.Review of the facility reported incident dated [DATE] for Resident #1 revealed the resident was found lying on her stomach in her room by S3LPN on [DATE] around 6:30 a.m. Further review revealed Resident #1 was unresponsive and had a hematoma to the right side of her head and a laceration to the back of her head on the right side, and blood was noted on the floor. S3LPN sent Resident #1 to the local emergency room by the ambulance service, and the resident expired at the hospital on [DATE].An interview on [DATE] at 4:40 p.m. with S2DON revealed she was notified on [DATE] around 7:00 a.m. by S3LPN that Resident #1 was found on the floor unresponsive with a hematoma to the right side of her head and a laceration to back of right side of her head. S2DON confirmed she notified S1Corporate Administrator about this fall on [DATE] at 9:15 a.m., but failed to notify him the fall was unwitnessed with serious bodily injury which included unresponsiveness with a hematoma to the right side of her head and a laceration to the back of her head. An interview on [DATE] at 11:40 a.m. with S3LPN revealed she was working the night shift on [DATE] with Resident #1. S3LPN reported when she went into resident's room to administer her morning medications around 6:30 a.m. she found Resident #1 lying face down on the floor in her room and she was unresponsive, she assessed resident for injuries and found a bruise to the side of the resident's head and a laceration to the back of the resident's head. S3LPN reported she notified S2DON of this incident on [DATE] around 7:00 a.m.An interview on [DATE] at 10:30 a.m. with S1Corporate Administrator confirmed he was notified of Resident #1 having a fall on [DATE] at 9:15 a.m. by S2DON with no additional details. S1Corporate Administrator confirmed S2DON should have notified him immediately of Resident #1's unwitnessed fall which resulted in serious bodily injury including unresponsiveness with a hematoma and laceration to her head.

Abbreviations:BIMS- Brief Interview for Mental StatusMDS- Minimum Data SetRP- Responsible PartySSD- Social Services DirectorDON- Director of NursingBased on record reviews and interviews, the facility failed to ensure the resident had the right to participate in the development and implementation of their person-centered plan of care by not inviting the resident and/or responsible party to quarterly care plan meetings for 3 (#1, #2, and #3) of 4 sampled residents reviewed.Findings:Resident #1Review of Resident #1's record revealed an admission date of [DATE] with diagnoses including unspecified atrial fibrillation, unspecified fractures of ribs right side, type 2 diabetes mellitus without complications, stroke, hypertension, and age related osteoporosis without current pathological fracture.Review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 13 indicating no cognitive impairment. Review of the record revealed Resident #1 expired at the hospital on [DATE]. Further review of the record revealed no documented evidence of quarterly care plan meetings for Resident #1An interview on [DATE] at 11:15 a.m. with S4SSD confirmed she was hired in [DATE] and was responsible for scheduling care plan meetings quarterly for Resident #1 but had not scheduled any care plan meetings.An interview on [DATE] at 12:00 p.m. with S2DON confirmed the facility failed to conduct care plan meetings for Resident #1.Resident #2Review of Resident #2's record revealed an admission date of [DATE] with diagnoses including conversion disorder with seizures or convulsions, unspecified dementia severe with other behaviors disturbance, benign prostatic hypertrophy with lower tract symptoms, vascular dementia severe with agitation, primary syphilis of other sites, hypertension, malignant neoplasm of prostate, other acute kidney failure, other specified depressive episodes, repeated falls, other specified mental disorders due to known physiological condition. Review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 6 indicating severe cognitive impairment. An interview on [DATE] at 11:15 a.m. with S4SSD confirmed she was hired in [DATE] and was responsible for scheduling care plan meetings quarterly for Resident #2 but had not scheduled any care plan meetings. S4SSD revealed the last care plan meeting for Resident #2 was on [DATE].An interview on [DATE] at 12:00 p.m. with S2DON confirmed the facility failed to conduct care plan meetings for Resident #2. Resident #3Review of Resident #3's record revealed an admission date of [DATE] with diagnoses including Bell's Palsy, chronic pain syndrome, paroxysmal atrial fibrillation, gastro-esophageal reflux disease without esophagitis, chronic diastolic (congestive) heart failure, major depressive disorder, trigeminal neuralgia generalized anxiety disorder, metabolic encephalopathy, and Parkinson's disease. Review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 12 indicating moderate cognitive impairment. An interview on [DATE] at 11:15 a.m. with S4SSD confirmed she was hired in [DATE] and was responsible for scheduling care plan meetings quarterly for Resident #3 but had not scheduled any care plan meetings.An interview on [DATE] at 12:00 p.m. with S2DON confirmed the facility failed to conduct care plan meetings for Resident #3.

Based on record review and interviews the facility failed to ensure the Infection Preventionist, who was responsible for the facility's infection prevention and control program, had completed specialized training in infection prevention and control. Findings: Review of the facility's Infection Control Records revealed there was no documented evidence the Infection Preventionist, S5Licensed Practical Nurse (LPN), had completed specialized training in infection prevention and control. On 06/10/2025 at 9:50 a.m. an interview with S5LPN revealed she did not have any specialized training in infection prevention. On 06/10/2025 at 1:10 p.m. an interview with S2Director of Nursing (DON) confirmed the facility did not have a nurse that had received specialized training in infection prevention.

Based on observations, interviews, and record reviews the facility failed to ensure adequate supervision and assistive devices to prevent accidents were in place for 1 (#23) of 5 (#5, #11, #14, #23, #30) residents investigated for accidents. The failed practice was evidenced by Resident #23 being identified as an unsafe smoker, she was observed smoking without a smoking apron, and was observed having smoking articles in her possession without direct supervision. Findings: Review of the facility`s Smoking Policy, with a revision date of June 2024, revealed in part the following: 4. All unsafe smoking residents shall wear a smoking apron while smoking in the designated smoking area. 15. Smoking articles for residents without independent smoking privileges: a. Residents without independent smoking privileges may not have or keep any types of smoking articles except when they are under direct supervision. Record review revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including Parkinson`s disease, schizoaffective disorder, vascular dementia, and urinary tract infection. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment. Review of the facility`s most recent smoking assessment for Resident #23 dated 01/28/2025 revealed Resident #23 had 1) insufficient fine motor skills needed to securely hold a cigarette, 2) burns to skin, clothing, or furniture, and 3) dropped ashes on herself. The assessment also revealed the following concerns: unable to light a cigarette safely, unable to hold a cigarette safely, unable to extinguish a cigarette safely, and unable to use an ashtray to extinguish a cigarette. On 06/09/2025 at 10:15 a.m., observation revealed Resident #23 got 2 cigarettes and a lighter from S3Licensed Practical Nurse (LPN) as she was administering medications to other residents. Resident #23 was observed rolling herself in her a wheelchair toward the smoking room with the 2 cigarettes and lighter without direct supervision. On 06/09/2025 at 10:40 a.m., Resident #23 was observed smoking a cigarette in the designated smoking room. S4Certified Nursing Assistant (CNA) reported Resident #23 only required supervision to smoke. Resident #23 was not wearing a smoking apron. On 06/10/2025 at 1:53 p.m., an interview with S2 Director of Nursing (DON) confirmed Resident #23 was an unsafe smoker. S2DON confirmed Resident #23 should wear an apron when smoking and should be supervised when she had possession of smoking articles. S2DON was informed Resident #23 was given a cigarette lighter and 2 cigarettes by S3LPN while in the hallway. S2DON was also informed Resident #23 rolled herself in her wheelchair down the hallway with the lighter and she had cigarettes in her possession without direct supervision.

Based on record reviews and interviews, the facility failed to ensure residents that received psychotropic drugs had a gradual dose reductions, and residents that had orders for psychotropic medications as needed (PRN) were not subjected to chemical restraints for 2 (#5, #19) of 6 (#5, #19, #25, #30, #38, #43) residents reviewed for unnecessary medications. The facility failed to ensure: 1). A resident that was on psychotropic drugs received gradual dose reductions (#19); and 2). PRN orders for psychotropic drugs were limited to 14 days (#5, #19). Findings: Resident #19: Record review revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including vascular dementia, generalized anxiety disorder, and chronic obstructive pulmonary disease. Record review of the significant change Minimal Data Set (MDS) dated [DATE] revealed Resident #19 had a brief mental status score (BIMS) of 15 which indicated she had no cognitive impairment. Further review revealed she required partial - moderate assistance for most activities of daily living (ADL). Review of Resident #19's June 2025 physician orders revealed an order for Buspar 10 milligrams (mg) every 8 hours as needed (PRN). Review of the Resident's June 2025 Medication Administration Record (MAR) revealed documentation the resident had received Buspar 10mg on 06/04/2025 and 06/10/2025. Review of the Pharmaceutical Consultant Report dated 01/13/2025 revealed the following recommendation for Buspar 10mg q 8 hours prn: a PRN psychotropic is limited to 14 days and required the prescriber to evaluate the Resident prior to extending the order. If extending the order, document the rationale for the extended time period in the medical record and indicated a specific duration. Review of May 2025 Consultant Pharmacist Drug Regimen Review (DRR) revealed the following recommendation for Buspar 10mg every 8 hours prn: provide specific duration/stop date for the PRN psychotropic medication due to the medication is limited to 14 days and required the prescriber to evaluate the resident. Further review revealed there was no documentation the facility addressed the above recommendation. On 06/11/2025 at 2:45p.m., S2Director of Nursing (DON) confirmed the above recommendation from the consultant pharmacist was not addressed in a timely manner and Resident #19 continued to receive the Buspar 10mg every 8 hours prn. S2DON also confirmed, the facility failed to ensure that Resident #19 received a gradual dose reduction for the past year per the consultant pharmacist recommendations. 18118 Resident #5: Review of the medical record for sampled Resident #5 revealed an admitted [DATE]. Resident #5 had diagnoses which included shortness of breath, diabetes mellitus, heart disease, anxiety and depression. Review of the quarterly MDS assessment dated [DATE] revealed Resident #5 had a BIMS score of 15, which indicated the Resident had intact cognition for daily decision making. Review of the June 2025 physician's orders dated 02/12/2025 revealed an order for Alprazolam (Xanax) 0.5 mg to be given every 8 hours as needed for anxiety. Review of the June 2025 MAR revealed Resident #5 received Xanax 0.5 mg prn on 06/07/2025. Review of the April 2025 and May 2025 Consultant Pharmacist DRR revealed the following recommendation for Xanax .5 mg every 8 hours prn: provide specific duration/stop date for the prn psychotropic medication due to the medication is limited to 14 days and requires the prescriber to evaluate the Resident. Further review revealed there was no documentation the facility addressed the above recommendation. On 06/11/2025 at 2:45 p.m. an interview with S2DON confirmed the above recommendation from the pharmacist consultant was not addressed in a timely manner and Resident #5 continued to receive the Xanax 0.5 mg every 8 hours prn.

Based on record reviews, and interviews the facility failed to ensure residents were informed of the risks, benefits and side effects of psychotropic medications for 6 (#19, #38, #25, #30, #43, #5) of 6 (#19, #38, #25, #30, #43, #5) residents reviewed for unnecessary medications. Findings: Resident #38 Review of the medical record for Resident #38 revealed she had an admitted [DATE] with diagnoses which included anxiety and depression. Review of the physician orders revealed Resident #38 received the psychotropic medications Alprazolam 0.25 milligrams (mg) daily and Olanzapine 5 mg daily for the treatment of anxiety and Sertraline 50 mg daily for the treatment of depression. Review of the medical record revealed there was no documentation of a consent for the psychotropic medications. Resident #25 Review of the medical record for Resident #25 revealed she was admitted on [DATE] with diagnosis which included depression. Review of the physician orders revealed Resident #25 received Trintellix 20 mg daily and Seroquel 150 mg daily for the treatment of depression. Review of the medical record revealed there was no documentation of a consent for the psychotropic medications. Resident #30 Review of the medical record for Resident #30 revealed she was admitted on [DATE] with diagnosis which included depression. Review of the physician orders revealed Resident #30 received Escitalopram 10 mg daily for the treatment of depression. Review of the medical record revealed there was no documentation for the consent for the psychotropic medication. Resident #43 Review of the medical record for Resident #43 revealed he was admitted on [DATE] with diagnosis which included depression. Review of the physician orders revealed Resident #43 received Lexapro 10 mg daily for the treatment of depression. Review of the medical record revealed there was no documentation for the consent for the psychotropic medication. 18118 Resident 5 Review of the medical record for Resident #5 revealed an admitted [DATE] with diagnoses which included anxiety and depression. Review of the June 2025 physician's orders for Resident #5 dated 02/12/2025 revealed an order for Alprazolam 0.5 mg to be given every 8 hours as needed for anxiety. Further review of the orders revealed an order dated 02/20/2025 for Lexapro 10 mg to be administered every day. Review of the medical record revealed there was no documented evidence of a psychotropic medication consent obtained prior to administering the medications. 22575 Resident #19 Review of the medical record for Resident #19 revealed she had an admitted [DATE] with diagnoses of generalized anxiety disorder and depression. Review of the physician orders revealed Resident #19 received the following psychotropic medications: Rexulti 2mg by mouth daily, Cymbalta 30mg by mouth twice daily, and Buspar 10mg 1 by mouth every 8 hours as needed. Review of the medical record revealed there was no documentation of a consent for the psychotropic medications. On 06/10/2025 at 11:10a.m., interview with S2Director of Nurses (DON) confirmed the facility had not obtained consents for any resident that currently received psychotropic medications.

Based on interviews and record reviews, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs by failing to obtain laboratory examinations as ordered by the physician for 1 (#43) of 6 (#19, #38, #25, #30, #43, #5) sampled residents reviewed for unnecessary medications. Findings: Resident #43 Review of the medical record for Resident #43 revealed he had an admitted [DATE] with diagnoses which included diabetes, depression, gastroenteritis and colitis. Review of the physician orders revealed the resident received Lexapro 10 milligrams (mg) daily, Lipitor 40 mg daily, and Novolog insulin three times daily and as needed based on blood sugar levels. Review of the physician orders revealed an order dated 05/03/2025 for the following lab work: Lipids to be drawn annually; Complete Metabolic Panel (CMP) and Complete Blood Count (CBC) to be drawn every 6 months; and a Hemoglobin A1C to be obtained every 3 months. Further review revealed a physician order dated 04/30/2025 to obtain a CBC, CMP, and Thyroid Stimulating Hormone (TSH) level. Review of the medical record revealed there was no evidence the above lab work had been obtained as ordered. On 06/11/2025 at 7:45a.m., an interview with S2Director of Nursing (DON) confirmed the lab work was not obtained as ordered.

Based on record reviews and interviews, the facility failed to ensure it had sufficient nursing staff with appropriate competencies and skills to provide nursing services to maintain the highest practicable physical, mental, and psychosocial well-being of each resident by having staff fail to follow physician orders for 1 (#38) of 6 (#19, #38, #25, #30, #43, #5) residents reviewed for unnecessary medications. The failed practice was also evidenced by staff not implementing physician orders in a timely manner for 1 (#23) of 1 (#23) residents investigated for the use of antibiotics. Findings: Resident #38 Review of the medical record for Resident #38 revealed she was admitted on [DATE] with a diagnosis of diabetes. Review of the June 2025 physician orders revealed a finger stick blood sugar (FSBS) check was to be performed 4 times daily and the physician was to be notified if a blood sugar was greater than 301. Review of the blood sugar monitoring revealed the following blood sugar results of 301 or greater. On 06/02/2025 at 6:00 a.m., Resident #38`s FSBS was 436. On 06/03/2025 at 4:00 p.m., Resident #38`s FSBS was 323. On 06/04/2025 at 4:00 p.m., Resident #38`s FSBS was 323. Review of the progress notes revealed there was no documentation that the physician was notified of Resident #38's above high blood sugar levels. On 06/10/2025 at 11:10 a.m., interview with S2Director of Nursing (DON) confirmed there was no documentation the physician was notified of Resident #38`s high blood sugar results. 40238 Resident #23 Record review revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including Parkinson`s disease, schizoaffective disorder, vascular dementia, and urinary tract infection. Review of the most recent Minimum Data Set assessment dated [DATE] revealed Resident #23 had a Brief Interview of Mental Status score of 12 which indicated moderate cognitive impairment. Review of lab results revealed a urinalysis pathogen report dated 06/04/2025 which indicated Resident #23 had pathogens present in her urine. An order for Doxycycline 100 milligrams (mg) was written and signed by a physician on 06/04/2025 at the bottom of the report. S6Licensed Practical Nurse (LPN) signed the order on 06/06/2025. Review of the June 2025 Medication Administration Record (MAR) revealed the first dose of Doxycycline 100 mg was given on 06/07/2025 at 8:00 a.m. On 06/10/2025 at 3:34 p.m., S2DON was informed an order for Doxycycline 100 mg was written by a physician on 06/04/2025 at 6:06 p.m. for Resident #23 and the order was signed by S6LPN on 06/06/2025 at 9:00 a.m. S2DON was also informed the first dose of the Doxycycline was administered on 06/07/2025 at 8:00 a.m.

Based on observations, record reviews, and interviews the facility failed to develop a comprehensive person-centered care plan that addressed declined care or services for 2 (#30, #1) of 25 (#57, #218, #13, #365, #19, #38, #49, #217, #58, #46, #32, #25, #24, #30, #215, #59, #47, #17, #36, #29, #16, #27, #216, #14, #43, #1, #51, #56, #40, #26, #42, #50, #11, #9, #23, #5, #6) total sampled residents. Findings: Resident #30 Review of the medical record for Resident #30 revealed an admitted [DATE] with diagnoses that included Parkinson's disease with dyskinesia, hypertension, repeated falls, and major depressive disorder. Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated that Resident #30 was cognitively intact. Additionally, the MDS documented that Resident #30 required set-up or clean-up assistance with meals. Review of the Physician's Orders documented Resident #30's diet as pureed texture with nectar liquids. Review of the dietary note dated 02/26/2025 documented that Resident #30 was non-compliant with the ordered diet. Review of the current plan of care revealed no documentation related to Resident #30's non-compliance with the ordered diet. On 06/11/2025 at 11:10 a.m., an interview with S2Director of Nursing (DON) was conducted. S2DON was informed that Resident #30's non-compliance with the ordered diet was not documented in the plan of care. 22575 Resident #1 Review of the medical record for Resident #1 revealed an admitted [DATE] with a diagnosis of spastic quadriplegic cerebral palsy. Review of the Quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated that Resident #15 was cognitively intact. Additionally, the MDS documented that Resident #15 was dependent on staff for all activities of daily living. On 06/09/2025 at 9:00 a.m. and 4:50 p.m. revealed Resident #1 was observed in her customized wheelchair with her legs dangling with no support noted to her lower extremities. On 06/10/2025 at 10:10 a.m. and 1:00 p.m. revealed Resident #1 was observed in her customized wheelchair with her legs dangling with no support noted to her lower extremities. Review of the current plan of care revealed no documentation related to Resident #1's non-compliance with the use of the wheelchair leg rests. On 06/11/2025 at 11:10 a.m., an interview with S2DON was conducted. S2DON was informed that Resident #1's non-compliance with the use of the wheelchair leg rests was not documented in the plan of care.

Based on observation of the medication pass, review of current physician orders, and interviews, the facility failed to ensure that it is free from medication error rate of five percent or greater by committing 2 errors out 32 opportunities for an error rate of 6.25%. Findings: Observation of the medication pass on 06/11/2024 at 7:24 a.m. for resident #267 revealed the following medication errors. Citracal-D3 200mg (milligrams) - 250 Unit, (Calcium Citrate supplement) 1 tablet daily. This medication was not administered. Review of the June 2024 physician orders for resident #267 revealed an order for Citracal-D3, 200mg-250Unit, 1 tablet daily at 8:00 a.m. Interview on 06/12/2024 at 10:40 a.m. with S3Licensed Practical Nurse (LPN) confirmed that she did not administer the medication Citracal-D3 to resident #267. S3LPN stated that this medication was not available. Observation of the medication pass for resident #267 on 06/11/2024 at 7:24 a.m. revealed S3LPN administered the angiotensin-converting enzyme inhibitor, Lisinopril, 20mg, 1 tablet. Review of the June 2024 physician orders for resident #267 revealed an order for Lisinopril 10mg, one tablet daily. Interview on 06/12/2024 at 12:55 p.m. with S3LPN confirmed that she administered Lisinopril 20mg tablet instead of Lisinopril 10mg. Further interview with S3LPN confirmed that the correct order was for Lisinopril 10mg daily. Interview on 06/12/2024 at 1:50 p.m. with S2Director of Nursing (DON) confirmed that medications are to be administered as ordered. S2 DON was informed of medication errors at this time. S2DON confirmed that she was notified by S3LPN that she did not administer medication Citracal to resident #267 and that resident #267 should have been administer Lisinopril 10mg instead of 20mg.

Based on record review, observations, and interviews, the facility failed to provide adequate supervision to prevent accidents and ensure the resident's environment remained free of hazards for 1 (#62) of 3 (#31, #37, #62) residents reviewed for safe smoking. Findings: Review of the facility's Smoking Policy with a revision date of 2023 revealed in, part: This facility shall establish and maintain safe resident smoking practices, to incorporate smoking safely and take into account non-smoking residents. Policy Interpretation and Implementation: All residents shall wear a smoking apron while smoking in the designated smoking area. Any smoking related privileges, restrictions, and concerns (for example, the need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. The facility may impose smoking restrictions on residents at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision. Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. Smoking articles for residents without independent smoking privileges: Resident's without independent smoking privileges may not have or keep any types of smoking articles except when they are under direct supervision. Smoking shall not be permitted in bed. Violation will result in immediate discharge from the facility. Violation of all or any portion of the smoking policy will result in immediate discharges from the facility. Review of the medical record for resident #62 revealed an admitted [DATE] with diagnoses of type 2 diabetes mellitus, cellulitis of right lower limb, alcohol dependence, noncompliance with medical treatment, repeated falls, hypertension, and nicotine dependence. Review of the quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 11,which indicated moderate cognitive impairment. Review of resident #62's current care plan revealed, a potential for injury related to smoking cigarettes as an unsafe smoker. Inventions: Resident will have a designated smoking area; Resident was assessed to be an unsafe smoker on 04/23/2024. Further review of the care plan revealed 05/06/2024 resident found smoking in his room; 06/01/2024 resident caught smoking in his room; 06/06/2024 had care plan meeting with the resident's sister and ombudsman regarding the resident smoking in his room. Review of the Smoking Evaluation Tool dated 06/01/2024 revealed the interdisciplinary team determined resident #62 was an unsafe smoker due to intermittent confusion and smoking in his room. Review of the nurse note dated 04/09/2024 at 10:44 p.m. revealed resident #62 used the call light for assistance and when this nurse walked in the room it had a strong cigarette odor. The nurse asked the resident if he had been smoking in his room and the resident #62 stated that it was just a little butt. The nurse then instructed the resident he cannot smoke in his room. Further review of the nurses notes dated 06/01/2024 at 9:13 a.m. revealed the CNA (Certified Nurse Aide) notified the nurse that resident #62 was sitting in his room smoking a cigarette. This nurse notified the resident this was unacceptable and took the cigarette. Review of the nurse note dated 06/10/2024 at 9:36 p.m. revealed resident #62 is being monitored in the smoking area tonight. Resident #62 was seen putting ashes in the trash can instead of the designated smoking container. The nurse informed the resident to only put ashes in the cigarette container due to the risk and danger with putting them in the trash can. Resident #62 stated he put water in the trash can so it was ok. The nurse moved the trash can and placed designated smoking container close to resident. Observation on 06/10/24 at 09:23 a.m. revealed resident #62 was sitting in a wheel chair in the designated smoking area. Resident #24 was seen lighting a cigarette for resident #62. Further observation revealed resident #62 smoked the cigarette and was placing the cigarette ashes and butt in a garbage can that contained a plastic liner and trash. Resident #62 was not wearing a smoking apron and no staff were present to monitor residents. Interview on 06/11/2024 at 1:40 p.m. with S4LPN (Licensed Practical Nurse) confirmed that resident #62 was observed smoking last night (06/10/2024) and placing ashes in a garbage can. S4LPN stated that she has observed resident #62 on multiple occasions smoking in his room. S4LPN confirmed resident #62 was an unsafe smoker. Interview on 06/12/2024 at 8:15 a.m. with S1Director of Operations confirmed that resident #62 had been identified as an unsafe smoker and that staff had observed the resident smoking in his room on multiple occasions. S1Director of Operations also confirmed that the facility did not follow their policy and procedure in regards to the facility's smoking policy.

Based on observation, record review, and interview, the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 (#3) of 3 (#3, #30, and #60) residents investigated for pressure ulcers. The facility failed to prevent pressure ulcers from developing as evidenced by resident #3 having six unidentified pressure ulcers. Findings: Record review revealed resident#3 was admitted to the facility on [DATE] with diagnoses including a personal history of transient ischemic attack (TIA), cerebral infarction without residual deficits, severe vascular dementia, primary open-angle glaucoma, cerebral palsy and a Stage 4 pressure ulcer of the right hip. During wound care on 06/12/2024 at 8:45 a.m. with S5Wound Care Nurse (WCN) and S6WCN, a visual inspection of resident #3's right feet revealed one deep tissue injury to the posterior area of the great toe, the lateral part of the great toe, and heel. Observation of the left foot revealed there was one deep tissue injury to the lateral part of the 5th toe, posterior part of the lateral 5th toe, and left ankle. There was pillow underneath the resident's legs, however, the tips of his feet toughing and in direct contact with the bed mattress. S5WCN and S6WCN confirmed they were unaware of resident #3's six deep tissues to his feet. Further inspection of the resident's feet revealed there was an area between resident #3's toes on the left foot that had a thick, flaky, and crusty buildup of peeling skin. S5WCN and S6WCN both confirmed that confirmed that resident #3's toes needed to be cleaned. On 06/12/2024 at 9:58 a.m., an interview with resident #3's floor nurse, confirmed she too, was not aware of resident #3's six newly identified pressure ulcers to the feet as no one had reported them to her. On 06/12/2024 at 10:15 a.m., during an interview with S1Director of Operations, he was notified of the findings regarding resident #3's six newly identified pressure ulcers. During an interview on 06/12/2024 at approximately 3:45 p.m., S2Director of Nursing was notified of the findings regarding resident #3's six newly identified pressure ulcers.

Based on observation, record review, and interviews, the facility failed to ensure a resident who is unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 2 (#3 and #37) of 2 (#3 and #37) residents reviewed for Activities of Daily Living (ADL) care. The facility [NAME] to 1) ensure resident hand mitts were changed when dirty and 2) ensure that resident finger and toenails were kept clean and trimmed. Findings: Resident #3 Review of the Nail Management Policy and Procedure revealed the nail management was the regular care of the toenails and fingernails to promote cleanliness and skin integrity of tissues to prevent infection and injury from scratching by fingernails or pressure of shoes on toenails. Further review of the policy revealed that debris was to be removed from under the nails with an orange stick while soaking and to trim the nails with a clipper, straight across for the toenails, rounded for the fingernails. Review of resident's record revealed he was admitted to the facility on [DATE] with diagnoses including a personal history of transient ischemic attack (TIA), cerebral infarction without residual deficits, severe vascular dementia, primary open-angle glaucoma, cerebral palsy and a Stage 4 pressure ulcer of the right hip. On 06/11/24 at 11:14 a.m., an observation revealed resident #3 was lying in his bed. Further observation revealed resident #3's right hand had a mitt covering the hand. The outside the mitt (palm area) had a large area of an old, dried reddish-brown colored stain that covered approximately two thirds of the palm of the mitt. On 06/11/2024 at approximately 11:40 a.m., S3Licensed Practical Nurse (LPN) was notified of the findings regarding the stain on resident #3's hand mitt. After observing the mitt with S3LPN, she confirmed that the hand mitt was unclean and needed to be changed. She then reapplied the dirty hand mitt. On 06/11/2024 at 4:35 p.m., S2Director of Nursing (DON) was notified of the observation of resident #3's right hand mitt being stained. During an observation with S2DON, she removed the dirty hand mitt from resident #3's hand and a visual inspection of resident's right hand revealed the skin on the inside palm of the hand was crusty and dirty. Further observation revealed the resident's fingernails were jagged, long, and untrimmed. S2DON confirmed that resident #3's mitt needed to be changed, the resident's fingernails needed to be trimmed and cleaned, and resident #3's hand needed to be cleaned. On 06/12/2024 at approximately 4:00 p.m., S1Director of Operations was notified of the findings regarding resident #3. Resident #37 Review of resident #37's record revealed he was admitted to the facility on [DATE] with diagnosed including Parkinson's disease, vascular dementia, and shortness of breath. On 06/10/24 at 9:00 a.m., an observation revealed resident #37 lying in his bed. Further observation revealed the resident's toe nails to both feet were jagged and long. 06/11/2024 at approximately 4:20 p.m., S2DON was notified of the findings. After an observation with S2DON, she confirmed that resident #37's toe nails needed to be trimmed. On 06/12/2024 at approximately 4:05 p.m., S1Director of Operations was notified of the findings regarding resident #37.

Based on observations, record reviews and interviews the facility failed to protect the residents' right to be free from verbal abuse and mental abuse for 2 (#3 and #5) of 4 (#1, #2, #3 and #5) residents reviewed for abuse; evidenced by resident #4 used sexually inappropriate language and gestures toward resident #3 and resident #5. This deficient practice resulted in an actual harm for resident #5, who had moderate cognitive impairment, on 10/18/2023 at 1:15 p.m. when resident #4 made an inappropriate sexual comment and gesture to resident #5. This resulted in resident #5 becoming upset and crying. Resident #5 was assisted to her room and was consoled by staff. While being consoled by staff, Resident #5 remained upset and cried for approximatley10 minutes. This deficient practice resulted in an actual harm for resident #3, who was cognitively intact, on 11/22/2023 at approximately 2:50 p.m. when resident #4 made an inappropriate sexual comment and gesture to resident #3. This resulted in resident #3 feeling uncomfortable and feeling afraid that resident #4 would return to her room. Staff consoled resident #3 until resident #4 was sent out to the hospital the same day. Resident #3 also received counselling from an outpatient counselor that came to the facility on [DATE]. Findings: Review of facility's current Abuse and Neglect Prohibition Policy in part revealed: Each Resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. Fundamental information Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish. Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. Verbal abuse is defined as the use or oral, written or gestured language that willfully, includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Resident #4 Review of the medical record revealed resident #4 was admitted to the facility on [DATE], with a readmitted [DATE]. Resident #4 had diagnoses that included metabolic encephalopathy, acute respiratory failure unspecified with hypoxia or hypercapnia, shortness of breath, type 2 diabetes mellitus, hypertension, Alzheimer's disease, altered mental status, anxiety, and vascular dementia with behavioral disturbances. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status of 11, which indicated the resident had moderate cognition for daily decision making. The MDS also documented that resident #4 required limited assistance of two person physical assist with transfers, supervision and set up, and limited assistance / one person physical assistance with dressing, toileting, personal hygiene, and bathing. The assessment also documented the resident was ambulatory with a walker, his gait was not steady, and he had no Range of Motion (ROM) impairment in the upper or lower extremities. Review of the care plan for resident #4 revealed the resident had impaired cognition and short/long term memory loss related to diagnosis of dementia with behavioral disturbance. He also was care planned for alteration in mood states due to anxiety. Resident #5 Review of the medical record for resident #5 revealed an admitted [DATE] with diagnoses that included the following: cerebral infarction, hemiplegia following cerebral infarction affecting right dominant side, essential hypertension, schizophrenia, unspecified convulsions, aphasia following cerebral infarction, and congestive heart failure. Review of quarterly MDS assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status of 11, which indicated the resident had moderate cognition for daily decision making. The 10/24/2023 assessment documented that resident #5 had impairment of ROM on one side upper and lower extremity, used a wheel chair for locomotion, and required partial/moderate assistance with Activities of Daily Living (ADLs) including transfers. The assessment also showed resident #5 was able to feed herself with set up and supervision. Review of the care plan for resident #5 revealed Psychotropic medication use related behaviors with diagnoses of schizophrenia, depression, pseudobulbar affect. Review of a Resident Incident Report dated 10/18/2023 at 1:15 p.m. revealed resident #5 was nonverbal but attempted to inform staff that a male resident (resident #4) grabbed himself and made an inappropriate comment while on the hallway that was unwitnessed. On 11/28/2023 at 9:00 a.m. an interview with S4Registered Nurse (RN) reported that S3Certified Nursing Assistant (CNA) told her that resident #4 had grabbed his crotch in the dining room in front of resident #5 and told her to come get this big d---. S4RN reported that she did not witness the event and just documented what S3CNA told her. On 11/28/2023 at 9:20 a.m. interview with S3CNA revealed she was monitoring the dining room on 10/18/2023 before lunch and she reported that resident #4 stood up and faced resident #5 and grabbed his privates and told her Come get this big d---. S3CNA reported resident #5 began to cry and propelled herself out of the dining room. S3CNA revealed she followed resident #5 and assisted her to her room. Further interview with S3CNA revealed she stayed with resident #5 and consoled her while she was still upset and she continued to cry for about 10 minutes after returning to her room. On 11/28/2023 at 9:30 a.m. an observation and interview of resident #5 revealed she had expressive aphasia (difficulty speaking) and was not able to communicate verbally but was able to answer yes and no questions by shaking her head. Resident #5 revealed she understood what the surveyor was saying. Resident #5 nodded yes when asked if resident #4 had grabbed his privates and used sexually inappropriate language toward her in the dining room. The surveyor asked resident #5 if this upset her and made her cry, she nodded her head yes. On 11/28/2023 at 1:20 p.m. interview with S4RN revealed she went and checked on resident #5 on 10/18/2023 after this incident and she was crying and upset. S4RN asked resident #5 what happened and she could not understand her because resident #5 was upset and crying. S4RN revealed resident #5 cried for about 10 minutes in her room. Resident #3 Review of the medical record revealed resident #3 was admitted to the facility on [DATE] with diagnoses that included encephalopathy, diabetes mellitus, and generalized anxiety disorder. Review of quarterly MDS assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status of 14, which indicated the resident had intact cognition for daily decision making. Further review of the 11/07/2023 assessment revealed resident #3 had ROM impairment on both lower extremities and she required substantial/maximal assistance with transfers, dressing, personal hygiene, toileting and bathing. Review of the care plan revealed alteration in psychosocial wellbeing related to anxiety. Review of the Resident Incident Report dated 11/22/2023 at 2:50 p.m. revealed resident #3 had a male resident (resident #4) enter her room and make a sexual comment while touching himself through his pants. He did not expose himself or touch the resident at any time. Resident #3 showed some increased anxiety. On 11/27/2023 at 11:25 a.m. observation and interview with resident #3 revealed she was alert and oriented. Resident #3 reported about a week ago resident #4 came into her room and stood at the foot of her bed and said do you want to suck my d---, as he grabbed his privates. Resident #3 told him no and to leave. Resident #3 revealed she started yelling for someone to help her. Resident #3 revealed a guy from therapy department came to her room and she told him what happened. Then some nurses came to check on me and one of the nurses stayed with her. Resident #3 reported the incident made her feel uncomfortable and scared that he would come back into her room. On 11/27/2023 at 12:05 p.m. an interview with S5Rehab Director revealed on 11/22/2023 while he was in the therapy department he heard a female screaming Help, Help, Help. S5Rehab Director revealed he and S6Physical Therapy Assistant (PTA) exited the therapy department and they noticed resident #4 exiting resident #3's room and walk back to his room. S5Rehab Director revealed he went into resident #3's room and she was upset and crying. Resident #3 reported that resident #4 had come into her room and asked her if she wanted to suck his d--- and she reported he grabbed his privates. On 11/27/2023 at 2:20 p.m. interview with S2Director of Nursing (DON) revealed she received a call from S8MDS Nurse on 11/22/2023 around 3:55 p.m. about what had occurred between resident #3 and resident #4. S2DON reported she instructed S8MDS Nurse to notify the physician and to get resident #4 to a behavioral health unit as soon as possible. On 11/27/2023 at 2:30 p.m. a telephone interview with S7RN revealed she was in the MDS office with S8MDS Nurse and S9Wound Care Nurse when S5Rehab Director informed them of the incident between resident #3 and resident #4. S7RN reported that she, S8MDS Nurse and S9Wound Care Nurse went to resident #3's room to check on her. S7RN reported that resident #3 was visibly still upset. On 11/28/2023 at 2:18 p.m. interview with S9Wound Care Nurse revealed she stayed with resident #3 and comforted her until after resident #4 had been sent out to the hospital. S9Wound Care Nurse reported resident #3 revealed she was afraid he would come back to her room. S9Wound Care Nurse revealed she continued to comfort her and reassure her resident #4 would not be coming back to her room and that he would be going to the hospital. Review of social worker noted dated 11/22/2023 at 6:11 p.m. revealed S10Social Worker went to check on resident #3 regarding the inappropriate comments and gestures that were made toward her by a male resident. She stated she was doing ok, just shocked about what had happened. During conversation social worker mentioned getting an outpatient counselor to come see her regarding what happened. Resident #3 said she would like that. On 11/27/2023 at 3:00 p.m. an interview with S10Social Worker reported she contacted local counselor on 11/22/2023 to come to the facility to talk with resident #3 and the counselor came to the facility and talked with resident #3 in her room that same day.

Based on record review and interviews the provider failed to ensure all allegations of verbal abuse / mental abuse was reported immediately, but no later than 2 hours after the allegation is made, to the State Survey Agency in accordance with State laws. The facility failed to: 1) report an allegation of verbal abuse and mental abuse to the state agency for 1 (#5) of 4 (#1, #2, #3, and #5) residents reviewed for abuse; and 2) report an allegation of verbal and mental abuse to the state agency within 2 hours of becoming aware of the abuse within 2 hours of becoming aware of the abuse situation, for 1 (#3) of 4 (#1, #2. #3, and #5) residents reviewed for abuse. Findings: Review of facility's current Abuse and Neglect Prohibition Policy in part revealed: Each Resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. Fundamental information Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish. Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. Verbal abuse is defined as the use or oral, written or gestured language that willfully, includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Investigation 1. The facility will conduct an investigation of any alleged abuse/neglect or misappropriation of resident property in accordance with state law. 2. The facility will report such allegations to the state, as per state regulation. 3. The facility will report all investigation findings to the state as per state regulations. Resident #5 Review of the medical record for resident #5 revealed an admitted [DATE] with diagnoses that included the following: cerebral infarction, hemiplegia following cerebral infarction affecting right dominant side, essential hypertension, schizophrenia, unspecified convulsions, aphasia following cerebral infarction, and congestive heart failure. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) of 11, which indicated the resident had moderate cognition for daily decision making. The 10/24/2023 assessment documented that resident #5 had impairment of ROM on one side upper and lower extremity, used a wheel chair for locomotion, and required partial/moderate assistance with Activities of Daily Living (ADLs) including transfers. Review of a Resident Incident Report dated 10/18/2023 at 1:15 p.m. revealed resident #5 was nonverbal but attempted to inform staff that a male resident (resident #4) grabbed himself and made an inappropriate comment while on the hallway that was unwitnessed. On 11/27/2023 at 1:00 p.m. an interview with S1 Administrator confirmed he did not report to the State Survey Agency for this alleged allegation of abuse. Resident #3 Review of the medical record revealed resident #3 was admitted to the facility on [DATE] with diagnoses that included encephalopathy, diabetes mellitus, and generalized anxiety disorder. Review of quarterly MDS assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status of 14, which indicated the resident had intact cognition for daily decision making. Further review of the 11/07/2023 assessment revealed resident #3 had Range of Motion (ROM) impairment on both lower extremities and she required substantial/maximal assistance with transfers, dressing, personal hygiene, toileting and bathing. Review of the Resident Incident Report dated 11/22/2023 at 2:50 p.m. revealed resident #3 had a male resident (resident #4) enter her room and make a sexual comment while touching himself through his pants. He did not expose himself or touch the resident at any time. Resident #3 showed some increased anxiety. Review of the report sent into the State Survey Agency revealed the incident occurred on 11/22/2023 at 2:54 p.m. The report also indicated that the incident was discovered on 11/22/2023 at 2:54 p.m. The original notification to State Survey Agency was given via email on 11/23/2023 at 10:00 a.m. by S1Admininstrator. On 11/27/2023 at 8:20 a.m. an interview with S1Administrator revealed he did have an incident report he was working on to turn into the state, but he had issues with his password and was not able access and input the data into the state program. S1Administrator reported he emailed the State Survey Agency Office the initial information of the incident on 11/23/2023 at 10:00 a.m., which was after the 2 hour time frame for reporting incidents of abuse.

Based on observation, record review and interviews, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (#1) of 5 (#1 - #5) sampled residents. The facility failed to thoroughly investigate resident #1's falls and implement appropriate and new interventions following each fall. Findings: Observation of resident #1 on 10/09/2023 at 1:36 p.m. revealed the resident was ambulating with a walker down the hall to the activity room to play BINGO. Review of the medical record for resident #1 revealed the resident was admitted on [DATE] with the following diagnoses, in part: anxiety disorder, major depression, hypertension, muscle spasm, syncope and collapse, falls, low back pain, insomnia, osteoarthritis, intervertebral disc degeneration, fractured shaft of left radius and ulna (08/26/2023), and pain. Review of the significant change Minimum Data Set, dated dated dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated that the resident was cognitively intact. The resident required one person extensive assistance with bed mobility, dressing and personal hygiene. The resident required two person limited assistance with transfers and toilet use. Further review revealed the resident's balance during transitions from seated to standing position was not steady and the resident was only able to stabilize with assistance. The resident was occasionally incontinent of bladder and continent of bowel. Review of the Fall Risk assessment dated [DATE] revealed the resident was at high risk for falls. Review of the Resident Incident Report dated 08/25/2023 at 8:00 p.m. revealed: Resident bending over to pick up baby doll from the floor and lost balance. Review of the nurses notes dated 08/25/2023 at 8:00 p.m. revealed: found resident on the floor beside bed, complains of generalized pain, new order to send to emergency room for evaluation, resident did state she bent down to pick up her baby and kept going, out to emergency room via stretcher, 140/54, 92, and 98% at room air. Review of the care plan revealed the following intervention for this fall: instruct resident to call for assistance when picking up items out of reach. Review of the Resident Incident Report dated 08/26/2023 at 4:00 p.m. revealed the resident stated she was attempting to move her nightstand without assistance when she fell and landed on her left arm. Skin tear to left upper arm. Immediate actions taken: head to toe assessment, range of motion assessed, pain to left arm noted, vital signs obtained, ambulance service called and resident transferred to hospital for further evaluation, skin cleansed, triple antibiotic ointment and dressing applied, 144/74, 85, 18, 97.5 , and pain scale 6. Review of the care plan revealed the following intervention for this fall: fall mat at bedside. Review of the Resident Incident Report dated 08/29/2023 at 1:47 a.m. revealed the resident attempted to transfer unassisted from the bed to the restroom. Call light in reach, non-compliant with usage. No apparent injury. 98.2, 91, 20, 127/85, no pain. Review of the care plan revealed the following intervention for this fall: call for assistance with transfers. Review of the Resident Incident Report dated 09/08/2023 at 5:00 p.m. revealed: upon entering the room, found resident on the floor in the bathroom underwear was pulled up yet pants were not, lying on her right side with head facing the bathroom doorway, small amount of blood noted to right hand for skin tear to knuckles, no other injuries were noted. Resident was very slow to respond to this nurse, did respond to sternal rub, new order noted to send to hospital for evaluation. Out 5:35 p.m. 189/86, 109, 20, 97.3, pupils are equal, round and reactive to light and accommodation. Review of the care plan revealed the following intervention for this fall: call for assistance with toileting. An interview on 10/11/2023 at 9:50 a.m. with S2Director of Nursing (DON) confirmed resident #1's falls were not thoroughly investigated. S2DON further confirmed that following the fall on 08/26/2023, the fall mat at the bedside was not an appropriate intervention. S2DON confirmed the facility did not implement new approaches following the resident's falls on 08/29/2023 and 09/08/2023.

Based on observation, record review and interviews, the facility failed to provide a resident the right to participate in the development and implementation of his or her person-centered plan of care for 1 (#1) of 5 (#1 - #5) sampled residents. The facility failed to inform resident #1 prior to rearranging the furniture in her room. Findings: Observation of resident #1 on 10/09/2023 at 1:36 p.m. revealed the resident was ambulating with a walker down the hall to the activity room to play BINGO. Review of the medical record for resident #1 revealed the resident was admitted on [DATE] with the following diagnoses, in part: anxiety disorder, major depression, hypertension, muscle spasm, syncope and collapse, falls, low back pain, insomnia, osteoarthritis, intervertebral disc degeneration, and pain. Review of the significant change Minimum Data Set, dated dated dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated that the resident was cognitively intact. Review of the care plan revealed the resident was at risk for falls. Further review of the care plan revealed an intervention on 08/28/2023 of the following: bed moved against the wall for safety reasons. Further review revealed the resident moved own bed away from the wall and refused to leave the bed against the wall. The resident also removed the fall mat. An interview with resident #1 on 10/05/2023 at 3:28 p.m. revealed that the facility moved her bed and she did not want the furniture rearranged. An interview with S4Licensed Practical Nurse (LPN) on 10/09/2023 at 4:17 p.m. confirmed the resident's bed had been turned against the wall and the fall mat was at the bedside. S4LPN reported the resident did not want the furniture rearranged. An interview with S3Certified Nursing Assistant (CNA) Supervisor on 10/10/2023 at 8:55 a.m. revealed S3CNA Supervisor moved resident #1's bed against the wall and placed a fall mat beside the bed. CNA Supervisor confirmed she rearranged the resident's furniture without the resident's permission and confirmed that the resident did not want her furniture rearranged. An interview with S2Director of Nursing (DON) on 10/11/2023 at 9:50 a.m. confirmed the resident did not participate in the decision to rearrange her furniture as an approach to her falls. S2DON further confirmed the resident did not want her furniture rearranged.

Based on observation and interview, the facility failed to ensure that maintenance services were provided to maintain a safe environment for 1 (#19) of 1 (#19) sampled residents investigated for environmental issues. The facility failed to ensure Resident #19's bathroom flooring surface was not broken. On 07/10/23 09:53 a.m., an observation of resident #19's bathroom revealed there were circular patterns on the floor's surface that surround floor drain. Further observation revealed the areas that were not intact. Further observation revealed the areas on the floor were unevenly broken. On 07/11/2023 at 1:50 p.m., S2 Maintenance Supervisor was notified of the findings regarding resident #19's bathroom flooring being unevenly broken around the floor drain. S2 Maintenance Supervisor confirmed that he had not checked the resident's bathroom for any type of environmental issues and he had missed it. He confirmed floor was in need of repair and was a potential accident hazard for staff and /or visitors. On 07/12/2023 at 3:25 p.m., S1 Administrator was notified of the findings regarding the flooring in resident #19's bathroom being unevenly broken an in need of repair.

Based on observation, interview and record review the facility failed to ensure a resident received adequate supervision and assistive devices to prevent accidents by failing to implement interventions and by failing to monitor effectiveness and modify an intervention for 1 (#3) of 5 (#1, 2, 3, 4, 5) residents reviewed for falls. Findings: Resident #3 On 06/05/2023 at 07:45 a.m., Resident #3 was observed sitting in a wheelchair at the nursing station. She was alert but pleasantly confused. Resident #3 asked me what in the world are you doing here, with a smile on her face. I informed her I was there to be sure she and other residents were getting the help they needed. On 06/06/2023 at 08:35 a.m., Resident #3 was observed sitting in a wheelchair in front of her bedside table as an employee was changing the linens on the bed. Resident #3 had an empty breakfast tray in front of her and appeared to be sleeping. Resident #3 was easily aroused and confirmed she was very sleepy and needed to get back in bed. The employee acknowledged she was about to help her get back to bed. Resident #3 reported she got very tired after she ate. Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses that included arthritis, repeated falls, confusion and Alzheimer`s disease. Review of most recent MDS (minimum data set) dated 04/04/2023 revealed Resident #3 had a BIMS (brief interview of mental status) score of 11 which indicated moderate cognitive impairment. Review of Section G, (functional status), revealed Resident #3 needed staff to provide 1 person assistance for bed mobility, transfer between surfaces to or from: bed, chair, wheelchair, standing position, and for use of the toilet. Review of A/I (accident/incident) reports revealed Resident #3 had 7 falls since admission on 03/28/2023. The seven accidents/incidents were falls that occurred on 04/01/2023, 04/02/2023, 04/13/2023, 04/16/2023, 04/28/2023, 05/26/2023, and 06/06/2023. Review of falls: The fall on 04/01/2023 revealed Resident #3 called for help after she fell on the floor attempting to go to the bathroom without calling for assistance. Further review of the report revealed Resident #3 was placed back to bed with bed in low position and call light within reach for the immediate action after the incident. The report recorded Resident #3 was disoriented and did not follow commands. The fall on 04/01/2023 was not listed on the care plan. The fall on 04/02/2023 revealed Resident #3 was found on floor in her room. Resident #3 reported she fell trying to go to the restroom. An immediate intervention was for staff to make hourly rounds. Record review revealed no documentation of hourly rounds conducted. The fall on 04/13/2023 revealed Resident #3 was found lying on the safety mat at the bedside when she yelled for help Record review revealed there was no documentation that an investigation was conducted. The fall on 04/13/2023 was not listed on the care plan. The fall on 04/16/2023 revealed Resident on floor in bathroom calling for help and the report indicated she went to the restroom without assistance. The care plan listed nonskid socks as an intervention. The fall on 04/28/2023 revealed Resident #3 was found on the floor at the bedside with a nose bleed. A floor mat was listed as an intervention. Review of physician orders revealed no orders written for Resident #3 to have nonskid socks, a bedside fall mat, or hourly observation by staff. Review of nurse`s notes, MAR (medication administration record), TAR(treatment administration record) revealed no daily record of Resident #3 having nonskid socks, a bedside fall mat, or hourly observation by staff as directed by the care plan. On 06/07/2023 at 10:35 am, an interview with S2 DON (director of nurses) was conducted in her office. S2 DON confirmed Resident #3`s care plan had not been updated with interventions for 4 of the 7 falls. S2 DON confirmed Resident #3 did not have a daily record to reflect nonskid socks were being worn, a safety mat was at the bedside, and hourly observations were conducted as directed as an intervention after a fall.

Based on observation, record review and interview, the facility failed to ensure that nurse aides demonstrate competency in skills and techniques necessary to care for resident's needs, as identified through resident assessments, and described in the plan of care for 1 (#31) of 4 (#22, #31, #40, #243) residents reviewed for pressure ulcers. The facility failed to identify bruising to resident #31's left below the elbow amputation (stump). Findings: Review of the medical record for resident #31 revealed the resident was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set, dated dated dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. The resident required one person extensive assistance with bed mobility, transfer, dressing, personal hygiene and total assistance with eating, toilet use and bathing. The resident was always incontinent of bowel and bladder. Review of the care plan revealed at risk for skin tears/bruising related to resident having fragile skin. The approaches were as follows: use caution transferring/repositioning resident to prevent skin tears/bruising, monitor skin daily during care for skin tears/bruising. Review of the Braden risk assessment report dated 05/25/2022 revealed the resident scored an 11 which indicated high risk for pressure ulcers. Review of the Pressure Ulcer Prevention and Management Policy - 2. Preventive Protocol: The following preventive measures will be evaluated and implemented, as needed, on each resident considered to be at high risk. All preventative measures should be careplanned. 3. d. CNA reporting sheet: a skin problem sheet is available for CNAs to document the resident's name, condition found, their name and the name of the nurse to whom the condition was reported. The CNA should place the sheet in a designated location for later review by an administrative nursing staff member. Observation on 06/27/2022 at 11:45AM revealed the resident was asleep in his specialized wheelchair and the bottom of his left arm stump was touching the left wheel. There were bruises observed on his left arm stump. Observation at 12:53PM revealed the resident was awake in his specialized wheelchair and his left arm stump was on the arm rest. The arm rests are cushioned, but firm. Observation on 06/29/2022 at 9:10AM and 1:40PM revealed the resident is awake and in his specialized wheelchair and his left arm stump is lying on the arm rest. Observation of resident #31's skin with S3CNA (Certified Nursing Assistant) on 06/30/2022 at 9:53AM revealed the bruising on the resident's left arm stump. Interview with S3CNA at this time revealed the bruising was there on 06/28/2022. S3CNA revealed she would report new areas to the LPN (Licensed Practical Nurse) and she didn't think the area was a new area. Observation of resident #31's skin with S4LPN on 06/30/2022 at 10:50AM revealed the bruising on the resident's left arm stump. Interview with S4LPN at this time revealed she doesn't remember the bruises being there on 06/28/2022. S4LPN reported the CNAs should report any new issues to the LPN. Review of the weekly body audit on 06/24/2022 revealed the resident had no new skin issues. Observation of resident #31's skin with S6WCN (Wound Care Nurse) on 06/30/2022 at 12:40PM confirmed the bruising to the resident's left arm stump. S6WCN reported she performs the weekly body audits and the area was not there on 06/24/2022. Observation of resident #31's skin with S2DON (Director of Nursing) on 06/30/2022 at 1:00PM confirmed the bruising on the resident's left arm stump. An interview with S2DON at this time confirmed the CNAs should report any skin issues to the LPN and the CNAs also have a CNA reporting sheet.

Based on record review and interviews, the facility failed to ensure that pain management was provided for 1 (Resident #1) of 5 (Residents #1-5) who was assessed to have a swollen, bruised lower leg that was rotated to the left at the mid-shin of the left leg for more than five hours before transferring the resident to an acute care facility. This failed practice resulted in an actual harm for Resident #1 on 05/17/17 at 9:00AM when S6LPN discovered Resident 1 had swelling, bruising, and the left lower leg rotated to the left from the mid-shin. S6LPN documented that she suspected the resident's leg was broken. S6LPN neglected to ensure immediate measures were initiated to provide a higher level of care for Resident #1. Resident #1 experienced episodic pain for more than five hours before being sent by ambulance to an acute care facility for management of the broken leg. The facility had a total of 66 residents. Findings: Review of the record revealed Resident #1 lived at the facility since 2001 and had [DIAGNOSES REDACTED]. Review of the most recent quarterly MDS dated [DATE] revealed, in part, the following: Section C -Cognitive Patterns revealed C0100: resident is rarely/never understood, C1000: cognitive skills for daily decision making, 3-severely impaired-never/rarely made decisions, Section G -Functional Status revealed the self-performance rated at 3 (extensive assistance) and support rated at 2 (one-person physical assist) for bed mobility, transfer, locomotion on unit, dressing, eating, toilet use, and personal hygiene, Bathing is rated at total dependence, and, Section J-Health Conditions J0200: Should pain assessment interview be conducted-no, resident rarely/never understood. A review of the Weekly Skin Audit dated 05/17/17 at 9AM revealed S6LPN noted left lower leg-shin area mid to lower lateral with reddish/purple, left lower leg from mid-shin rotation to left, left leg temperature hot at mid-shin. Review of the ambulance transfer records dated 05/17/17 for Resident #1 revealed the following: narrative-inspection of left leg reveals an obvious deformity mid shaft tib/fib with swelling, tenderness upon palpation, chief complaint-closed left lower leg fracture, chief complaint category- pain, physical assessment noted left leg closed fracture. Review of Resident #1's nurses' notes dated 05/17/17 at 2:26PM by S6LPN revealed at 9AM, S10Temp Agency CNA came to nurses' station to report resident with reddish/purple area and swelling to left lower extremity. Upon assessment of left lower extremity, nurse noted area of reddish, purple to mid shin to left lateral shin, swelling from knee to foot, left foot slight rotated. Review of the acute care facility ED Physician Notes titled Leg Pain-swelling dated 05/17/17 revealed a presenting problem of leg pain. The description revealed swelling and left lower leg deformity. Review of acute care facility radiology findings dated 05/17/17 revealed, in part, an oblique fracture through the middle-distal third of the diaphysis of the tibia. There is a comminuted oblique [MEDICAL CONDITION] more distal diaphysis of the fibula. Distal tibial fragment is displaced anterior and lateral a few millimeters. There is generalized osteopenia. No dislocation of the knee or ankle. The impression was noted as acute fractures of the tibia and fibula. On 07/12/17 at 3:50PM, a telephone interview with S10Temp Agency CNA confirmed that she worked the day shift on 05/17/17 and found Resident #1's leg to be leaning to left side, swollen, and red when she uncovered the resident's legs to give her a bed bath around 9AM. S10Temp Agency CNA reported that she immediately went to tell S6LPN and the nurse came and looked at the resident's leg. S10Temp Agency CNA reported that after an hour or so S6LPN told CNA to go ahead and give the resident her bed bath but be careful with the resident's leg. S10Temp Agency CNA told S6LPN right after she gave Resident #1 a bed bath that when she turned the resident, she moaned and appeared to be in pain. S10Temp Agency CNA reported that when the resident was turned side to side she would moan like she was in pain. She stated when the resident was turned on her left side, her foot would fall over the left and when the resident was turned to the right, her foot would lean over to the right. S10Temp Agency CNA confirmed that she performed incontinent care on the resident at 11AM and again at 1PM the resident grimaced and moaned both times like she was in pain. On 07/13/17 at 9:40AM, an interview with S11CNA revealed that on 05/17/17 around 9AM S10Temp Agency CNA came to get her after breakfast to look at Resident #1's leg. She reported that when she looked at the resident's leg she knew it was broken. S11CNA reported that the resident's leg was on a pillow but it was bent over at the shin and foot was facing the wrong way. When asked if the resident was showing signs of pain, S11CNA confirmed that Resident #1 was grimacing and would yell out at times. On 07/11/17 at 10:15AM, a telephone interview with S6LPN confirmed that she was the nurse assigned to Resident #1 on 05/17/17. She stated that around 9AM the resident's CNA, S10Temp Agency CNA, came and told her that the resident had a swollen area on her leg and a bruise. LPN stated that she walked down to the resident's room and assessed the resident's leg. She stated that she observed swelling from the knee to the foot. She stated that an area about the size of a baseball or softball in the mid-shin area was reddish-purple and the resident's foot was rotated to the left. LPN reported that she placed her left hand under the resident's heel and her right hand under the resident's knee. She stated that as she raised the resident's lower leg, she felt the leg move in the shin area and suspected the resident's leg was broken. S6LPN reported with any other incident she wound send the resident out right away, on her own but because of the seriousness of this, she chose to involve the Interim DON. S6LPN stated I know I should have sent her out but I felt like they needed to be made aware of this. When asked if she reported the resident's probable broken leg to S1Administrator or S7Corporate Nurse that were both in the facility, S6LPN stated that she did not go over the Interim DON's head. Surveyor asked S6LPN if she had the authority to send Resident #1 for evaluation and treatment. S6LPN confirmed that she that did. S6LPN added I know that I should have sent her out but I wanted the Interim DON to be made aware of her leg because I felt like it was broken. On 07/10/17 at 3:00PM, an interview with S2Interim DON confirmed that S6LPN came by her office on 05/17/17 between 10:30 and 11:00AM and told her with no sense of urgency that Resident #1 had some discoloration and swelling to her leg. S2Interim DON stated that S6LPN did not tell her anything earlier in the day regarding Resident #1. S2Interim DON reported that Resident #1 is bed bound and has had issues with swelling in her legs in the past. S2Interim DON stated that she told the nurse that she would look at the resident's leg after the nurse's lunch. S2Interim DON reported that she assumed S6LPN would notify the doctor and family of the discoloration and swelling to the resident's leg. S2Interim DON reported that she went with S6LPN to look at Resident #1's leg around 12:45PM. S2Interim DON confirmed that she knew immediately when she attempted to move the resident's leg that it needed medical attention right away. S2Interim DON stated that she walked out of the resident's room and went to the administrator's office immediately to get S1Administrator and S7Corporate Nurse. S2Interim DON confirmed that after they viewed the resident's leg, the family was called. S2Interim DON reported that they could not get the Responsible Party and the administrator notified the 3rd contact who gave permission to send the resident to the hospital for evaluation and treatment. S2Interim DON stated that S1Administrator and S7Corporate Nurse were out and about in the facility all morning and S6LPN did not report any swelling or discoloration to either of the administrative staff. On 07/11/17 at 12:35PM, an interview with Resident #1's S5Primary Care Physician reported that she was familiar with the resident and had been her physician for several years. The physician confirmed that she was looking at the resident's record at her office and stated that she had last seen Resident #1 on 05/02/17. When asked about the resident's leg, S5Primary Care Physician reported that she was not aware the resident had broken her leg but reported the medical director could have given the order to send her out for evaluation and treatment. On 07/12/17 at 9:45AM, an interview with S1Administrator confirmed that she knew S6LPN did not follow policy at 12:45PM on 05/17/17 when she saw Resident #1's leg. Review of the Notice of Employee Disciplinary Action and In-Service Training Report for S6LPN with Administrator confirmed that S6LPN was not re-inserviced until one month after the incident on 06/17/17. Time cards provided by S1Administrator revealed S6LPN worked a total of 100.75 hours before she was re-inserviced for neglecting to send Resident #1 out for evaluation and medical treatment per policy and protocol. When asked why the nurse had not been re-inserviced for a month, S1Administrator stated there had been a lot going on. She reported that an officer from the police department came to the facility and interviewed staff for about a week starting on 05/22/17 so she pulled back on her investigation. Additionally, S1Administrator confirmed that she had not reviewed the 05/17/17 Weekly Body Audit completed by S6LPN until after the surveyor requested the resident's weekly body audits on 07/11/17. S1Administrator reported that if she had reviewed the 05/17/17 Weekly Body Audit during her investigation, it would likely have taken the investigation in another direction. S1Administrator reported that the weekly body audit was not due that day and it was not an assigned task for S6LPN on 05/17/17. S1Administrator provided an in-service dated 06/17/17 and documentation revealed the administrator in-serviced S6LPN on the Incident/Accident Policy. The policy should be followed for each incident and accident per policy. Review of the policy for Accident/Incident Reports revealed the following: 1. Do not move resident until a licensed nurse evaluated the condition 2. Notify the nurse in charge. 3. Licensed Nurse-Administer any necessary first aid. If severe injury has occurred, call an ambulance immediately and notify physician. Complete a thorough head to toe assessment of the resident for possible injury, including range of motion. 4. Take vital signs 5. If there is a possibility that the resident bumped his/her head, complete neurological checks 6. Make resident comfortable. 7. Notify the resident's physician-receive orders for follow-through. 8. Notify the family. 9. Complete an accident/incident report. 10. Note the location and time of the incident, the names of witnesses, and the exact circumstances of the incident. 11. Obtain a descriptive statement of incident from the resident involved. 12. Chart an objective account of the incident in the nurses' notes in the resident's medical record. 13. Send accident/incident report to the DON/Designee. Review of the In-Service sign-in document indicated S6LPN was the only person in-serviced by S1Administrator on 06/17/17 with a time in of 3:20PM and time out at 3:49PM. A 06/17/17 handwritten statement by S6LPN documented that she involved the S2Interim DON due to her assessment findings. She noted that she had never neglected a patient/resident in her care in [AGE] years of nursing. On 07/13/17 at 2:30PM, an interview with S1Administrator confirmed that she realized on 05/17/17 at 12:45PM that S6LPN neglected to follow policy and procedure and immediately initiate measures to ensure Resident #1 was provided with a higher level of medical care after the nurse noted she suspected Resident #1's leg was broken at 9AM.

Based on record review and interviews, the facility failed to implement their policy/procedures to prohibit neglect of a resident (#1) assessed by the nurse as having her left lower leg swollen, bruised and rotated to the left at the mid-shin for 1 (Resident #1) of 5 (Residents #1-5) sampled residents. The facility further failed to thoroughly investigate an incident of unknown origin for 1 (Resident #1) of 5 (Residents #1-5) sampled residents reviewed. This failed practice resulted in an actual harm for Resident #1 on 05/17/17 at 9:00AM when S6LPN discovered Resident 1 had swelling, bruising, with the left lower leg rotated to the left at the mid-shin and S6LPN suspected the resident's leg was broken. S6LPN neglected to ensure immediate measures were initiated to provide a higher level of medical care for Resident #1 on 05/17/17 at 9:00AM. Resident #1 remained in the facility for more than five hours before being sent by ambulance to an acute care facility for management of the broken leg. The facility had a total census of 66 residents. Findings: Review of the record revealed Resident #1 lived at the facility since 2001 and had [DIAGNOSES REDACTED]. Review of the most recent quarterly MDS dated [DATE] revealed, in part, the following: Section C -Cognitive Patterns revealed C0100: resident is rarely/never understood, C1000: cognitive skills for daily decision making, 3-severely impaired-never/rarely made decisions, Section G -Functional Status revealed the self-performance rated at 3 (extensive assistance) and support rated at 2 (one-person physical assist) for bed mobility, transfer, locomotion on unit, dressing, eating, toilet use, and personal hygiene, Bathing is rated at total dependence, and, Section J-Health Conditions J0200: Should pain assessment interview be conducted-no, resident rarely/never understood. A review of the Weekly Skin Audit dated 05/17/17 at 9AM revealed S6LPN documented left lower leg-shin area mid to lower lateral with reddish/purple, left lower leg from mid-shin rotation to left, left leg temperature hot at mid-shin. Review of Resident #1's nurses' notes dated 05/17/17 at 2:26PM by S6LPN revealed at 9AM, S10Temp Agency CNA came to nurses' station to report resident with reddish/purple area and swelling to left lower extremity. Upon assessment of left lower extremity, nurse noted area of reddish, purple to mid shin to left lateral shin, swelling from knee to foot, left foot slight rotated. Notified S2Interim DON and she stated she would look at it after nurse takes lunch. S6LPN informed Interim DON that she did not take lunch. Interim DON asked if nurse would be through with noon meds by 12:30 and LPN stated she would. At 12:45PM, S2Interim DON in room to evaluate resident. At 1:31PM, S1Administrator call to family contact and voice mail left. At 1:32PM, S1Administrator called family contact #3 and family was notified of the findings. Family contact requested resident be sent to hospital for evaluation and treatment. At 2:00PM, ambulance service notified of transfer. At 2:10PM, ambulance here for transfer to hospital. At 2:20PM, Resident #1 out to hospital. Review of the acute care facility ED Physician Notes titled Leg Pain-Swelling dated 05/17/17 revealed a presenting problem of leg pain. The description revealed swelling and left lower leg deformity. Review of acute care facility's radiology findings dated 05/17/17 revealed, in part, an oblique fracture through the middle-distal third of the diaphysis of the tibia. There is a comminuted oblique [MEDICAL CONDITION] more distal diaphysis of the fibula. Distal tibial fragment is displaced anterior and lateral a few millimeters. There is generalized osteopenia. No dislocation of the knee or ankle. The impression was noted as acute fractures of the tibia and fibula. On 07/12/17 at 3:50PM, a telephone interview with S10Temp Agency CNA confirmed that she worked the day shift on 05/17/17 and found Resident #1's leg to be leaning to left side, swollen, and red when she uncovered the resident's legs to give her a bed bath around 9AM. S10Temp Agency CNA reported that she immediately went to tell S6LPN and the nurse came and looked at the resident's leg. S6LPN told CNA that she was going to tell the Interim DON. S10Temp Agency CNA reported that after an hour or so she went to S6LPN and asked if she had told the Interim DON because no one had gone in to check on the resident. S6LPN told CNA to go ahead and give the resident her bed bath but be careful with the resident's leg. S10Temp Agency CNA told S6LPN right after she gave Resident #1 a bed bath that when she turned the resident, she moaned and appeared to be in pain. S6LPN told the CNA to be sure somebody else was in the room to help her provide incontinent care so they could hold the resident's leg so she wouldn't move her leg too much. S10Temp Agency CNA reported that when the resident was turned side to side she would moan like she was in pain. She stated when the resident was turned on her left side, her foot would fall over the left and when the resident was turned to the right, her foot would lean over to the right. S10Temp Agency CNA confirmed that she performed incontinent care on the resident at 11AM and again at 1PM the resident grimaced and moaned both times like she was in pain. S10Temp Agency CNA confirmed that she told another CNA, S11CNA, to come look at Resident #1's leg. S10Temp Agency CNA confirmed that she could not remember the name of the CNA who helped her with bathing and providing incontinent care that day because she was a temp and didn't work at the facility full time. S10Temp Agency CNA was asked if she told anyone else about Resident #1's leg and she stated I did what I was supposed to do and told her LPN. On 07/13/17 at 9:40AM, an interview with S11CNA revealed she had been working at the facility for eight years. She stated that on 05/17/17 around 9AM S10Temp Agency CNA came to get her after breakfast to look at Resident #1's leg. She reported that when she looked at the resident's leg she knew it was broken. S11CNA reported that the resident's left leg was on a pillow but it was bent over at the shin and her foot was facing the wrong way. When asked if the resident was showing signs of pain, S11CNA confirmed that Resident #1 was grimacing and would yell out at times. She stated that S10Temp Agency CNA confirmed that she had told the nurse and the nurse had told her to go ahead and bathe the resident. The surveyor asked S11CNA if she manipulated the resident's leg and S11CNA reported that her leg was propped on a pillow and she didn't want to touch it. S11CNA added that she was worked with Resident #1 the day before and her leg wasn't like that. On 07/11/17 at 10:15AM, a telephone interview with S6LPN confirmed that she was the nurse assigned to Resident #1 on 05/17/17. She stated that around 9AM the resident's CNA, S10Temp Agency CNA, came and told her that the resident had a swollen area on her leg and a bruise. S6LPN reported that she walked down to the resident's room and assessed the resident's leg. She stated that she observed swelling from the knee to the foot. She stated that an area about the size of a baseball or softball in the mid-shin area was reddish-purple and the resident's foot was rotated to the left. LPN reported that she placed her left hand under the resident's heel and her right hand under the resident's knee. She stated that as she raised the resident's lower leg, she felt the leg move in the shin area and felt like the resident's leg was broken. When asked if she completed the Weekly Body Audit dated 05/17/17, S6LPN confirmed that she had documented, dated and signed the Weekly Body Audit on 05/17/17 sometime around 9AM. S6LPN added if there were skin issues, she would write it on the weekly body audit. LPN stated that she told the Interim DON at 9AM that the resident had swelling and bruising to her leg and that she felt like the resident's leg was broken. S6LPN reported that she told the Interim DON because she felt like there needed to be an investigation because she felt like the resident's leg was broken. S6LPN reported with any other incident she wound send the resident out right away, on her own but because of the seriousness of this, she chose to involve the Interim DON. S6LPN stated I know I should have sent her out but I felt like they needed to be made aware of this. She stated that the Interim DON told her she would look at the resident's leg after the nurse took her lunch. LPN told Interim DON that she did not take lunch and the Interim DON told her she would look at it after she finished lunch med pass. Surveyor asked S6LPN if that time line was acceptable to her when she felt like Resident #1's leg was broken. S6LPN replied that it was not. Surveyor asked what she did when the timeline was unacceptable and she stated that she told the CNA that the Interim DON would look at the resident's leg after noon med pass. S6LPN reported that she trusted the Interim DON would look at the resident. When asked if she reported the resident's probable broken leg to the Administrator or corporate nurse that were both in the facility, S6LPN stated that she did not go over the Interim DON's head. S6LPN stated that she went back to the DON's office at 12:45PM and the Interim DON stated, Let's go look. S6LPN reported after S2Interim DON saw Resident #1's leg, Interim DON went to the Administrator's office and S1Administrator, S7Corporate Nurse, and Interim DON all went to the resident's room to look at the resident's leg. Surveyor asked S6LPN if she had the authority to send Resident #1 for evaluation and treatment. S6LPN confirmed that she that did. S6LPN added I know that I should have sent her out but I wanted the Interim DON to be made aware of her leg because I felt like it was broken. On 07/10/17 at 3:00PM, an interview with S2Interim DON confirmed that S6LPN came by her office on 05/17/17 between 10:30 and 11:00AM and told her with no sense of urgency that Resident #1 had some discoloration and swelling to her leg. S2Interim DON stated that S6LPN did not tell her anything earlier in the day regarding Resident #1. S2Interim DON reported that Resident #1 is bed bound and has had issues with swelling in her legs in the past. S2Interim DON stated that she told the nurse that she would look at the resident's leg after the nurse's lunch. S2Interim DON reported that she assumed S6LPN would notify the doctor and family of the discoloration and swelling to the resident's leg. S2Interim DON reported that she went with S6LPN to look at Resident #1's leg around 12:45PM. S2Interim DON confirmed that she knew immediately when she attempted to move the resident's leg that it needed medical attention right away. S2Interim DON stated that she walked out of the resident's room and went to the administrator's office immediately to get S1Administrator and S7Corporate nurse. S2Interim DON confirmed that after they viewed the resident's leg, the family was called. S2Interim DON reported that they could not get the Responsible Party and the administrator notified the 3rd contact who gave permission to send the resident to the hospital for evaluation and treatment. S2Interim DON stated that S1Administrator and S7Corporate Nurse were out and about in the facility all morning and S6LPN did not report any swelling or discoloration to either of the administrative staff. On 07/11/17 at 12:35PM, a telephone interview with Resident #1's S5Primary Care Physician revealed that she had been the resident's physician for years. S5Primary Care Physician reported that she had last seen Resident #1 on 05/02/17. The physician stated that she wasn't aware Resident #1 had fractured her leg but reported the medical director could have given the order to send her out for evaluation and treatment. Reading from the radiology report dated 05/17/17, the surveyor asked if it was possible that the resident could have sustained a tibia fracture and comminuted fibula fracture spontaneously. The physician stated that type of fracture usually happens with force. S5Primary Care Physician added possibly it could happen, but she hadn't seen it in her experience. On 07/12/17 at 9:45AM, an interview with S1Administrator confirmed that she knew S6LPN did not follow policy at 12:45PM on 05/17/17 when she saw Resident #1's leg. Review of the Notice of Employee Disciplinary Action and In-Service Training Report for S6LPN with Administrator confirmed that S6LPN was not re-inserviced until one month after the incident on 06/17/17. Time cards provided by S1Administrator revealed S6LPN worked a total of 100.75 hours before she was re-inserviced for neglecting to send Resident #1 out for evaluation and medical treatment per policy and protocol. When asked why the nurse had not been re-inserviced for a month, S1Administrator stated there had been a lot going on. She reported that an officer from the police department came to the facility and interviewed staff for about a week starting on 05/22/17 so she pulled back on her investigation. Additionally, S1Administrator confirmed that she had not reviewed the 05/17/17 Weekly Body Audit completed by S6LPN until after the surveyor requested the resident's weekly body audits on 07/11/17. S1Administrator reported that if she had reviewed the 05/17/17 Weekly Body Audit during her investigation, it would likely have taken the investigation in another direction. S1Administrator reported that the weekly body audit was not due that day and it was not an assigned task for S6LPN on 05/17/17. S1Administrator confirmed that she had not interviewed the resident's physician. In-service documentation provided by S1Administrator was dated 06/17/17 and revealed the administrator in-serviced S6LPN on the Incident/Accident Policy should be followed for each incident and accident per policy. Review of the policy for Accident/Incident Reports revealed the following: 1. Do not move resident until a licensed nurse evaluated the condition 2. Notify the nurse in charge. 3. Licensed Nurse-Administer any necessary first aid. If severe injury has occurred, call an ambulance immediately and notify physician. Complete a thorough head to toe assessment of the resident for possible injury, including range of motion. 4. Take vital signs 5. If there is a possibility that the resident bumped his/her head, complete neurological checks 6. Make resident comfortable. 7. Notify the resident's physician-receive orders for follow-through. 8. Notify the family. 9. Complete an accident/incident report. 10. Note the location and time of the incident, the names of witnesses, and the exact circumstances of the incident. 11. Obtain a descriptive statement of incident from the resident involved. 12. Chart an objective account of the incident in the nurses' notes in the resident's medical record. 13. Send accident/incident report to the DON/Designee. Review of the In-Service sign-in document indicated S6LPN was the only person in-serviced by S1Administrator on 06/17/17 with a time in of 3:20PM and time out at 3:49PM. A 06/17/17 handwritten statement by S6LPN noted that she involved the S2Interim DON due to her assessment findings and noted that she had never neglected a patient/resident in her care in [AGE] years of nursing. On 07/13/17 at 2:30PM, an interview with S1Administrator confirmed that she realized on 05/17/17 at 12:45PM that S6LPN neglected to follow policy and procedure and immediately initiate measures to ensure Resident #1 was provided with a higher level of medical care after the nurse documented that she suspected Resident #1's leg was broken at 9AM. S1Administrator further confirmed that she failed to review the Weekly Body Audits of Resident #1 during her investigation of the injury of unknown origin. S1Administrator reported that she had not interviewed Resident #1's primary care physician during the investigation. Additionally, S1Administrator confirmed that S6LPN had worked six double shifts before she was in-serviced a month after Resident #1's higher level of medical care was delayed by more than five hours. S1Administrator also confirmed that there had not been any CNA in-services since the incident on 05/17/17 instructing CNAs what to do if a nurse neglects to address an injured resident after they report it.

I. Based on observation, record review and interview, the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being by failing to ensure that nursing staff implemented infection control procedures and that housekeeping staff utilized appropriate cleaning agents for potentially infectious organisms for 2 of 2 (#6 and #7) sampled residents diagnosed with [REDACTED]. (Sample #1 - #7) The facility failed to: 1) train staff on appropriate infection control procedures, including contact and isolation precautions; 2) implement contact and isolation precautions after resident #6 was diagnosed with [REDACTED]. 3) prevent the transmission of [MEDICAL CONDITION] to other residents in the facility when resident #6 was diagnosed with [REDACTED]. Resident #7 was in Immediate Jeopardy on 09/27/12 when her roommate, resident #6 was diagnosed with [REDACTED]. As a result of the facility failing to implement isolation precautions, resident #7 was diagnosed with [REDACTED]. All other residents in the facility (#2, 3, 4, 5, R1 - R127) were in an Immediate Jeopardy situation due to the improper infection control practices and possible exposure to the [MEDICAL CONDITION] infection. On 10/3/12 at 2:35PM, the survey team notified S1Administrator and S2DON of the Immediate Jeopardy (IJ) situation that currently existed in the facility. The IJ situation began on 9/27/12 when sampled resident #6 was diagnosed with [REDACTED]. As a result of the facility failing to implement isolation and contact precautions per Center for Disease Control when sampled resident #6 was diagnosed on [DATE], sampled resident #7 (sampled resident #6's roommate) was diagnosed with [REDACTED]. The facility submitted a plan of removal the survey team on 10/4/12 for the Immediate Jeopardy situation. The plan of removal included the following. Immediate inservices would be conducted with LPNs, CNAs, housekeeping and laundry personnel regarding [MEDICAL CONDITION], isolation precautions, isolation cart, red biohazard bags for laundry, and disposable products for meal service. Sampled residents #6 and #7's room was terminally cleaned with a bleach solution. An isolation cart was placed outside the room of residents #6 and #7. A QA form was developed and isolation procedures would be monitored on a daily basis. On 10/4/12 at 10:17AM, the Immediate Jeopardy situation was removed after the facility implemented their plan. The deficient practice continued at a scope and severity of an Actual Harm for resident #7. Findings: 1. Review of the medical record for sampled resident #6 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record dated 09/21/12 revealed the nurse faxed the physician to inform him of sampled resident #6 having loose stools. The physician ordered to obtain stools for culture and sensitivity, [MEDICAL CONDITION] and for parasites. Further review of the medical record revealed the physician wrote an order dated 9/21/12 for [MEDICATION NAME] 500 milligrams 1 pill to be given three times a day for 7 days. Review of the nurses notes dated 09/26/12 revealed the stool sample was obtained as ordered. Review of the laboratory results dated [DATE] revealed the stool culture was positive for [MEDICAL CONDITION] Toxin. Review of the physician orders [REDACTED]. On 10/03/12 at 9:55AM an interview with S7LPN revealed the facility was using universal precautions for the resident due to her infection with [MEDICAL CONDITION]. 2. Review of the medical record for sampled resident #7 (the room mate of sampled resident #6) revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Further review of the record revealed that the resident had a confirmed positive stool culture for [MEDICAL CONDITION] Toxin on 10/01/12. Physician orders [REDACTED]. Review of the October 2012 MAR indicated [REDACTED]. On 10/03/12 at 9:00AM observation of sampled resident #7 revealed S3CNA supervisor and S10CNA repositioned the resident in her wheelchair without wearing gloves. Further observations revealed that S10CNA entered another resident's room on the hall without washing her hands. On 10/03/12 at 9:35AM observation of sampled resident #6 and #7 revealed they were sitting in their room. Further observation revealed a bedside commode was on resident #6's side of the room. A dirty pull-up and dirty gloves were noted in the trash can in the room. On 10/03/12 at 9:45AM, observation revealed the resident was sliding down in her wheelchair again. S3CNA supervisor entered the room and repositioned the resident without wearing gloves. Interview with S3 at that time revealed that sampled residents #6 and #7 had [MEDICAL CONDITION] infection and could not leave their rooms. On 10/03/12 at 9:50AM observation of the outside of the room revealed a sign was not posted on the door to alert staff and/or visitors to see the nurse before entering the room. Further observation of the outside of the room revealed there was not a cart containing contact isolation equipment to be used when entering the room. On 10/03/12 at 10:00AM an interview with sampled resident #6 revealed she was unable to leave her room because she had an infection. On 10/03/12 at 10:15AM, an interview with S10CNA revealed residents #6 and #7 were not able to leave their room due to an infection that they both had. Further interview with S10CNA revealed she was unaware of the type of infection that the residents had. On 10/03/12 at 10:20AM, an interview with S4Housekeeper revealed that she had heard that resident #6 and #7 had an infection, but she was not using anything different to clean their room. On 10/03/12 at 10:25AM, interviews with S6CNA, S10CNA and S11CNA revealed they were not instructed to wear gloves when providing care or activities of daily living for the sampled residents. On 10/3/12 at 10:30AM, observation revealed random resident #R5 rolled her wheelchair into the room of sampled residents #6 and #7. The resident was confused and was observed touching the bathroom door and door handle in the resident's room. On 10/03/12 at 10:35AM, an interview with S12Laundry Worker revealed she was not doing anything different for the residents when collecting, washing and drying their laundry. On 10/03/12 at 12:10PM, observation of the lunch meal revealed sampled residents #6 and #7 were eating their lunch in their room. Further observation revealed the residents were served on regular plates, glasses and utensils. S6CNA was feeding sampled resident #7 in the room without wearing gloves. On 10/03/12 at 12:20PM, an interview with S6CNA revealed sampled residents #6 and #7 required assistance with activities of daily living and they both shared the commode and sink in the bathroom located in their room. On 10/3/12 at 1:50PM interview with S4 Housekeeper confirmed there were no biohazard bags in the room. Further observation at this time revealed S4Housekeeper took the bottles of cleaning solution from her housekeeping cart and went into resident #6 and #7 ' s room and placed them on the bedside table to begin cleaning. On 10/3/12 at 2:00PM, review of the policy and procedure for isolation precautions revealed: any resident suspected or diagnosed as having a communicable disease shall be placed in the appropriate type of isolation as delineated in these policies and procedures. Further review of the policy and procedure revealed it shall be the responsibility of the Administrator, through the Infection Control Committee and Infection Control Coordinator to assure that all Infection Control Policies and Procedures are implemented and followed as appropriate. The policy and procedure states the facility has adopted Universal Precautions on a facility wide basis in order to comply with CDC and OSHA recommendations. The facility continues to post signs and acknowledge other category specific isolation precautions in order to assure comprehensive quality care. Review of the supervision policy and procedure in the infection control policy revealed: 1. The infection control coordinator shall be responsible for organizing and directing the implementation of the infection control procedures when isolation becomes necessary. 2. The charge nurse of each unit shall be responsible for carrying out all functions of the isolation precaution as directed by the infection control coordinator and policies and procedures of the facility. This includes supervision of personnel and assurance that all personnel and visitors follow established isolation precautions as well as any specific instructions that become necessary. Review of the Isolation procedure in the policy revealed: The isolation room is easily identified with an appropriate isolation sign which disposed outside the room entrance by the infection control coordinator (ICC) or Nurse supervisor. Review of the Placement in isolation procedure revealed: 1. If there is reason to believe (based on Guidelines for Determining an infection) that a resident has a communicable disease, the attending physician shall be notified immediately and the appropriate isolation precautions will be initiated. 2. Immediate notification of staff is essential as all orders concerning isolation must be carried out as soon as possible. 3. All residents placed in isolation for suspected or confirmed infections, shall have isolation precautions implemented in accordance with procedures established in the CDC Guidelines for Isolation Precautions in Hospitals. Isolation precautions shall be utilized only to the degree needed to isolate the infecting organism, based upon the CDC guidelines. 4. Only authorized persons, including care givers, family members, and visitors shall be allowed to enter the Isolation room and shall be required to follow all isolation precautions indicated. 5. Isolation procedures shall be followed until precautions are discontinued by the attending physician or until a negative culture or cessation of symptoms occurs. 6. The ICC designees (the charge nurse on that shift, or the supervisor) is responsible for obtaining the needed isolation precautions supplies and equipment, setting up the isolation station, posting the appropriate isolation sign outside the resident's room, and placing an appropriate isolation sticker in the resident's clinical record. 7. After confirmation of the category of isolation precautions that is needed, the ICC or designee will post the appropriate isolation precautions that is needed, the ICC or designee will post the appropriate isolation sign outside the resident's door and place an isolation cabinet in the corridor outside the room. Supplies in the cabinet include melt-away laundry bags, trash bags, outer bags to double bag laundry, disposable gowns and gloves. 8. The day shift nurse supervisor will monitor the isolation cabinet each day. 9. Residents placed in isolation shall be served all meals on disposable trays, dishes, and utensils until isolation procedures are discontinued. 10. Cleaning of the isolation room; Housekeeping will put on PPE (personal protective equipment) and take only needed supplies into the isolation room. Staff will damp dust furniture and window sills, bed and all horizontal surfaces, always working from the cleanest to the dirtiest area of the room to avoid cross contamination. The bathroom will be cleaned last. Wipe the mop handle with disinfectant, place contaminated mop head in melt-away bag and then into red plastic outer bag held from outside the room and take to laundry. On 10/03/12 at 2:10PM, an interview with S1Administrator and S2DON confirmed that sampled resident #7 was not removed from the room when sampled resident #6 was diagnosed with [REDACTED].#6 and #7's [DIAGNOSES REDACTED]. On 10/03/12 at 2:35PM, S1Administrator and S2DON was informed of the Immediate Jeopardy situation which existed when the facility failed to train staff on appropriate contact and isolation precautions; implement contact and isolation precautions; prevent the transmission of [MEDICAL CONDITION] to other residents in the facility; and follow the policy regarding isolation precautions. On 10/3/12 at 3:10PM, interview with S4housekeeper stated today (10/3/12) was the first day the red biohazard containers were placed in the room and an isolation cart was placed outside in the hall by the doorway. Observation on 10/3/12 at 3:15PM revealed S4housekeeper was cleaning resident #6 and #7 ' s room. S4housekeeper mopped the floor, put the cleaning spray bottle on resident #6 ' s bed, picked the cleaning bottle back up and then dropped the bottle on the floor and then picked it back up again. S4housekeeper then leaned the mop against the wall, and placed the spray bottle on the floor in the hallway. S4housekeeper placed the used mop pad, floor duster, and cleaning rags in a regular black trash bag and not a biohazard bag. S4housekeeper touched the dirty black trash bag with her hands then picked up both bottles of cleaning solution and put them on the housekeeping cart, then picked up the broom and dust pan with bare hands, and placed them on the housekeeping cart without cleaning the items. On 10/3/12 at 3:20PM interview with S4Housekeeper revealed she used Spic and Span disinfectant cleaner and Liquid Comet bathroom cleaner and Pro Line Disinfecting floor cleaner to clean residents #6 and #7's room and bathroom. Review of the ingredients on the comet bottle revealed: Water, citric acid, sodium cumene [MEDICATION NAME], surfactants, and perfume. Review of the ingredients on the Spic and Span all purpose spray and glass cleaner bottle revealed: Ammonium Chloride 0.5% and [MEDICATION NAME]. Review of the ingredients for the Disinfecting floor cleaner revealed: Ammonium Chloride 7.68% and other 92.32%. Further review of the label on the bottle revealed it did not list [MEDICAL CONDITION] as an organism that would be killed by using the product. On 10/3/12 at 3:30PM interview with S4housekeeper confirmed she put the dirty cleaning rags, the used mop pad, and the floor duster in a regular trash bag and put it on the housekeeping cart to take to the laundry. On 10/3/12 at 3:35PM an interview with S1Administrator confirmed they were using a Proctor and Gamble product that is supposed to be like Virex but does not contain bleach. S1Administrator and S2DON confirmed there was no sign on resident #6 and #7 ' s door indicating isolation. S1Administrator and S2DON confirmed S4housekeeper should not have used a regular trash bag and the technique used to clean the room was not correct. On 10/3/12 at 3:45PM interview with S5 housekeeping supervisor confirmed they were not using the proper chemicals to clean resident #6 and #7 ' s isolation room. On 10/3/12, review of the Center for Disease Control (CDC) revealed there are guidelines to prevent the spread of [MEDICAL CONDITION]. The CDC states to isolate the patients with [DIAGNOSES REDACTED]icile immediately, wear gloves and gowns when treating patients with [DIAGNOSES REDACTED]icile, even during short visits. Hand sanitizer does not kill [DIAGNOSES REDACTED]icile, and hand washing may not be sufficient. Clean the room surfaces with bleach or another EPA-approved, spore-killing disinfectant after a patient with [DIAGNOSES REDACTED]icile has been treated there.

I. Based on observation, record review and interview, the facility failed to provide professional standards of quality by failing to ensure that nursing staff implemented infection control procedures and that housekeeping staff utilized appropriate cleaning agents for potentially infectious organisms for 2 of 2 (#6 and #7) sampled residents diagnosed with [REDACTED]. (Sample #1 - #7) The facility failed to: 1) train staff on appropriate infection control procedures, including contact and isolation precautions; 2) implement contact and isolation precautions after resident #6 was diagnosed with [REDACTED]. 3) prevent the transmission of [MEDICAL CONDITION] to other residents in the facility when resident #6 was diagnosed with [REDACTED]. Resident #7 was in Immediate Jeopardy on 09/27/12 when her roommate, resident #6 was diagnosed with [REDACTED]. As a result of the facility failing to implement isolation precautions, resident #7 was diagnosed with [REDACTED]. All other residents in the facility (#2, 3, 4, 5, R1 - R127) were in an Immediate Jeopardy situation due to the improper infection control practices and possible exposure to the [MEDICAL CONDITION] infection. On 10/3/12 at 2:35PM, the survey team notified S1Administrator and S2DON of the Immediate Jeopardy (IJ) situation that currently existed in the facility. The IJ situation began on 9/27/12 when sampled resident #6 was diagnosed with [REDACTED]. As a result of the facility failing to implement isolation and contact precautions per Center for Disease Control when sampled resident #6 was diagnosed on [DATE], sampled resident #7 (sampled resident #6's roommate) was diagnosed with [REDACTED]. The facility submitted a plan of removal the survey team on 10/4/12 for the Immediate Jeopardy situation. The plan of removal included the following. Immediate inservices would be conducted with LPNs, CNAs, housekeeping and laundry personnel regarding [MEDICAL CONDITION], isolation precautions, isolation cart, red biohazard bags for laundry, and disposable products for meal service. Sampled residents #6 and #7's room was terminally cleaned with a bleach solution. An isolation cart was placed outside the room of residents #6 and #7. A QA form was developed and isolation procedures would be monitored on a daily basis. On 10/4/12 at 10:17AM, the Immediate Jeopardy situation was removed after the facility implemented their plan. The deficient practice continued at a scope and severity of an Actual Harm for resident #7. Findings: 1. Review of the medical record for sampled resident #6 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record dated 09/21/12 revealed the nurse faxed the physician to inform him of sampled resident #6 having loose stools. The physician ordered to obtain stools for culture and sensitivity, [MEDICAL CONDITION] and for parasites. Further review of the medical record revealed the physician wrote an order dated 9/21/12 for [MEDICATION NAME] 500 milligrams 1 pill to be given three times a day for 7 days. Review of the nurses notes dated 09/26/12 revealed the stool sample was obtained as ordered. Review of the laboratory results dated [DATE] revealed the stool culture was positive for [MEDICAL CONDITION] Toxin. Review of the physician orders [REDACTED]. On 10/03/12 at 9:55AM an interview with S7LPN revealed the facility was using universal precautions for the resident due to her infection with [MEDICAL CONDITION]. 2. Review of the medical record for sampled resident #7 (the room mate of sampled resident #6) revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Further review of the record revealed that the resident had a confirmed positive stool culture for [MEDICAL CONDITION] Toxin on 10/01/12. Physician orders [REDACTED]. Review of the October 2012 MAR indicated [REDACTED]. On 10/03/12 at 9:00AM observation of sampled resident #7 revealed S3CNA supervisor and S10CNA repositioned the resident in her wheelchair without wearing gloves. Further observations revealed that S10CNA entered another resident's room on the hall without washing her hands. On 10/03/12 at 9:35AM observation of sampled resident #6 and #7 revealed they were sitting in their room. Further observation revealed a bedside commode was on resident #6's side of the room. A dirty pull-up and dirty gloves were noted in the trash can in the room. On 10/03/12 at 9:45AM, observation revealed the resident was sliding down in her wheelchair again. S3CNA supervisor entered the room and repositioned the resident without wearing gloves. Interview with S3 at that time revealed that sampled residents #6 and #7 had [MEDICAL CONDITION] infection and could not leave their rooms. On 10/03/12 at 9:50AM observation of the outside of the room revealed a sign was not posted on the door to alert staff and/or visitors to see the nurse before entering the room. Further observation of the outside of the room revealed there was not a cart containing contact isolation equipment to be used when entering the room. On 10/03/12 at 10:00AM an interview with sampled resident #6 revealed she was unable to leave her room because she had an infection. On 10/03/12 at 10:15AM, an interview with S10CNA revealed residents #6 and #7 were not able to leave their room due to an infection that they both had. Further interview with S10CNA revealed she was unaware of the type of infection that the residents had. On 10/03/12 at 10:20AM, an interview with S4Housekeeper revealed that she had heard that resident #6 and #7 had an infection, but she was not using anything different to clean their room. On 10/03/12 at 10:25AM, interviews with S6CNA, S10CNA and S11CNA revealed they were not instructed to wear gloves when providing care or activities of daily living for the sampled residents. On 10/3/12 at 10:30AM, observation revealed random resident #R5 rolled her wheelchair into the room of sampled residents #6 and #7. The resident was confused and was observed touching the bathroom door and door handle in the resident's room. On 10/03/12 at 10:35AM, an interview with S12Laundry Worker revealed she was not doing anything different for the residents when collecting, washing and drying their laundry. On 10/03/12 at 12:10PM, observation of the lunch meal revealed sampled residents #6 and #7 were eating their lunch in their room. Further observation revealed the residents were served on regular plates, glasses and utensils. S6CNA was feeding sampled resident #7 in the room without wearing gloves. On 10/03/12 at 12:20PM, an interview with S6CNA revealed sampled residents #6 and #7 required assistance with activities of daily living and they both shared the commode and sink in the bathroom located in their room. On 10/3/12 at 1:50PM interview with S4 Housekeeper confirmed there were no biohazard bags in the room. Further observation at this time revealed S4Housekeeper took the bottles of cleaning solution from her housekeeping cart and went into resident #6 and #7 ' s room and placed them on the bedside table to begin cleaning. On 10/3/12 at 2:00PM, review of the policy and procedure for isolation precautions revealed: any resident suspected or diagnosed as having a communicable disease shall be placed in the appropriate type of isolation as delineated in these policies and procedures. Further review of the policy and procedure revealed it shall be the responsibility of the Administrator, through the Infection Control Committee and Infection Control Coordinator to assure that all Infection Control Policies and Procedures are implemented and followed as appropriate. The policy and procedure states the facility has adopted Universal Precautions on a facility wide basis in order to comply with CDC and OSHA recommendations. The facility continues to post signs and acknowledge other category specific isolation precautions in order to assure comprehensive quality care. Review of the supervision policy and procedure in the infection control policy revealed: 1. The infection control coordinator shall be responsible for organizing and directing the implementation of the infection control procedures when isolation becomes necessary. 2. The charge nurse of each unit shall be responsible for carrying out all functions of the isolation precaution as directed by the infection control coordinator and policies and procedures of the facility. This includes supervision of personnel and assurance that all personnel and visitors follow established isolation precautions as well as any specific instructions that become necessary. Review of the Isolation procedure in the policy revealed: The isolation room is easily identified with an appropriate isolation sign which disposed outside the room entrance by the infection control coordinator (ICC) or Nurse supervisor. Review of the Placement in isolation procedure revealed: 1. If there is reason to believe (based on Guidelines for Determining an infection) that a resident has a communicable disease, the attending physician shall be notified immediately and the appropriate isolation precautions will be initiated. 2. Immediate notification of staff is essential as all orders concerning isolation must be carried out as soon as possible. 3. All residents placed in isolation for suspected or confirmed infections, shall have isolation precautions implemented in accordance with procedures established in the CDC Guidelines for Isolation Precautions in Hospitals. Isolation precautions shall be utilized only to the degree needed to isolate the infecting organism, based upon the CDC guidelines. 4. Only authorized persons, including care givers, family members, and visitors shall be allowed to enter the Isolation room and shall be required to follow all isolation precautions indicated. 5. Isolation procedures shall be followed until precautions are discontinued by the attending physician or until a negative culture or cessation of symptoms occurs. 6. The ICC designees (the charge nurse on that shift, or the supervisor) is responsible for obtaining the needed isolation precautions supplies and equipment, setting up the isolation station, posting the appropriate isolation sign outside the resident's room, and placing an appropriate isolation sticker in the resident's clinical record. 7. After confirmation of the category of isolation precautions that is needed, the ICC or designee will post the appropriate isolation precautions that is needed, the ICC or designee will post the appropriate isolation sign outside the resident's door and place an isolation cabinet in the corridor outside the room. Supplies in the cabinet include melt-away laundry bags, trash bags, outer bags to double bag laundry, disposable gowns and gloves. 8. The day shift nurse supervisor will monitor the isolation cabinet each day. 9. Residents placed in isolation shall be served all meals on disposable trays, dishes, and utensils until isolation procedures are discontinued. 10. Cleaning of the isolation room; Housekeeping will put on PPE (personal protective equipment) and take only needed supplies into the isolation room. Staff will damp dust furniture and window sills, bed and all horizontal surfaces, always working from the cleanest to the dirtiest area of the room to avoid cross contamination. The bathroom will be cleaned last. Wipe the mop handle with disinfectant, place contaminated mop head in melt-away bag and then into red plastic outer bag held from outside the room and take to laundry. On 10/03/12 at 2:10PM, an interview with S1Administrator and S2DON confirmed that sampled resident #7 was not removed from the room when sampled resident #6 was diagnosed with [REDACTED].#6 and #7's [DIAGNOSES REDACTED]. On 10/03/12 at 2:35PM, S1Administrator and S2DON was informed of the Immediate Jeopardy situation which existed when the facility failed to train staff on appropriate contact and isolation precautions; implement contact and isolation precautions; prevent the transmission of [MEDICAL CONDITION] to other residents in the facility; and follow the policy regarding isolation precautions. On 10/3/12 at 3:10PM, interview with S4housekeeper stated today (10/3/12) was the first day the red biohazard containers were placed in the room and an isolation cart was placed outside in the hall by the doorway. Observation on 10/3/12 at 3:15PM revealed S4housekeeper was cleaning resident #6 and #7 ' s room. S4housekeeper mopped the floor, put the cleaning spray bottle on resident #6 ' s bed, picked the cleaning bottle back up and then dropped the bottle on the floor and then picked it back up again. S4housekeeper then leaned the mop against the wall, and placed the spray bottle on the floor in the hallway. S4housekeeper placed the used mop pad, floor duster, and cleaning rags in a regular black trash bag and not a biohazard bag. S4housekeeper touched the dirty black trash bag with her hands then picked up both bottles of cleaning solution and put them on the housekeeping cart, then picked up the broom and dust pan with bare hands, and placed them on the housekeeping cart without cleaning the items. On 10/3/12 at 3:20PM interview with S4Housekeeper revealed she used Spic and Span disinfectant cleaner and Liquid Comet bathroom cleaner and Pro Line Disinfecting floor cleaner to clean residents #6 and #7's room and bathroom. Review of the ingredients on the comet bottle revealed: Water, citric acid, sodium cumene [MEDICATION NAME], surfactants, and perfume. Review of the ingredients on the Spic and Span all purpose spray and glass cleaner bottle revealed: Ammonium Chloride 0.5% and [MEDICATION NAME]. Review of the ingredients for the Disinfecting floor cleaner revealed: Ammonium Chloride 7.68% and other 92.32%. Further review of the label on the bottle revealed it did not list [MEDICAL CONDITION] as an organism that would be killed by using the product. On 10/3/12 at 3:30PM interview with S4housekeeper confirmed she put the dirty cleaning rags, the used mop pad, and the floor duster in a regular trash bag and put it on the housekeeping cart to take to the laundry. On 10/3/12 at 3:35PM an interview with S1Administrator confirmed they were using a Proctor and Gamble product that is supposed to be like Virex but does not contain bleach. S1Administrator and S2DON confirmed there was no sign on resident #6 and #7 ' s door indicating isolation. S1Administrator and S2DON confirmed S4housekeeper should not have used a regular trash bag and the technique used to clean the room was not correct. On 10/3/12 at 3:45PM interview with S5 housekeeping supervisor confirmed they were not using the proper chemicals to clean resident #6 and #7 ' s isolation room. On 10/3/12, review of the Center for Disease Control (CDC) revealed there are guidelines to prevent the spread of [MEDICAL CONDITION]. The CDC states to isolate the patients with [DIAGNOSES REDACTED]icile immediately, wear gloves and gowns when treating patients with [DIAGNOSES REDACTED]icile, even during short visits. Hand sanitizer does not kill [DIAGNOSES REDACTED]icile, and hand washing may not be sufficient. Clean the room surfaces with bleach or another EPA-approved, spore-killing disinfectant after a patient with [DIAGNOSES REDACTED]icile has been treated there. II. Based on record review and interview, the facility failed to provide services to meet professional standards of quality by failing to administer medications as ordered by the physician for 3 of 3 sampled residents in a total sampled of 7. (Sampled #3, 6, 7) Findings: 1. Review of the medical record for sampled resident #7 revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Further review of the record revealed that the resident had a confirmed positive stool culture for [MEDICAL CONDITION] Toxin on 10/01/12. Physician orders [REDACTED]. Review of the October 2012 MAR indicated [REDACTED]. On 10/3/12 at 10:50AM, interview with S7LPN confirmed that the physician order [REDACTED]. 2. Review of the medical record for sampled resident #6 revealed [DIAGNOSES REDACTED]. Review of the laboratory results dated [DATE] revealed the resident's stool tested positive for [MEDICAL CONDITIONS]. Review of the physician orders [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 10/04/12 at 10:30AM S2DON confirmed the resident received 2 extra doses of the antibiotic. 3. Review of the medical record for sampled resident #3 revealed a physician order [REDACTED]. Review of the October 2012 MAR indicated [REDACTED]. On 10/2/12 at 9:40AM, interview with S14LPN confirmed she was going to get the resident's first dose of Bactrim antibiotic out of the ER kit for his first dose. Further interview with S14LPN revealed that the order had not been faxed to the resident's pharmacy yet. Based on record review and interview, the facility failed to provide services to meet professional standards of quality by failing to administer medications as ordered by the physician for 3 of 3 sampled residents in a total sampled of 7. (Sampled #3, 6, 7) Findings: 1. Review of the medical record for sampled resident #7 revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Further review of the record revealed that the resident had a confirmed positive stool culture for [MEDICAL CONDITION] Toxin on 10/2/12. Physician orders [REDACTED]. Review of the October 2012 MAR indicated [REDACTED]. On 10/3/12 at 10:50AM, interview with S7LPN confirmed that the physician order [REDACTED]. 2. Review of the medical record for sampled resident #7 revealed [DIAGNOSES REDACTED]. Review of the laboratory results dated [DATE] revealed the resident's stool tested positive for [MEDICAL CONDITIONS]. Review of the physician orders [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 10/04/12 at 10:30AM S2DON confirmed the resident received 2 extra doses of the antibiotic. 3. Review of the medical record for sampled resident #3 revealed a physician order [REDACTED]. Review of the October 2012 MAR indicated [REDACTED]. On 10/2/12 at 9:40AM, interview with S14LPN confirmed she was going to get the resident's first dose of Bactrim antibiotic out of the ER kit for his first dose. Further interview with S14LPN revealed that the order had not been faxed to the resident's pharmacy yet.

Based on observation, interview, record review and review of the Infection Control Policy, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection for 2 of 2 (#6 and #7) sampled residents diagnosed with [REDACTED]. (Sample #1 - #7) The facility failed to: 1) train staff on appropriate contact and isolation precautions; 2) implement contact and isolation precautions after resident #6 was diagnosed with [REDACTED]. 3) prevent the transmission of[DIAGNOSES REDACTED] to other residents in the facility when resident #6 was diagnosed with [REDACTED]. 4) follow the policy regarding isolation precautions. Resident #7 was in Immediate Jeopardy on 09/27/12 when her roommate, resident #6 was diagnosed with [REDACTED]. As a result of the facility failing to implement isolation precautions, resident #7 was diagnosed with [REDACTED]. All other residents in the facility (#2, 3, 4, 5, R1 - R127) were in an Immediate Jeopardy situation due to the improper infection control practices and possible exposure to the[DIAGNOSES REDACTED] infection. On 10/3/12 at 2:35PM, the survey team notified S1Administrator and S2DON of the Immediate Jeopardy (IJ) situation that currently existed in the facility. The IJ situation began on 9/27/12 when sampled resident #6 was diagnosed with [REDACTED]. As a result of the facility failing to implement isolation and contact precautions per Center for Disease Control when sampled resident #6 was diagnosed on [DATE], sampled resident #7 (sampled resident #6's roommate) was diagnosed with [REDACTED]. The facility submitted a plan of removal the survey team on 10/4/12 for the Immediate Jeopardy situation. The plan of removal included the following. Immediate inservices would be conducted with LPNs, CNAs, housekeeping and laundry personnel regarding[DIAGNOSES REDACTED], isolation precautions, isolation cart, red biohazard bags for laundry, and disposable products for meal service. Sampled residents #6 and #7's room was terminally cleaned with a bleach solution. An isolation cart was placed outside the room of residents #6 and #7. A QA form was developed and isolation procedures would be monitored on a daily basis. On 10/4/12 at 10:17AM, the Immediate Jeopardy situation was removed after the facility implemented their plan. The deficient practice continued at a scope and severity of an Actual Harm for resident #7. Findings: 1. Review of the medical record for sampled resident #6 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record dated 09/21/12 revealed the nurse faxed the physician to inform him of sampled resident #6 having loose stools. The physician ordered to obtain stools for culture and sensitivity,[DIAGNOSES REDACTED] and for parasites. Further review of the medical record revealed the physician wrote an order dated 9/21/12 for [MEDICATION NAME] 500 milligrams 1 pill to be given three times a day for 7 days. Review of the nurses notes dated 09/26/12 revealed the stool sample was obtained as ordered. Review of the laboratory results dated [DATE] revealed the stool culture was positive for Clostridium Difficile Toxin. Review of the physician orders [REDACTED]. On 10/03/12 at 9:55AM an interview with S7LPN revealed the facility was using universal precautions for the resident due to her infection with[DIAGNOSES REDACTED]. 2. Review of the medical record for sampled resident #7 (the room mate of sampled resident #6) revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Further review of the record revealed that the resident had a confirmed positive stool culture for Clostridium Difficile Toxin on 10/01/12. Physician orders [REDACTED]. Review of the October 2012 MAR revealed the first dose of [MEDICATION NAME] was not administered until 10/03/12 at 8AM. On 10/03/12 at 9:00AM observation of sampled resident #7 revealed S3CNA supervisor and S10CNA repositioned the resident in her wheelchair without wearing gloves. Further observations revealed that S10CNA entered another resident's room on the hall without washing her hands. On 10/03/12 at 9:35AM observation of sampled resident #6 and #7 revealed they were sitting in their room. Further observation revealed a bedside commode was on resident #6's side of the room. A dirty pull-up and dirty gloves were noted in the trash can in the room. On 10/03/12 at 9:45AM, observation revealed the resident was sliding down in her wheelchair again. S3CNA supervisor entered the room and repositioned the resident without wearing gloves. Interview with S3 at that time revealed that sampled residents #6 and #7 had[DIAGNOSES REDACTED] infection and could not leave their rooms. On 10/03/12 at 9:50AM observation of the outside of the room revealed a sign was not posted on the door to alert staff and/or visitors to see the nurse before entering the room. Further observation of the outside of the room revealed there was not a cart containing contact isolation equipment to be used when entering the room. On 10/03/12 at 10:00AM an interview with sampled resident #6 revealed she was unable to leave her room because she had an infection. On 10/03/12 at 10:15AM, an interview with S10CNA revealed residents #6 and #7 were not able to leave their room due to an infection that they both had. Further interview with S10CNA revealed she was unaware of the type of infection that the residents had. On 10/03/12 at 10:20AM, an interview with S4Housekeeper revealed that she had heard that resident #6 and #7 had an infection, but she was not using anything different to clean their room. On 10/03/12 at 10:25AM, interviews with S6CNA, S10CNA and S11CNA revealed they were not instructed to wear gloves when providing care or activities of daily living for the sampled residents. On 10/3/12 at 10:30AM, observation revealed random resident #R5 rolled her wheelchair into the room of sampled residents #6 and #7. The resident was confused and was observed touching the bathroom door and door handle in the resident's room. On 10/03/12 at 10:35AM, an interview with S12Laundry Worker revealed she was not doing anything different for the residents when collecting, washing and drying their laundry. On 10/03/12 at 12:10PM, observation of the lunch meal revealed sampled residents #6 and #7 were eating their lunch in their room. Further observation revealed the residents were served on regular plates, glasses and utensils. S6CNA was feeding sampled resident #7 in the room without wearing gloves. On 10/03/12 at 12:20PM, an interview with S6CNA revealed sampled residents #6 and #7 required assistance with activities of daily living and they both shared the commode and sink in the bathroom located in their room. On 10/3/12 at 1:50PM interview with S4 Housekeeper confirmed there were no biohazard bags in the room. Further observation at this time revealed S4Housekeeper took the bottles of cleaning solution from her housekeeping cart and went into resident #6 and #7 ' s room and placed them on the bedside table to begin cleaning. On 10/3/12 at 2:00PM, review of the policy and procedure for isolation precautions revealed: any resident suspected or diagnosed as having a communicable disease shall be placed in the appropriate type of isolation as delineated in these policies and procedures. Further review of the policy and procedure revealed it shall be the responsibility of the Administrator, through the Infection Control Committee and Infection Control Coordinator to assure that all Infection Control Policies and Procedures are implemented and followed as appropriate. The policy and procedure states the facility has adopted Universal Precautions on a facility wide basis in order to comply with CDC and OSHA recommendations. The facility continues to post signs and acknowledge other category specific isolation precautions in order to assure comprehensive quality care. Review of the supervision policy and procedure in the infection control policy revealed: 1. The infection control coordinator shall be responsible for organizing and directing the implementation of the infection control procedures when isolation becomes necessary. 2. The charge nurse of each unit shall be responsible for carrying out all functions of the isolation precaution as directed by the infection control coordinator and policies and procedures of the facility. This includes supervision of personnel and assurance that all personnel and visitors follow established isolation precautions as well as any specific instructions that become necessary. Review of the Isolation procedure in the policy revealed: The isolation room is easily identified with an appropriate isolation sign which disposed outside the room entrance by the infection control coordinator (ICC) or Nurse supervisor. Review of the Placement in isolation procedure revealed: 1. If there is reason to believe (based on Guidelines for Determining an infection) that a resident has a communicable disease, the attending physician shall be notified immediately and the appropriate isolation precautions will be initiated. 2. Immediate notification of staff is essential as all orders concerning isolation must be carried out as soon as possible. 3. All residents placed in isolation for suspected or confirmed infections, shall have isolation precautions implemented in accordance with procedures established in the CDC Guidelines for Isolation Precautions in Hospitals. Isolation precautions shall be utilized only to the degree needed to isolate the infecting organism, based upon the CDC guidelines. 4. Only authorized persons, including care givers, family members, and visitors shall be allowed to enter the Isolation room and shall be required to follow all isolation precautions indicated. 5. Isolation procedures shall be followed until precautions are discontinued by the attending physician or until a negative culture or cessation of symptoms occurs. 6. The ICC designees (the charge nurse on that shift, or the supervisor) is responsible for obtaining the needed isolation precautions supplies and equipment, setting up the isolation station, posting the appropriate isolation sign outside the resident's room, and placing an appropriate isolation sticker in the resident's clinical record. 7. After confirmation of the category of isolation precautions that is needed, the ICC or designee will post the appropriate isolation precautions that is needed, the ICC or designee will post the appropriate isolation sign outside the resident's door and place an isolation cabinet in the corridor outside the room. Supplies in the cabinet include melt-away laundry bags, trash bags, outer bags to double bag laundry, disposable gowns and gloves. 8. The day shift nurse supervisor will monitor the isolation cabinet each day. 9. Residents placed in isolation shall be served all meals on disposable trays, dishes, and utensils until isolation procedures are discontinued. 10. Cleaning of the isolation room; Housekeeping will put on PPE (personal protective equipment) and take only needed supplies into the isolation room. Staff will damp dust furniture and window sills, bed and all horizontal surfaces, always working from the cleanest to the dirtiest area of the room to avoid cross contamination. The bathroom will be cleaned last. Wipe the mop handle with disinfectant, place contaminated mop head in melt-away bag and then into red plastic outer bag held from outside the room and take to laundry. On 10/03/12 at 2:10PM, an interview with S1Administrator and S2DON confirmed that sampled resident #7 was not removed from the room when sampled resident #6 was diagnosed with [REDACTED].#6 and #7's [DIAGNOSES REDACTED]. On 10/03/12 at 2:35PM, S1Administrator and S2DON was informed of the Immediate Jeopardy situation which existed when the facility failed to train staff on appropriate contact and isolation precautions; implement contact and isolation precautions; prevent the transmission of[DIAGNOSES REDACTED] to other residents in the facility; and follow the policy regarding isolation precautions. On 10/3/12 at 3:10PM, interview with S4housekeeper stated today (10/3/12) was the first day the red biohazard containers were placed in the room and an isolation cart was placed outside in the hall by the doorway. Observation on 10/3/12 at 3:15PM revealed S4housekeeper was cleaning resident #6 and #7 ' s room. S4housekeeper mopped the floor, put the cleaning spray bottle on resident #6 ' s bed, picked the cleaning bottle back up and then dropped the bottle on the floor and then picked it back up again. S4housekeeper then leaned the mop against the wall, and placed the spray bottle on the floor in the hallway. S4housekeeper placed the used mop pad, floor duster, and cleaning rags in a regular black trash bag and not a biohazard bag. S4housekeeper touched the dirty black trash bag with her hands then picked up both bottles of cleaning solution and put them on the housekeeping cart, then picked up the broom and dust pan with bare hands, and placed them on the housekeeping cart without cleaning the items. On 10/3/12 at 3:20PM interview with S4Housekeeper revealed she used Spic and Span disinfectant cleaner and Liquid Comet bathroom cleaner and Pro Line Disinfecting floor cleaner to clean residents #6 and #7's room and bathroom. Review of the ingredients on the comet bottle revealed: Water, citric acid, sodium cumene [MEDICATION NAME], surfactants, and perfume. Review of the ingredients on the Spic and Span all purpose spray and glass cleaner bottle revealed: Ammonium Chloride 0.5% and [MEDICATION NAME]. Review of the ingredients for the Disinfecting floor cleaner revealed: Ammonium Chloride 7.68% and other 92.32%. Further review of the label on the bottle revealed it did not list[DIAGNOSES REDACTED] as an organism that would be killed by using the product. On 10/3/12 at 3:30PM interview with S4housekeeper confirmed she put the dirty cleaning rags, the used mop pad, and the floor duster in a regular trash bag and put it on the housekeeping cart to take to the laundry. On 10/3/12 at 3:35PM an interview with S1Administrator confirmed they were using a Proctor and Gamble product that is supposed to be like Virex but does not contain bleach. S1Administrator and S2DON confirmed there was no sign on resident #6 and #7 ' s door indicating isolation. S1Administrator and S2DON confirmed S4housekeeper should not have used a regular trash bag and the technique used to clean the room was not correct. On 10/3/12 at 3:45PM interview with S5 housekeeping supervisor confirmed they were not using the proper chemicals to clean resident #6 and #7 ' s isolation room. On 10/3/12, review of the Center for Disease Control (CDC) revealed there are guidelines to prevent the spread of Clostridium Difficile. The CDC states to isolate the patients with [DIAGNOSES REDACTED]icile immediately, wear gloves and gowns when treating patients with [DIAGNOSES REDACTED]icile, even during short visits. Hand sanitizer does not kill [DIAGNOSES REDACTED]icile, and hand washing may not be sufficient. Clean the room surfaces with bleach or another EPA-approved, spore-killing disinfectant after a patient with [DIAGNOSES REDACTED]icile has been treated there.

Based on observation, record review, interview and review of the Infection Control Policy, the facility failed to be administered in a manner that used resources effectively and efficiently to attain or maintain the highest practicable physical well-being for 2 of 2 (#6 and #7) sampled residents in a total sample of 7. (Sample #1 - #7) Administration failed to: 1) train staff on appropriate contact and isolation precautions; 2) implement contact and isolation precautions after resident #6 was diagnosed with [REDACTED]. 3) prevent the transmission of [MEDICAL CONDITION] to other residents in the facility when resident #6 was diagnosed with [REDACTED]. 4) follow the policy regarding isolation precautions. Resident #7 was in Immediate Jeopardy on 09/27/12 when her roommate, resident #6 was diagnosed with [REDACTED]. As a result of the facility failing to implement isolation precautions, resident #7 was diagnosed with [REDACTED]. All other residents in the facility (#2, 3, 4, 5, R1 - R127) were in an Immediate Jeopardy situation due to the improper infection control practices and possible exposure to the [MEDICAL CONDITION] infection. On 10/3/12 at 2:35PM, the survey team notified S1Administrator and S2DON of the Immediate Jeopardy (IJ) situation that currently existed in the facility. The IJ situation began on 9/27/12 when sampled resident #6 was diagnosed with [REDACTED]. As a result of the facility failing to implement isolation and contact precautions per Center for Disease Control when sampled resident #6 was diagnosed on [DATE], sampled resident #7 (sampled resident #6's roommate) was diagnosed with [REDACTED]. The facility submitted a plan of removal the survey team on 10/4/12 for the Immediate Jeopardy situation. The plan of removal included the following. Immediate inservices would be conducted with LPNs, CNAs, housekeeping and laundry personnel regarding [MEDICAL CONDITION], isolation precautions, isolation cart, red biohazard bags for laundry, and disposable products for meal service. Sampled residents #6 and #7's room was terminally cleaned with a bleach solution. An isolation cart was placed outside the room of residents #6 and #7. A QA form was developed and isolation procedures would be monitored on a daily basis. On 10/4/12 at 10:17AM, the Immediate Jeopardy situation was removed after the facility implemented their plan. The deficient practice continued at a scope and severity of an Actual Harm for resident #7. Findings: 1. Review of the medical record for sampled resident #6 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record dated 09/21/12 revealed the nurse faxed the physician to inform him of sampled resident #6 having loose stools. The physician ordered to obtain stools for culture and sensitivity, [MEDICAL CONDITION] and for parasites. Further review of the medical record revealed the physician wrote an order dated 9/21/12 for [MEDICATION NAME] 500 milligrams 1 pill to be given three times a day for 7 days. Review of the nurses notes dated 09/26/12 revealed the stool sample was obtained as ordered. Review of the laboratory results dated [DATE] revealed the stool culture was positive for [MEDICAL CONDITION] Toxin. Review of the physician orders [REDACTED]. On 10/03/12 at 9:55AM an interview with S7LPN revealed the facility was using universal precautions for the resident due to her infection with [MEDICAL CONDITION]. 2. Review of the medical record for sampled resident #7 (the room mate of sampled resident #6) revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Further review of the record revealed that the resident had a confirmed positive stool culture for [MEDICAL CONDITION] Toxin on 10/01/12. Physician orders [REDACTED]. Review of the October 2012 MAR indicated [REDACTED]. On 10/03/12 at 9:00AM observation of sampled resident #7 revealed S3CNA supervisor and S10CNA repositioned the resident in her wheelchair without wearing gloves. Further observations revealed that S10CNA entered another resident's room on the hall without washing her hands. On 10/03/12 at 9:35AM observation of sampled resident #6 and #7 revealed they were sitting in their room. Further observation revealed a bedside commode was on resident #6's side of the room. A dirty pull-up and dirty gloves were noted in the trash can in the room. On 10/03/12 at 9:45AM, observation revealed the resident was sliding down in her wheelchair again. S3CNA supervisor entered the room and repositioned the resident without wearing gloves. Interview with S3 at that time revealed that sampled residents #6 and #7 had [MEDICAL CONDITION] infection and could not leave their rooms. On 10/03/12 at 9:50AM observation of the outside of the room revealed a sign was not posted on the door to alert staff and/or visitors to see the nurse before entering the room. Further observation of the outside of the room revealed there was not a cart containing contact isolation equipment to be used when entering the room. On 10/03/12 at 10:00AM an interview with sampled resident #6 revealed she was unable to leave her room because she had an infection. On 10/03/12 at 10:15AM, an interview with S10CNA revealed residents #6 and #7 were not able to leave their room due to an infection that they both had. Further interview with S10CNA revealed she was unaware of the type of infection that the residents had. On 10/03/12 at 10:20AM, an interview with S4Housekeeper revealed that she had heard that resident #6 and #7 had an infection, but she was not using anything different to clean their room. On 10/03/12 at 10:25AM, interviews with S6CNA, S10CNA and S11CNA revealed they were not instructed to wear gloves when providing care or activities of daily living for the sampled residents. On 10/3/12 at 10:30AM, observation revealed random resident #R5 rolled her wheelchair into the room of sampled residents #6 and #7. The resident was confused and was observed touching the bathroom door and door handle in the resident's room. On 10/03/12 at 10:35AM, an interview with S12Laundry Worker revealed she was not doing anything different for the residents when collecting, washing and drying their laundry. On 10/03/12 at 12:10PM, observation of the lunch meal revealed sampled residents #6 and #7 were eating their lunch in their room. Further observation revealed the residents were served on regular plates, glasses and utensils. S6CNA was feeding sampled resident #7 in the room without wearing gloves. On 10/03/12 at 12:20PM, an interview with S6CNA revealed sampled residents #6 and #7 required assistance with activities of daily living and they both shared the commode and sink in the bathroom located in their room. On 10/3/12 at 1:50PM interview with S4 Housekeeper confirmed there were no biohazard bags in the room. Further observation at this time revealed S4Housekeeper took the bottles of cleaning solution from her housekeeping cart and went into resident #6 and #7 ' s room and placed them on the bedside table to begin cleaning. On 10/3/12 at 2:00PM, review of the policy and procedure for isolation precautions revealed: any resident suspected or diagnosed as having a communicable disease shall be placed in the appropriate type of isolation as delineated in these policies and procedures. Further review of the policy and procedure revealed it shall be the responsibility of the Administrator, through the Infection Control Committee and Infection Control Coordinator to assure that all Infection Control Policies and Procedures are implemented and followed as appropriate. The policy and procedure states the facility has adopted Universal Precautions on a facility wide basis in order to comply with CDC and OSHA recommendations. The facility continues to post signs and acknowledge other category specific isolation precautions in order to assure comprehensive quality care. Review of the supervision policy and procedure in the infection control policy revealed: 1. The infection control coordinator shall be responsible for organizing and directing the implementation of the infection control procedures when isolation becomes necessary. 2. The charge nurse of each unit shall be responsible for carrying out all functions of the isolation precaution as directed by the infection control coordinator and policies and procedures of the facility. This includes supervision of personnel and assurance that all personnel and visitors follow established isolation precautions as well as any specific instructions that become necessary. Review of the Isolation procedure in the policy revealed: The isolation room is easily identified with an appropriate isolation sign which disposed outside the room entrance by the infection control coordinator (ICC) or Nurse supervisor. Review of the Placement in isolation procedure revealed: 1. If there is reason to believe (based on Guidelines for Determining an infection) that a resident has a communicable disease, the attending physician shall be notified immediately and the appropriate isolation precautions will be initiated. 2. Immediate notification of staff is essential as all orders concerning isolation must be carried out as soon as possible. 3. All residents placed in isolation for suspected or confirmed infections, shall have isolation precautions implemented in accordance with procedures established in the CDC Guidelines for Isolation Precautions in Hospitals. Isolation precautions shall be utilized only to the degree needed to isolate the infecting organism, based upon the CDC guidelines. 4. Only authorized persons, including care givers, family members, and visitors shall be allowed to enter the Isolation room and shall be required to follow all isolation precautions indicated. 5. Isolation procedures shall be followed until precautions are discontinued by the attending physician or until a negative culture or cessation of symptoms occurs. 6. The ICC designees (the charge nurse on that shift, or the supervisor) is responsible for obtaining the needed isolation precautions supplies and equipment, setting up the isolation station, posting the appropriate isolation sign outside the resident's room, and placing an appropriate isolation sticker in the resident's clinical record. 7. After confirmation of the category of isolation precautions that is needed, the ICC or designee will post the appropriate isolation precautions that is needed, the ICC or designee will post the appropriate isolation sign outside the resident's door and place an isolation cabinet in the corridor outside the room. Supplies in the cabinet include melt-away laundry bags, trash bags, outer bags to double bag laundry, disposable gowns and gloves. 8. The day shift nurse supervisor will monitor the isolation cabinet each day. 9. Residents placed in isolation shall be served all meals on disposable trays, dishes, and utensils until isolation procedures are discontinued. 10. Cleaning of the isolation room; Housekeeping will put on PPE (personal protective equipment) and take only needed supplies into the isolation room. Staff will damp dust furniture and window sills, bed and all horizontal surfaces, always working from the cleanest to the dirtiest area of the room to avoid cross contamination. The bathroom will be cleaned last. Wipe the mop handle with disinfectant, place contaminated mop head in melt-away bag and then into red plastic outer bag held from outside the room and take to laundry. On 10/03/12 at 2:10PM, an interview with S1Administrator and S2DON confirmed that sampled resident #7 was not removed from the room when sampled resident #6 was diagnosed with [REDACTED].#6 and #7's [DIAGNOSES REDACTED]. On 10/03/12 at 2:35PM, S1Administrator and S2DON was informed of the Immediate Jeopardy situation which existed when the facility failed to train staff on appropriate contact and isolation precautions; implement contact and isolation precautions; prevent the transmission of [MEDICAL CONDITION] to other residents in the facility; and follow the policy regarding isolation precautions. On 10/3/12 at 3:10PM, interview with S4housekeeper stated today (10/3/12) was the first day the red biohazard containers were placed in the room and an isolation cart was placed outside in the hall by the doorway. Observation on 10/3/12 at 3:15PM revealed S4housekeeper was cleaning resident #6 and #7 ' s room. S4housekeeper mopped the floor, put the cleaning spray bottle on resident #6 ' s bed, picked the cleaning bottle back up and then dropped the bottle on the floor and then picked it back up again. S4housekeeper then leaned the mop against the wall, and placed the spray bottle on the floor in the hallway. S4housekeeper placed the used mop pad, floor duster, and cleaning rags in a regular black trash bag and not a biohazard bag. S4housekeeper touched the dirty black trash bag with her hands then picked up both bottles of cleaning solution and put them on the housekeeping cart, then picked up the broom and dust pan with bare hands, and placed them on the housekeeping cart without cleaning the items. On 10/3/12 at 3:20PM interview with S4Housekeeper revealed she used Spic and Span disinfectant cleaner and Liquid Comet bathroom cleaner and Pro Line Disinfecting floor cleaner to clean residents #6 and #7's room and bathroom. Review of the ingredients on the comet bottle revealed: Water, citric acid, sodium cumene [MEDICATION NAME], surfactants, and perfume. Review of the ingredients on the Spic and Span all purpose spray and glass cleaner bottle revealed: Ammonium Chloride 0.5% and [MEDICATION NAME]. Review of the ingredients for the Disinfecting floor cleaner revealed: Ammonium Chloride 7.68% and other 92.32%. Further review of the label on the bottle revealed it did not list [MEDICAL CONDITION] as an organism that would be killed by using the product. On 10/3/12 at 3:30PM interview with S4housekeeper confirmed she put the dirty cleaning rags, the used mop pad, and the floor duster in a regular trash bag and put it on the housekeeping cart to take to the laundry. On 10/3/12 at 3:35PM an interview with S1Administrator confirmed they were using a Proctor and Gamble product that is supposed to be like Virex but does not contain bleach. S1Administrator and S2DON confirmed there was no sign on resident #6 and #7 ' s door indicating isolation. S1Administrator and S2DON confirmed S4housekeeper should not have used a regular trash bag and the technique used to clean the room was not correct. On 10/3/12 at 3:45PM interview with S5 housekeeping supervisor confirmed they were not using the proper chemicals to clean resident #6 and #7 ' s isolation room. On 10/3/12, review of the Center for Disease Control (CDC) revealed there are guidelines to prevent the spread of [MEDICAL CONDITION]. The CDC states to isolate the patients with [DIAGNOSES REDACTED]icile immediately, wear gloves and gowns when treating patients with [DIAGNOSES REDACTED]icile, even during short visits. Hand sanitizer does not kill [DIAGNOSES REDACTED]icile, and hand washing may not be sufficient. Clean the room surfaces with bleach or another EPA-approved, spore-killing disinfectant after a patient with [DIAGNOSES REDACTED]icile has been treated there.