Every finding on record at Tice Valley Post Acute

Based on interview and record review, the facility failed to follow state Title 22 regulations and ensure the social services department was staffed and supervised by qualified and competent staff which affect all 123 residents.This failure resulted in all 123 residents receiving social services care from unqualified staff. During an interview on 9/23/25, at 10:35 a.m., with Social Services Director (SSD), SSD stated they were the director of the social services department and were responsible for admission assessments, discharge planning. SSD stated the social services department assisted residents with dental, optometry, podiatry and psychiatric appointments to ensure residents' physical, mental and psychosocial needs were met. SSD stated they had been working since 5/2025.During a concurrent interview and record review on 9/24/25, at 4:23 p.m., with Director of Staff Development (DSD), SSD's two job descriptions, dated 5/15/25 and 8/18/25, were reviewed. DSD stated after review of the job descriptions, SSD did not meet the qualifications of the 5/25/25 description and did not meet the preferred qualifications of the 8/18/25 copy because SSD did not meet the education requirement of Bachelor's Degree in Social Work or in Human Services.During a concurrent interview and record review on 9/24/25, at 4:30 p.m., with DSD, SSD's resume titled [SSD] Professional Summary, undated, and education registration form titled SSD Online Certification Course, undated, was reviewed. DSD stated the SSD's resume did not indicate list any education and the education registration form indicated SSD had completed a high school education.During a concurrent interview and record review on 9/25/25, at 10:14 a.m., with Human Resources (HR), SSD's two job descriptions, dated 5/15/25 and 8/18/25, were reviewed. HR stated they were responsible to ensure staff had current credentials and qualifications before hire. After review SSD's job descriptions the 5/15/25 job description, HR stated SSD was not qualified for the position because SSD did not have a bachelor's degree in social work. HR stated SSD was hired without the required qualifications because everyone was confused by the qualifications section on the job description. HR stated the SSD didn't need to have a bachelor's degree and the facility created another job description which SSD signed on 8/18/25.During a concurrent interview and review of facility policy and procedure (P&P) on 9/25/25, at 4:15 p.m., with Administrator (ADM), the facility's P&P titled, Social Services, dated September 2024, was reviewed. The ADM stated the P&P indicated the director of social services was a qualified social worker. ADM stated the social services department did not have social workers, and there was no plan to hire a qualified social worker. ADM stated SSD was the only supervisor of the social services department. ADM stated they were unaware of any regulations which required the social services department to be supervised by a qualified social worker.During a review of facility's facility assessment titled, [Facility] Facility Assessment, dated 8/27/25, the facility assessment indicated a staffing plan which included Total Number Needed or Average or Range.Social Worker.FULL-TIME on AM and PM shift.During a review of California state regulation titled, Title 22 S72433, the state regulation indicated 'Social Work Service' means those services which assist.a patient and a patient's family to understand and cope with.personal, emotional and related health and environmental problems.During a review of California state regulation titled, Title 22 S72437, the state regulation indicated Social Work Service Unit-Staff.the social work service unit shall be organized, directed and supervised by a social worker, who is responsible for supervision of other social work staff, including social work assistants.

Based on observation, interview and record review, the facility failed to ensure it kept accurate records of controlled medications (medication with a potential for abuse) as evidenced by: 1. The facility failed to ensure, for residents 1-8, the scheduled (controlled medication, narcotic) medication system was complete (all documents available) and accurate (information matched). The record system included Shipping Manifests (pharmacy delivery receipt), Controlled Substance Accountability Sheets (CDR, Controlled Drug Record), Medication Administration Records (MAR, record of medication administration) and destruction logs. The facility records were incomplete. The facility records were inaccurate. These failures had the potential to result in undetected loss and diversion of scheduled medications. In addition, these failures had the potential to result in preventable medication errors (medication not given as ordered).2. The facility failed to ensure, between 2/1/24-6/30/24, the Consultant Pharmacist identified the scheduled (controlled medication, narcotic) medication system was incomplete (all documents available) and inaccurate (information matched). The record system included Shipping Manifests (pharmacy delivery receipt), Controlled Substance Accountability Sheets (CDR, Controlled Drug Record), Medication Administration Records (MAR, record of medication administration) and destruction logs. The facility records were incomplete. The facility records were inaccurate. These failures had the potential to result in undetected loss and diversion of scheduled medications. In addition, these failures had the potential to result in preventable medication errors (medication not given as ordered).Findings:1. During a concurrent observation and interview on 9/22/25 at 9:50 a.m., Registered Nurse (RN 1) was requested to describe the scheduled medication process. RN 1's description included that the pharmacy delivered medication with a corresponding Shipping Manifest and CDR. She further described that the medication and CDR were placed in the medication cart. Her description included that the CDR was used to maintain a record of medication use. The CDR included medication count, date/time and nurse signature. Continuing the concurrent observation and interview on 9/22/25 at 9:50 a.m., RN 1 identified the Lexington medication room. Inspection of the medication room showed an automated dispensing cabinet (ADU, device to dispense medication). RN 1 was requested to describe the role of the ADU in the scheduled medication process. RN 1's description included the ADU was used to obtain medication for the residents. The nurse would obtain pharmacy authorization, and the ADU would dispense the scheduled medication. RN 1 stated that the ADU did not provide a corresponding receipt of the dispensed scheduled medication. In addition, RN 1 stated that the scheduled medication administration would be documented in the MAR.During an interview on 9/22/25 at 10:45 a.m., Medical Record Director (MRD) was asked to describe the scheduled medication record keeping process. MRD's description included the pharmacy delivery receipts and corresponding CDRs were filed in Medical Records. MRD was requested to provide the pharmacy delivery receipts for scheduled medications from 3/1/24 to 5/31/24.During an interview on 9/22/25 at 3:45 p.m., MRD was requested to provide the ADU scheduled medication delivery receipts and corresponding CDRs from 3/1/24 to 5/31/24.During an interview on 9/23/25 at 9:35 a.m., MRD was asked to describe the process for scheduled medications obtained from the ADU. MRD's description included that the facility did not have ADU delivery receipts or the equivalent. MRD stated the facility did not have ADU CDRs or the equivalent. During a concurrent interview and record review 9/25/25 at 10 a.m., Director of Nursing (DON) identified the ADU Transaction by Item/Procedure report (scheduled medications removed from the ADU). DON acknowledged the ADU removal did not have a corresponding MAR entry on the following dates and times:Resident 1 Oxycodone (narcotic pain reliever)-Acetamin (non-narcotic pain reliever) 5-325 tablet #15/19/24 10:15 pmResident 2 Hydrocodon (narcotic pain reliever)-Acetaminophn 10-325 #15/15/24 0228 am5/14/24 10:37 pmDuring a concurrent interview and record review on 9/25/25 at 10:25 a.m., DON identified Resident 8's MAR. DON compared the R71273170 Oxycodone 15mg (milligram) tablet CDR against the MAR. DON acknowledged the CDR removals did not have a corresponding MAR administration on the dates and times listed below.2/27/24 16402/28/24 16302/29/24 1230, 16303/2/24 0430, 0830, 1230, 2030During a concurrent interview and record review on 9/25/25 at 10:28 a.m., DON identified Resident 7's MAR. She compared the R73660709 Oxycontin 10mg tablet CDR against the MAR. DON acknowledged the CDR removal did not have a corresponding MAR administration on the date and time listed below.3/29/25 2100During a concurrent interview and record review on 9/25/25 at 10:32 a.m., DON identified Resident 6's MAR. She compared the R73595744 Hydrodone-Acet 5mg-325mg tablet CDR against the MAR. DON acknowledged the CDR removal did not have a corresponding MAR administration on the date and times listed below.3/18/25 0800, 2044During a concurrent interview and record review on 9/25/25 at 10:37 a.m., DON identified Resident 3's MAR. She compared the R73804476 Hydrocodone-Acet 5mg-325mg tablet CDR against the MAR. DON acknowledged the CDR removal did not have a corresponding MAR administration on the date and time listed below.4/11/25 2200During a concurrent interview and record review on 9/25/25 at 10:40 a.m., DON identified Resident 5's MAR. She compared the R73697484 Hydrodone-Acet 5mg-325mg tablet CDR against the MAR. DON acknowledged the CDR removal did not have a corresponding MAR administration on the date and time listed below.3/24/25 1215During a concurrent interview and record review on 9/25/25 at 10:55 a.m., DON identified Resident 4's MAR. She compared the R71805741 Hydrodone-Acet 5mg-325mg tablet CDR against the MAR. DON acknowledged the CDR removals did not have a corresponding MAR administration on the dates and times listed below.5/24/24 20115/27/24 09405/31/24 21356/1/24 21306/3/24 21306/4/24 0900During a concurrent interview and record review on 9/25/25 at 3:15 p.m., DON acknowledged the Shipping Manifests, CDRs and MARs did not account for all scheduled medications. She acknowledged the Controlled Substance policy required inventory to be monitored and reconciled. An administrative record review, of the Policy for Controlled Substances (Dated: 2001 Med-Pass) showed, Dispensing and Reconciling Controlled Substances, 1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. Continued review showed, 2. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage; b. Medication administration records; c. Declining inventory records. 2. During a concurrent observation and interview on 9/22/25 at 9:50 a.m., Registered Nurse (RN 1) was requested to describe the scheduled medication process. RN 1's description included that the pharmacy delivered medication with a corresponding Shipping Manifest and CDR. She further described that the medication and CDR were placed in the medication cart. Her description included that the CDR was used to maintain a record of medication use. The CDR included medication count, date/time and nurse signature. Continuing the concurrent observation and interview on 9/22/25 at 9:50 a.m., RN 1 identified the Lexington medication room. Inspection of the medication room showed an automated dispensing cabinet (ADU, device to dispense medication). RN 1 was requested to describe the role of the ADU in the scheduled medication process. RN 1's description included the ADU was used to obtain medication for the residents. The nurse would obtain pharmacy authorization, and the ADU would dispense the scheduled medication. RN 1 stated that the ADU did not provide a corresponding receipt of the dispensed scheduled medication. In addition, RN 1 stated that the scheduled medication administration would be documented in the MAR.During an interview on 9/22/25 at 10:45 a.m., Medical Record Director (MRD) was asked to describe the scheduled medication record keeping process. MRD's description included the pharmacy delivery receipts and corresponding CDRs were filed in Medical Records. MRD was requested to provide the pharmacy delivery receipts for scheduled medications from 3/1/24 to 5/31/24.During an interview on 9/22/25 at 3:45 p.m., MRD was requested to provide the ADU scheduled medication delivery receipts and corresponding CDRs from 3/1/24 to 5/31/24.During an interview on 9/23/25 at 9:35 a.m., MRD was asked to describe the process for scheduled medications obtained from the ADU. MRD's description included that the facility did not have ADU delivery receipts or the equivalent. MRD stated the facility did not have ADU CDRs or the equivalent. During a concurrent interview and record review on 9/25/25 at 10 a.m., Director of Nursing (DON) identified the ADU Transaction by Item/Procedure report (scheduled medications removed from the ADU). DON acknowledged the ADU removal did not have a corresponding MAR entry on the following dates and times:Resident 1 Oxycodone (narcotic pain reliever)-Acetamin (non-narcotic pain reliever) 5-325 tablet #15/19/24 10:15 pmResident 2 Hydrocodon (narcotic pain reliever)-Acetaminophn 10-325 #15/15/24 0228 am5/14/24 10:37 pmDuring a concurrent interview and record review on 9/25/25 at 10:25 a.m., DON identified Resident 8's MAR. She compared the R71273170 Oxycodone 15mg (milligram) tablet CDR against the MAR. DON acknowledged the CDR removals did not have a corresponding MAR administration on the dates and times listed below.2/27/24 16402/28/24 16302/29/24 1230, 16303/2/24 0430, 0830, 1230, 2030During a concurrent interview and record review on 9/25/25 at 10:28 a.m., DON identified Resident 7's MAR. She compared the R73660709 Oxycontin 10mg tablet CDR against the MAR. DON acknowledged the CDR removal did not have a corresponding MAR administration on the date and time listed below.3/29/25 2100During a concurrent interview and record review on 9/25/25 at 10:32 a.m., DON identified Resident 6's MAR. She compared the R73595744 Hydrodone-Acet 5mg-325mg tablet CDR against the MAR. DON acknowledged the CDR removal did not have a corresponding MAR administration on the date and times listed below.3/18/25 0800, 2044During a concurrent interview and record review on 9/25/25 at 10:37 a.m., DON identified Resident 3's MAR. She compared the R73804476 Hydrocodone-Acet 5mg-325mg tablet CDR against the MAR. DON acknowledged the CDR removal did not have a corresponding MAR administration on the date and time listed below.4/11/25 2200During a concurrent interview and record review on 9/25/25 at 10:40 a.m., DON identified Resident 5's MAR. She compared the R73697484 Hydrodone-Acet 5mg-325mg tablet CDR against the MAR. DON acknowledged the CDR removal did not have a corresponding MAR administration on the date and time listed below.3/24/25 1215During a concurrent interview and record review on 9/25/25 at 10:55 a.m., DON identified Resident 4's MAR. She compared the R71805741 Hydrodone-Acet 5mg-325mg tablet CDR against the MAR. DON acknowledged the CDR removals did not have a corresponding MAR administration on the dates and times listed below.5/24/24 20115/27/24 09405/31/24 21356/1/24 21306/3/24 21306/4/24 0900During a concurrent interview and record review on 9/25/25 at 3:15 p.m., DON acknowledged the pharmacy delivery receipt, CDR, MAR and ADU documentation did not accurately account for all scheduled medications (not reconciled). She acknowledged the Role of the Consultant Pharmacist Policy was to provide consultation on all aspects of pharmacy services. Pharmacy services included ensuring the scheduled medication record system was complete and accurate. She further stated the Consultant Pharmacist Summary reports 2/1/24-6/30/24 did not document the issues with controlled substance documentation (including ADU receipts, CDRs and MARs). She stated that it was the faculty's expectation that these issues were to be identified (evaluate). An administrative record review, of the Quality Improvement: Consultant Pharmacist Summary, February 1, 2024- June 30, 2024 (five reports) did not identify issues with scheduled medication ADU receipts, CDRs and MARs.An administrative record review, of the Policy for Controlled Substances (Dated: 2001 Med-Pass) showed, Dispensing and Reconciling Controlled Substances, 1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. Continued review showed, 2. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage; b. Medication administration records; c. Declining inventory records.An administrative record review, of the Policy for Pharmacy Services-Role of the Consultant Pharmacist (April 2024), Policy Interpretation and Implementation, 3. The consultant pharmacist shall provide consultation on all aspects of pharmacy services in the facility, and collaborate with the facility and medical director to: a. develop, implement, evaluate, and revise (as necessary) the procedures for the provision of all aspects of pharmacy services.

Based on interview and record review, the facility failed to provide services to maintain grooming and personal hygiene for one of three sampled residents (Resident 1) when Certified Nursing Assistant (CNAs) did not provide Resident 1 showers as scheduled by the facility. This failure placed Resident 1 at risk for poor hygiene, body odor, infection, and transmission of diseases. During a review of Resident 1's admission Record (AR), printed 3/25/26, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease and dependence on renal dialysis (Kidney failure impossible to service without dialysis). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 2/18/26, the MDS indicated Resident 1's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was 11 and indicated impaired mental status. MDS indicated Resident 1 had clear speech, makes self-understood and understands others. MDS indicated Resident 1 was dependent on staff for shower. Resident 1 needed the assistance of two or more helpers required to complete the activity. During an interview on 3/19/26, at 1:33 p.m., with Resident 1, Resident 1 stated CNAs did not give her shower for two weeks. During a review of Resident 1's Nurse's Note (NN), dated 2/26/26, the NN indicated Resident 1 stated I didn't get a shower. During a review of Resident 1's Shower Schedule (SS), the SS indicated the facility scheduled Resident 1 to receive showers twice weekly on Wednesday and Saturday. During an interview on 3/25/26, at 1:02 p.m., with CNA 1, CNA 1 stated Resident 1 refused shower due to back pain. CNA 1 stated Resident 1 complained of back pain and difficulty sitting. CNA 1 stated bed bath was provided for Resident 1. CNA 1 stated there was no documentation of Resident 1's refusal to shower. CNA 1 stated he did not notify charge nurse that Resident 1 refused to shower. During a review of Resident 1's ADL documentation report dated February and March 2026, the report indicated no documentation that CNAs provided Resident 1 a shower as scheduled. During a concurrent interview and record review on 5/7/25, at 3:10 p.m., with Director of Nursing (DON), Resident 1's shower schedule, progress notes and ADL documentation reports for February and March 2026, were reviewed. DON stated the facility's expectation was that Resident 1 receive a shower as scheduled. DON could not provide documentation that CNAs offered or provided Resident 1 shower as scheduled. DON could not provide documentation that charge nurse was notified of Resident 1's refusal to shower. During a review of the facility's policy and procedure (P&P) titled, Shower/Tub Bath, revised October 2025, the P&P indicated, The following information should be recorded on the resident's ADL record and /or in the resident's medical record:The date and time the shower/tub bath was performed.The name and title of the individual(s) who assisted the resident with the shower/tub bath.All assessment data (e.g., any reddened areas, sores, etc., on the resident's skin) obtained during the shower/tub bath.How the resident tolerated the shower/tub bath.If the resident refused the shower/tub bath, the reason(s) why and the intervention taken.The signature and title of the person recording data.Notify the supervisor if the resident refuses the shower/tub bath.Notify the physician of any skin areas that may need to be treated.Report other information in accordance with facility policy and professional standards of practice.

Based on interview and record review, the facility failed to follow state Title 22 regulations and ensure the social services department was staffed and supervised by qualified and competent staff which affected all 120 residents.This failure resulted in all 120 residents receiving social services care from unqualified staff.During an interview on 9/23/25, at 10:35 a.m., with Social Services Director (SSD), SSD stated they were the director of the social services department and were responsible for admission assessments, discharge planning. SSD stated the social services department assisted residents with dental, optometry, podiatry and psychiatric appointments to ensure residents' physical, mental and psychosocial needs were met. SSD stated they had been working since 5/2025.During a concurrent interview and record review on 9/24/25, at 4:23 p.m., with Director of Staff Development (DSD), SSD's two job descriptions, dated 5/15/25 and 8/18/25, were reviewed. DSD stated after review of the job descriptions, SSD did not meet the qualifications of the 5/25/25 description and did not meet the preferred qualifications of the 8/18/25 copy because SSD did not meet the education requirement of Bachelor's Degree in Social Work or in Human Services.During a concurrent interview and record review on 9/24/25, at 4:30 p.m., with DSD, SSD's resume titled, [SSD] Professional Summary, undated, and education registration form titled, SSD Online Certification Course, undated, were reviewed. DSD stated the SSD's resume did not indicate or list any education and the education registration form indicated SSD had completed a high school education.During a concurrent interview and record review on 9/25/25, at 10:14 a.m., with Human Resources (HR), SSD's two job descriptions, dated 5/15/25 and 8/18/25, were reviewed. HR stated they were responsible to ensure staff had current credentials and qualifications before hire. After review of SSD's job descriptions, for the 5/15/25 job description, HR stated SSD was not qualified for the position because SSD did not have a bachelor's degree in social work. HR stated SSD was hired without the required qualifications because everyone was confused by the qualifications section on the job description. HR stated the SSD didn't need to have a bachelor's degree and the facility created another job description which SSD signed on 8/18/25.During a concurrent interview and review of facility policy and procedure (P&P), on 9/25/25, at 4:15 p.m., with Administrator (ADM), the facility's P&P titled, Social Services, dated September 2024, was reviewed. The ADM stated the P&P indicated the director of social services was a qualified social worker. ADM stated the social services department did not have social workers, and there was no plan to hire a qualified social worker. ADM stated SSD was the only supervisor of the social services department. ADM stated they were unaware of any regulations which required the social services department to be supervised by a qualified social worker.During a review of facility's facility assessment titled, [Facility] Facility Assessment, dated 8/27/25, the facility assessment indicated a staffing plan which included Total Number Needed or Average or Range.Social Worker.FULL-TIME on AM and PM shift.During a review of California state regulation titled, Title 22 S72433, the state regulation indicated 'Social Work Service' means those services which assist.a patient and a patient's family to understand and cope with.personal, emotional and related health and environmental problems.During a review of California state regulation titled, Title 22 S72437, the state regulation indicated Social Work Service Unit-Staff.the social work service unit shall be organized, directed and supervised by a social worker, who is responsible for supervision of other social work staff, including social work assistants.

Based on observation, interview and medical record and document review, the facility failed to provide services for activities of daily living for 1 (Resident 50) of 8 sampled residents when: For Resident 50, fingernails were long and had black debris under the fingernails. These failures resulted in resident not having their hygiene maintained and had the potential to increase risk for infection. Findings:During an observation on 9/23/25, at 10:35 a.m., Resident 50 sat in bed and ate yogurt. Resident 50 stated she could feed herself. Resident 50 had black debris under her fingernails to both hands. Resident 50 stated the staff helped to clean her fingernails. Resident 50 stated she is forgetful.During an observation on 9/24/25, at 9:40 a.m., Resident 50 ate from her breakfast tray. Resident 50 had black debris under her fingernails to both hands.During an interview on 9/24/25, at 10:07a.m., CNA 2 stated he tries to clean Resident 50's nails.During a follow-up interview on 9/25/25, at 10:00 a.m., CNA 2 stated it was unhygienic to have unclean fingernails. CNA 2 stated if Resident 50 scratched herself, skin could break down and lead to infection.During a review of Resident 50's facility Face Sheet, the Face Sheet indicated an admit date [DATE] with diagnoses of muscle weakness, kidney failure and diabetes (disease in which the body cannot regulate the amount of sugar in the blood).During a review of Resident 50's quarterly Minimum Data Set (MDS-assessment tool used to guide care), dated 07/18/25, the MDS indicated a BIMS score of 13 (meaning resident has intact cognitive response). The MDS, section B (B0700) indicated Resident 50 had difficulty communicating some words or finishing thoughts but is able if prompted or given time. The MDS, section B (B0800) indicated Resident 50 usually understands verbal content as part/intent of message is missed but comprehends most conversation. Further review of the MDS, section GG for Functional Abilities-OBRA/Interim, the MDS indicated during personal hygiene, Resident 50 required supervision or touching assistance-helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.During a review of the facility's policy and procedure (P&P), titled Fingernails/Toenails, Care of, with a revised date February 2018, the P&P indicated a general guideline for nail care included daily cleaning and regular trimming.trimmed and smooth nails prevent accidental scratching and skin injury.Steps in the procedure include 9. Gently, remove the dirt from around and under each nail with an orange stick.

Based on observation, interview, and medical record review, the facility failed to follow the hemodialysis (treatment to remove waste products and excess fluid from the blood when kidneys are not functioning properly) care plan for one (Resident 50) of eight sampled residents reviewed. This failure did not ensure a hemodialysis resident received the service consistent with professional standards of practice and a person-centered care plan. Findings:During an observation and concurrent interview on 9/22/25, at 10:35 a.m., Resident 50 had bandages on her left upper arm. Resident 50 stated the bandages were put on at dialysis this past Saturday, two days ago. Resident 50 stated she did not know when they were to be removed.During an observation on 9/23/25, at 9:40 a.m., Resident 50 had the same bandages from yesterday on her left upper arm. Resident 50 stated she is going to dialysis after lunch today.During a review of Resident 50's facility Face Sheet, the Face Sheet indicated an admit date [DATE] with diagnoses of kidney failure and dependence on dialysis (a treatment that helps remove waste products and excess fluid from the blood when the kidneys are not functioning properly). During a review of Resident 50's Hemodialysis, ESRD, fistula to Left upper arm Care Plan, with a review date 7/18/25, the care plan indicated Resident 50's dialysis treatments were Tuesdays, Thursdays, and Saturdays from 3:00 p.m. to 6:00 p.m. Nursing interventions included checking the left upper arm fistula site dressing upon return from dialysis and leaving the dressing intact for 4 hours following dialysis treatments.

Based on observation, interview and record review, the facility failed to provide appropriate diet texture according to physician orders for two of three sampled residents (Resident 23 and 5) when both received a minced and moist meat texture instead of chopped.These failures resulted in Resident 5 and 23 experiencing a lower quality of life when they received a less advanced diet which was not to their documented preference.A review of Resident 23's admission record titled, admission Record, dated 9/25/25, indicated Resident 23 was admitted to the facility for senile degeneration of brain and hypertension (high blood pressure).During a record review of Resident 23's minimum data set (MDS, an assessment tool to guide resident care), dated 6/24/25, the MDS indicated Resident 23 had Brief Interview for Mental Status score of 12 (BIMS, is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of eight to twelve indicates a moderate cognitive impairment.) The MDS further indicated Resident 23 required supervision and set up and did not have difficulty swallowingDuring a record review of Resident 23's physicians' orders set titled, [Facility] Order Summary Report, dated 9/25/25, indicated Resident 23 had an order for Fortified diet Chopped Meat texture.start date 1/18/2025.A review of Resident 5's admission record titled, admission Record, dated 9/25/25, indicated Resident 5 was admitted to the facility for unspecified dementia, anemia (low red blood cell count) and cirrhosis of liver (inflammation of liver).During a record review of Resident 5's minimum data set (MDS, an assessment tool to guide resident care), dated 8/19/25, the MDS indicated Resident 5 had BIMS score of 12. The MDS further indicated Resident 5 did not have difficulty swallowing but was dependent on staff for feeding.During a record review of Resident 5's physicians' orders set titled, [Facility] Order Summary Report, dated 9/25/25, indicated Resident 5 had an order for Regular Chopped Meat texture.start date 6/13/2025.During an interview on 9/24/25, at 10:00 a.m., with Dietary Manager (DM), DM stated the facility followed the International Dysphagia Diet Standardization Initiative (IDDSI, a guideline to determine appropriate food texture and drink thickness for residents with difficulty swallowing, the guideline indicates a 4-7 scale for food texture) when determining appropriate food textures for residents.During an observation on 9/24/25, at 12:49 p.m., Resident 5's lunch time meal tray and meal ticket were inspected. The meal tray contained minced meat with gravy. The meal ticket indicated Resident 5 had Diet Order: Reg/Chopped Meats. A photo of the tray was taken.During a concurrent observation and interview on 9/24/25, at 1:17 p.m., with Registered Dietitian (RD), a lunch test tray was inspected. A meat patty chopped into small pieces was on the test tray. RD stated the chopped diet was the meat patty mechanically chopped into bite size pieces and represented the soft and bite sized texture on the IDDSI guideline.During a concurrent observation and record review on 9/24/25, at 1:22 p.m., Resident 23's partially consumed lunch tray and meal ticket were inspected. The meal ticket indicated Resident 23 had Diet Order: Reg/Chopped Meats. The meat on the meal tray was minced with gravy. A photo of the tray was taken.During a concurrent interview and record review on 9/25/25, at 1:50 p.m., with RD, Resident 5's nutrition assessment titled, Nutritional Risk Review (Quarterly), dated 8/19/25, and the picture of Resident 5's lunch tray, dated 9/24/25, were reviewed. RD stated RD had completed the assessment and the assessment indicated Resident 5 was dependent on staff for feeding and had no issues swallowing but had order meat to be chopped. The assessment further indicated a diet plan to honor res's rights and wished and preferred diet to promote quality of life. After reviewing Resident 5's lunch tray picture, RD stated the meat texture corresponded to minced and moist.During a concurrent interview and record review on 9/25/25, at 1:55 p.m., with RD, Resident 23's nutrition assessment titled, Nutritional Risk Review (Quarterly), dated 9/11/25, and the picture of Resident 23's lunch tray, dated 9/24/25, were reviewed. RD stated RD had completed the assessment and the assessment indicated Resident 23 was able to feed themselves and had no issues swallowing but prefers meat to be chopped. After reviewing Resident 23's lunch tray picture, RD stated the meat texture corresponded to minced and moist. RD stated all residents should be served the highest diet possible to promote quality of life and respect residents rights to eat food according to their preferences.During a review of Resident 23's care plan titled, Care Plan Report, dated 7/15/25, the care plan indicated Resident 23 had a care plan for risk of nutritional decline evidenced by.altered mechanical texture, (history) of inadequate oral intake, (history) of unintentional weight loss and had interventions which indicated staff honor food preferences.provide diet as ordered: regular diet, SB6 (IDDSI scale 6 indicating soft and bite sized food texture) meats only texture.During a review of Resident 5's care plan titled, Care Plan Report, dated 9/2/25, the care plan indicated Resident 5 had a care plan for risk of malnutrition and had interventions which indicated staff provided diet as ordered .provide regular diet per resident's wishesA review of facility policy and procedure (P&P) titled, Therapeutic Diets, dated 10/17, the P&P indicated therapeutic diets are prescribed by the attending physician to support resident's treatment and plan of care and in accordance with his or her goals and preferences.

Based on observation, interview and record review, the facility failed to ensure two (Residents 9 and 69) out of eight sampled residents received appropriate catheter care per facility policy when there were inconsistent cleaning methods used by staff.This failure had the potential to result in increased risk of urinary tract infections for residents 9 and 69. Findings: During a review of the medical record titled, PACS Medication Administration Record, dated 8/26/25, the record indicated Resident 9 was admitted [DATE] with instructions to provide catheter care every shift. During a review of the medical record, dated 9/19/25, titled, Care Plan Report, the record indicated Resident 9 was at risk for complications with urinary system related to urinary tract infections (UTI- an infection of the urinary system often caused by bacteria).During a review of the medical record, dated 9/2/25, titled, SBAR Communication Form, the record indicated resident 9 had a history of benign prostatic hyperplasia (enlarged prostate which can cause blocking of the flow of urine out of the bladder) with lower urinary tract symptoms, retention (holding) of urine, with a change of condition identified as a urinary tract infection (UTI).During a review of the medical record, dated 9/25/25, titled Diagnostic Report, the record indicated Resident 69 had stage 3 kidney disease (moderate damage to the kidneys), a history of malignant neoplasm (cancerous cells which can spread to other tissues and organs) of the prostate, and prostatic hyperplasia with lower urinary tract symptoms, and foley catheter (A thin, flexible tube inserted into the urethra, the tube that carries urine from the bladder to the outside of the body) placed 9/4/25. During a review of the medical record, dated 9/25/25, titled, Care Plan, the record indicated Resident 69 was admitted to facility on 9/6/25 to provide indwelling catheter care to prevent complications with urinary systems. During an interview on 9/24/25, at 10:40 a.m., Resident 69 stated he has an indwelling foley catheter and the staff cleaned it about a week ago. During an interview on 9/24/25, at 10:50 a.m., with Resident 9, Resident 9 stated he has an indwelling urinary catheter and the staff cleaned it about a week ago. During an interview on 9/24/25, at 10:25 a.m., with Certified Nursing Assistant (CNA) 3, CNA 3 stated she cleaned Residents 9 and 69's urinary catheter with Remedy Essentials Spray Cleaner, a scented cleansing solution used to condition skin and nails. During an interview on 9/24/25, at 10:50 a.m., with (CNA) 2, CNA 2 stated she cleaned resident's urinary catheter using Chlorhexidine wipes (An antiseptic solution used to clean skin, wounds, often used to prep the skin before surgery). During an interview on 9/24/25, at 10:35 a.m., with Registered Nurse (RN) 1, RN 1 stated she was unaware of different wipes and solutions being used by CNA's for catheter care. RN 1 stated it was important to use warm soapy water and to make sure bacteria was not introduced into the meatus (a passage or opening leading to the interior of the body), to prevent a urinary tract infection. During an interview on 9/24/25, at 11:10 a.m., with Director of Staff Development (DSD), DSD stated CNA's are trained on how to clean the catheter and can use chlorhexidine (a potent antiseptic, antibacterial, for short term use) or warm soapy water, wiping from meatus away from catheter tubing to prevent bacteria from entering meatus (a passage or opening leading to the interior of the body) which can cause an introduction of bacteria.During concurrent interview and record review on 9/25/25, at 9:20 a.m., with Assistant Director of Nursing (ADON), ADON stated that only warm soapy water should be used to clean the foley catheter tubing and chlorhexidine is used only if there is a doctor's order. During review of Resident 9's and 69's physicians order, there was no order to use chlorhexidine for catheter care. ADON stated that solution for skin and nails should not be used for catheter care. During a review of the facility policy and procedure (P&P), dated 2001, titled, Catheter Care, Urinary indicated, the purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Instructions for catheter. care include using clean washcloths with warm water and soap . to cleanse and rinse the catheter from insertion site to approximately four inches outward.Antiseptic wipes for daily cleansing are not recommended. During a review of the Director of Staff Development's (DSD) lesson plan for training staff, titled, UTI Prevention ., dated 6/18/25, the lesson plan indicated best practice for catheter care was to ensure daily cleaning to prevent infection.

Based on observation, interview, and record review, the facility failed to provide appropriate safety measures and adequate supervision to prevent one of three residents (Resident 1) from slipping out of bed and falling on the floor during incontinence care. The failure to provide adequate measures to prevent a dependent resident from slipping off the bed and falling onto the floor during incontinence care, resulted in Resident 1 being transported to the emergency department for further evaluation, requiring 15 stitches to maintain closure of the laceration (cut) on the right lower leg, and fracturing (partial or complete break in the bone) their right shoulder. Findings: A review of Resident 1's Admission Record, printed 12/12/24, indicated Resident 1 was admitted to the facility in 2016 with diagnoses of dementia (memory loss), diabetes (high blood sugar), essential tremor (a nervous system disorder that cause rhythmic shaking), and morbid obesity (having too much body fat). A review of Resident 1's Minimum Data Set (MDS, resident assessment tool used to provide care), dated 10/21/24, indicated Resident 1 had clear speech, was understood, and was able to understand others. The MDS indicated Resident 1 was dependent (helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity) on most Activities of Daily Living (ADLs, the basic self-care tasks an individual does on a day-to-day basis) including toileting hygiene, shower/bathe self, and lower body dressing. The MDS also indicated resident required substantial/maximal assistance (the helper does more than half the effort of lifting or holding trunk or limbs) when rolling from lying on back to left and right side and return to lying on back on the bed. The MDS further indicated Resident 1 had a urinary ostomy (a surgical opening in the belly to re-direct urine away from the damaged bladder) and was always incontinent (no voluntary control of feces) of bowel (defecation). A review of Resident 1's Care Plan titled, Falls: Resident is at risk for falls with or without injury related to .dementia, bipolar disorder, essential tremor ., date initiated 7/8/24, indicated a goal of, Will minimize complications related to falls to extent possible The care plan interventions/tasks indicated, Anticipate and meet needs . A review of Resident 1's clinical record titled, Situation, Background, Appearance, Review and Notify (SBAR) Communication Form, dated 11/4/24, at 5:36 a.m., indicated resident had a fall, with a pain intensity of 10 (rate on scale of 1-10, with 10 being the worst). The SBAR indicated, Resident laying on her back on the floor, screaming, stating, I am in so much pain all over. A review of Resident 1's Nursing Progress Notes, dated 11/4/24, at 8:21 a.m., by Licensed Vocational Nurse 1 (LVN 1), LVN 1 indicated Resident 1 had a witnessed fall on 11/4/24, at around 5:15 am; LVN 1 found resident in prone position (lying on her stomach) in between the bed and wooden furniture, so LVN 1 and CNA 1 assisted the resident down to the floor on her back. The Progress Notes also indicated resident complained of right arm pain, requested to be sent out to the Emergency Department (ED), and was sent out to the hospital via 911 (an emergency call/code) for evaluation. During a telephone interview on 1/13/25, at 3 p.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated she was with the resident when Resident 1 slowly slipped out of the bed during incontinent care. CNA 1 stated she was positioned on the left side of the bed, while resident was turned to the opposite side facing the window. As the resident grabbed on to the headboard frame, CNA 1 stated her one hand was on the resident's waist while CNA's other hand applied the brief under the resident. CNA 1 stated she tried to pull the resident back toward her, but resident rolled out of the bed in a prone position, in between the bed and wooden furniture. CNA 1 stated she yelled for help and together with LVN 1, they assisted the resident down to the floor on her back. During a telephone interview on 1/14/25, at 12 p.m., with LVN 1, LVN 1 stated during night shift while he was in the hallway doing rounds, LVN 1 heard someone from a resident room yelling for help. LVN 1 stated he went to Resident 1's room and saw CNA 1 held on to Resident 1 in prone position in between the bed and wooden furniture, so LVN 1 and CNA 1, with the help of the other staff members who came and rushed to the room assisted the resident down to the floor on her back. LVN 1 stated Resident 1 complained of pain, was bleeding, and wanted to be sent out to the hospital for further evaluation, and 911 was called. During an interview on 1/15/25, at 12:15 p.m., with Resident 1, in her room, Resident 1 stated during that early morning, as she was being changed by CNA 1, CNA 1 pushed her too hard that resident slipped from the bed. Resident stated her right arm fell first and resident used this to support herself up, but her arm gave up and resident fell on to the floor in a prone position. Resident 1 stated she was taken to the hospital where they took an X-ray (X-radiation, a quick, painless test to create images of the inside of the body) of her right arm and fixed the laceration to her right lower leg. At this time during the interview, Resident 1 started crying as she continued with her recollection of the incident. Resident stated she felt bad that this had happened to her and continued to feel upset whenever the incident was discussed. A review of Resident 1's hospital record titled, After Visit Summary, dated 11/4/24, indicated special instructions upon resident's return to facility, 1. The unna boot (a semi-rigid compression bandage that treats leg ulcers, sprains, strains, and other conditions) was applied to the leg laceration. Stiches were placed for the leg wound. WOUND CARE CLINIC NEED TO EVALUATE THE WOUND FOR FURTHER CARE. 2. PLEASE START TAKING ANTIBIOTICS TO PREVENT INFECTION OF THE AREA. 3. If you develop fevers, new or worsening symptoms then please return to the emergency room (ER). 4. The right greater tuberosity (a bony bump at the top of the humerus bone in the shoulder) is fractured and the orthopedic clinic will follow up, a referral is ordered. Keep the sling in place until told otherwise and evaluated by orthopedic surgery. Further review of the resident 1's hospital record indicated an antibiotic (a drug that treats bacterial growth) order of Cephalexin (Keflex) 500 milligram (mg) capsule, take one capsule by mouth two times a day for seven days. A review of the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, revision date 2001, indicated, .The staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .A fall is defined as: Unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force .An episode where a resident lost his or her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered, a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred .

Based on observation, interview, and record review, the facility failed to ensure supplies stored in the Lexington medication storage room were appropriate for use when: 1. Ten Female Luer Lock Caps (a device used to seal syringes [pumps used for drawing up and expelling liquids or suspensions into the body]) were expired. 2. Two Statlock Catheter Stabilization Devices (designed to stabilize peripherally-inserted central catheters or PICCs [a long, thin tube inserted through an arm and passed through to the larger veins near the heart]) were expired. 3. One IV Catheter was expired. 4. One Kangaroo Feeding Bag Set (a spike, tubing, and bag for liquid nutrition delivery directly into the digestive tract) was expired. These failures had the potential for residents to receive expired, ineffective, and contaminated medications and treatments. Findings: During a concurrent observation and interview on [DATE], at 10:50 a.m., with Licensed Vocational Nurse 1 (LVN 1), in the Lexington medication storage area: 1. Ten Female Luer Lock Caps had an expiration date of [DATE]. 2. Two Statlock Catheter Stabilization Devices had an expiration date of [DATE]. 3. One IV Catheter had an expiration date of [DATE]. 4. One Kangaroo Feeding Bag Set had an expiration date of [DATE]. LVN 1 stated expired items should be removed from resident use. During an interview on [DATE], at 10:45 a.m., with the Director of Nursing (DON), the DON stated the facility used intravenous medical supplies and feeding bags regularly, and these expired supplies should have been discarded or returned to central supply. During a review of the facility's policy and procedure (P&P) titled, Requisitioning Daily Supplies, dated 2001, the P&P indicated, Supervisors are responsible to remove all expired supplies and to ensure that supplies are replenished immediately.

Based on observation, interview, and record review, the facility failed to ensure a stock medication bottle of Senna (a laxative for short-term treatment of constipation) had a legible expiration date and was removed from resident use. These failures had the potential for the residents to receive expired and ineffective medication treatment. Findings: During a concurrent observation and interview on 6/19/24, at 3:00 p.m., with Licensed Vocational Nurse 2 (LVN 2), at the Lexington Medication Cart #4, a stock medication bottle of Senna was observed with the expiration date completely faded and not readable. LVN 2 stated, I probably should not be using this, I cannot read the expiration date, and removed it from the cart for disposal. LVN 2 stated that many residents in the facility receive Senna. During an interview on 6/20/24, at 8:19 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated medications with expired or illegible expiration dates should be removed from resident use and discarded immediately, as they may lose effectiveness. During a review of the facility's policy and procedure (P & P) titled, Administering Oral Medications, dated 2001, indicated, Steps in the Procedure .7. Check expiration date on the medication. Return any expired medications to the pharmacy. During a review of the facility's P & P titled, Storage or Medications, dated 2001, indicated, 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing.

Based on observation, interview and record review, the facility failed to follow kitchen practices that prevent cross-contamination and food borne illness when: 1. Chopping boards were in poor condition and stained; 2. Freezer temperature log did not have temperatures recorded for 6/15/24 and 6/16/24. These failures had the potential to cause food borne illness to a highly susceptible population of 117 residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview on 6/17/24, at 9:15 a.m., during the initial tour of the kitchen, there were four cutting boards (white, gray, green and red) that had black marks and smudges, faded colors, scratches, and deep cuts on the surfaces. Dietary Manager (DM) stated the boards needed to be changed due to food contamination. During an interview on 6/18/24, at 10:20 a.m., with Registered Dietician (RD), RD stated deep scratches on the chopping boards carried the risk of contamination. During an interview on 6/18/24, at 10:40 a.m., DM stated kitchen inspection walk was done with RD early this month and chopping board inspection was missed. During an interview on 6/20/24, at 7:32 a.m., with [NAME] (CK), CK stated cuts on chopping boards were dangerous, moldy, poisonous, patients get sick. According to the 2017 Federal Food Code, food contact surfaces are to be smooth, free from inclusions, pits, and similar imperfections and are to be smooth and clean to sight and touch. Also, according to the Food Code Annex, cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces. 2. During a concurrent observation and interview on 6/17/24, at 9:15 a.m., during the initial tour of the kitchen, the freezer temperature log did not have temperatures recorded for PM shift on 6/15/24 and 6/16/24. DM stated the freezer log did not get completed by PM shift cook. During a record review, the Freezer Temperature log for June 2024 did not have entries for the PM columns on 6/15/24 and 6/16/24 for Inside Thermometer Temperature, Outside Thermometer Temperature and (Staff) Initials. During an interview on 6/18/24, at 10:20 a.m., with RD, RD stated the freezer temperature log ensured food item temperatures were checked and were not in a temperature danger zone. During an interview on 6/18/24, at 2:55 p.m., with Dietary Aide (DA), DA stated he forgot and did not document PM freezer temperatures on the log. DA could not identify the potential harmful consequences of not having the required freezer temperatures. During an interview on 6/20/24, at 7:32 a.m., with CK, CK stated the cook is responsible to fill out the freezer temperature log. During a review of the facility's policy and procedure (P&P) titled, Refrigerators and Freezers, dated November 2022, the P&P indicated, Food service supervisors or designated employees check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening.

Based on observation, interview and record review, the facility failed to ensure staff followed infection control procedures for four of nine sampled residents (Residents 43, 326, 331, and 328) when facility did not ensure staff: 1. washed hands with soap and water after caring for resident rooms who had clostridioides difficile (c. diff, bacteria that causes diarrhea and inflammation of the colon which can be life-threatening), 2. used appropriate germicidal wipes to disinfect equipment after use on a resident with c. diff and, 3. were trained on infection control and hand hygiene techniques. This failure had the potential for the spread of c. diff through the facility. Findings: 1. A record review of Resident 43's admission record indicated Resident 43 was admitted for enterocolitis (inflammation of the digestive tract) due to c. diff., difficulty in walking, and muscle weakness. During a record review of Resident 43's minimum data set (MDS, an assessment tool to guide resident care), dated 5/26/24, the MDS indicated Resident 43 had a Brief Interview for Mental Status score of 14 (BIMS, was a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status). During a record review of Resident 43's physician order set titled, Order Summary Report, dated 6/20/24, indicated Resident 43 was on contact precautions (infection control measure which includes wearing gloves and gown when entering the room and washing hands with soap and water after exiting the room) for c. diff and received vancomycin (antibiotic to treat c. diff infection) oral suspension daily for c. diff until 7/3/24. A review of Resident 326's admission record indicated Resident 326 was admitted for sepsis, a personal history of other diseases of the digestive system, muscle weakness and difficulty walking. A review of Resident 326's MDS, dated [DATE], indicated Resident 326 had a BIMS of 15, was frequently urine and bowel incontinent, and was on physical therapy. A record review of Resident 326's physician order set titled, Order Summary Report, dated 6/20/24, indicated Resident 326 had physician orders to be on contact precautions and vancomycin oral solution twice a day for hx of clostridium difficile infection for 14 days. During a record review of Resident 326's care plan titled, Isolation Precautions: Resident requires contact single room isolation precautions due to C. Diff., undated, the care plan indicated staff maintain isolation using contact single room precautions due to c. diff .perform hand washing after completing care and leaving the room .use PPE as recommended for type of infection. A review of Resident 328's admission record indicated Resident 328 was admitted for acute respiratory failure, difficulty walking and muscle weakness. A review of Resident 331's admission record indicated Resident 331 was admitted for Parkinson's disease (a disease which causes gradual loss of muscle control) and muscle weakness. During an observation on 6/19/24, at 12:13 p.m., Certified Nursing Assistant 3 (CNA 3) was in the middle of cleaning up Resident 43. Linens and chucks (disposable barriers to protect linen) soiled with stool were visible. After cleaning up Resident 43, CNA 3 removed her PPE and performed hand hygiene using hand sanitizer. After exiting the room, CNA 3 entered and exited the soiled utility room and used hand sanitizer to perform hand hygiene. CNA 3 went to a linen cart outside of Resident 43's room and removed a pillowcase. CNA 3 donned PPE and entered Resident 43's room to finish making Resident 43's bed. CNA 3 removed her PPE, used hand sanitizer for hand hygiene, and exited the room to document her care on a computer in the hallway. During a continuous observation on 6/19/24, at 12:51 p.m., CNA 3 donned PPE and entered Resident 326's room with Resident 326's meal tray. CNA 3 assisted Resident 326 by setting up the meal tray on the bedside table. CNA 3 repositioned various objects on the bedside table and repositioned the bedside table in front of Resident 326. CNA 3 doffed her PPE and exited the room without performing any hand hygiene. CNA 3 walked to the meal cart, opened the door to the meal tray and took out Resident 43's meal tray. CNA 3 donned PPE, entered Resident 43's room, gave Resident 43's meal tray, doffed PPE and exited the room using only hand sanitizer. CNA 3 entered Resident 331's room and began to set up Resident 331's table with ungloved hands. CNA 3 used the silverware from the meal tray to cut up Resident 331's food. CNA 3 exited the room using hand sanitizer for hand hygiene. CNA 3 then entered Resident 328's room, put on gloves and began to feed Resident 328. During a record review of Resident 328's progress notes, dated 6/20/24, a progress note entered on 6/19/24, at 3:56 p.m., indicated Resident 328 was resting in bed and had her breakfast and lunch 25%. Due to cognitive impairment staff assisted accordingly. During a concurrent observation and interview on 6/19/24, at 2:50 p.m., with Resident 43, Resident 43 was in bed with the covers on. Resident 43 recalled CNA 3 came in at around 12:00 p.m. to clean her up. During an interview and record review on 6/19/24, at 3:17 p.m., with Infection Preventionist (IP), CNA 3's unit orientation documents were reviewed. IP recalled CNA 3 was very specifically informed Resident 43 and Resident 326 were on contact precautions for c. diff and that washing hands with soap and water was required after removing PPE. IP stated both residents were on contact precautions for c. diff. IP stated for c. diff infected residents, only washing with soap and water would be effective in preventing the spread of c. diff. IP stated hand sanitizer was not effective in preventing spread of c. diff. IP stated the expectation was for all staff to wash their hands with soap and water at the resident's bathroom or at the sink at the nurse's station after caring for residents with c. diff infection. IP stated staff were expected to not touch anything after exiting the room if they decided to wash their hands at the nurse's station. During a review of facility policy and procedure (P&P) titled, Handwashing/Hand Hygiene, dated 10/2023, the P&P indicated staff wash hands with soap and water .after contact with a resident with infectious diarrhea including . C. difficile .the use of gloves does not replace handwashing/ hand hygiene. During a review of CDC fact sheet titled Clostridioides Difficile (formerly known as Clostridium difficile), undated, the fact sheet indicated healthcare professional can prevent c. diff spread by washing hands with soap and water, wearing gloves and gown when treating patients with c. diff. The fact sheet indicated hand sanitizer doesn't kill c. diff. 2. During an observation on 6/20/24, at 10:21 a.m., physical therapy aide (PTA), wearing PPE, was in Resident 326's room for a physical therapy session. PTA placed a heart rate device (device to measure heart rate) on Resident 326's finger to measure Resident 326's heart rate during physical therapy exercises. After using the device, PTA slipped their hands under their gown and placed the heart rate device into their pocket. PTA used a gait belt and assisted Resident 326 to a standing position. After PTA had finished Resident 326's physical therapy session, PTA doffed their PPE and then exited the room. PTA used a germicidal wipe, on the PPE cart outside of Resident 326's room, to clean the heart rate device and gait belt. During a concurrent observation and interview on 6/20/24, at 1:08 p.m., with the Director of Nursing (DON), the germicidal wipe on the PPE cart outside of Resident 326's room was inspected. The DON inspected the informational sticker on the germicidal wipe container and stated there was no indication the germicidal wipes were an effective disinfectant for c. diff contaminated equipment. The DON stated bleach products were effective disinfectants for c. diff and the germicidal wipe did not contain bleach. The same germicidal wipe was also found on the PPE cart outside of Resident 43's room. During a record review of the germicidal wipe brochure titled, (Germicidal wipe name) Clinical Wipes, undated, the brochure indicated clinical evidence of c. diff reductions but did not indicate it was approved in preventing the spread of c. diff infections. During a review of CDC fact sheet titled Clostridioides Difficile (formerly known as Clostridium difficile), undated, the fact sheet indicated healthcare professional can prevent c. diff spread by cleaning surfaces .with EPA-approved spore killing disinfectant. A record review of Environmental Protection Agency (EPA) document titled, EPA's registered Antimicrobial Products Effective Against Clostridioides difficile spores, dated 6/26/24, was reviewed. The EPA document did not list the (germicidal wipe brand) as effective against spread of c. diff contaminated surfaces. 3. During a concurrent observation and interview on 6/17/24, at 12:20 p.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated staff did not need to wash their hands with soap and water after exiting a contact precaution room for a resident with c. diff. CNA 1 stated she had learned from working at other facilities that alcohol based hand sanitizer was effective in eliminating c. diff. CNA 1 stated she was not oriented to the unit by facility staff. CNA 1 stated she was assigned to Resident 43 and stated the contact precaution sign was affixed to Resident 43 because of a c. diff infection. During a record review on 6/17/24, at 12:55 p.m., the Facility Daily Staffing sheet, dated 6/17/24, was reviewed. The Facility Daily Staffing sheet indicated CNA 1 was assigned to Resident 43. During a concurrent observation and interview on 6/17/24, at 12:24 p.m., with case manager (CM), CM stated Resident 326 had a c. diff infection and based on the contact precaution sign at the Resident 326's door, staff only need to use hand sanitizer for hand hygiene after exiting the room. CM stated he was unsure what type of hand hygiene was required for residents on contact precautions with c. diff. During a concurrent interview and record review on 6/17/24, at 12:57 p.m., with Director of Staff Development (DSD), CNA 1 and CM's orientation to facility hand hygiene standards were reviewed. The DSD stated CNA 1 was contracted from an outside staffing agency and could not verify CNA 1 had completed hand hygiene training from the staffing agency. The DSD stated CNA 1 was expected to have an onsite orientation by facility staff before working in the facility. The DSD stated she did not orient CNA 1 and could not find records of CNA 1's orientation to the facility. The DSD stated CM was hired on 3/2024 and was expected to have completed infection control and hand hygiene orientation. After checking the last three months of infection control and hand hygiene in-service records, DSD stated the records did not indicate CNA 1 or CM had attended any of those in-services. The DSD stated all staff were trained and expected to follow facility P&P which was based on Centers for Disease Control (CDC) guidance for c. diff prevention. During an interview on 6/17/24, at 2:03 p.m., with the DON, the DON stated the facility did not have records of CM having hand hygiene in-services or orientation. During a review of CDC fact sheet titled Clostridioides Difficile (formerly known as Clostridium difficile), undated, the fact sheet indicated healthcare professional can prevent c. diff spread by washing hands with soap and water. The fact sheet indicated hand sanitizer doesn't kill c. diff. During a review of facility P&P titled, P&P Infection Prevention and Control, dated 12/2023, the P&P indicated infection prevention and control P&P apply to all personnel, consultants, contractors .all personnel are trained on infection prevention control policies and procedures upon hire and periodically after. During a review of facility policy and procedure (P&P) titled, Handwashing/Hand Hygiene, dated 10/2023, the P&P indicated staff wash hands with soap and water .after contact with a resident with infectious diarrhea including . C. difficile .the use of gloves does not replace handwashing/ hand hygiene.

Based on observation, interview, and record review, the facility failed to provide hygiene care in a reasonable time for one of nine sampled residents (Resident 43) when Resident 43 had to wait in stool and urine for 45 minutes before staff could change the resident. This failure caused Resident 43 to feel dejected because she had to wait 45 minutes for assistance and had the potential for Resident 43 to be at risk of skin breakdown due to exposure to urine and stool. Findings: A review of Resident 43's admission record, the record indicated Resident 43 was admitted for enterocolitis (inflammation of the digestive tract) due to clotridium difficile (a bacteria that causes diarrhea and inflammation of the colon which can be life-threatening), difficulty in walking, and muscle weakness. During a record review of Resident 43's minimum data set (MDS, an assessment tool to guide resident care), dated 5/26/24, the MDS indicated Resident 43 had a Brief Interview for Mental Status score of 14 (BIMS, was a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status). The MDS indicated Resident 43 required moderate assistance in toileting hygiene. During an interview on 6/17/24, at 12:09 p.m., Resident 43 was in her private room in bed. Resident 43 stated she needed one staff member to assist in cleaning her up after bowel movements. Resident 43 stated 25% of the time it took the staff an hour to answer the call light. During an observation on 6/19/24, at 11:15 a.m., Resident 43's room had the call light on and visible in the hallway. At the nurse's station, the call light monitoring panel indicated Resident 43's call light was on. During an observation on 6/19/24, at 11:27 a.m., Registered Nurse 1 (RN 1) observed the call light for Resident 43 was on and asked CNA 2 to answer the call light. During an observation on 6/19/24, at 11:29 a.m., Certified Nursing Assistant 2 (CNA 2) entered Resident 43's room to answer the call light. From outside the room, Resident 43 could be heard stating she was soiled and asked to be changed. CNA 2 responded to Resident 43 that Certified Nursing Assistant 3 (CNA 3) would change the resident after CNA 3 came back from break. CNA 2 exited the room and assisted another resident in a wheelchair out of the unit. During an observation on 6/19/24, at 11:32 a.m., CNA 3 came back to the unit from break. During an observation on 6/19/24, at 11:41 a.m., CNA 2 informed CNA 3 that Resident 43 needed to be changed. CNA 3 then went into another resident's room to assist them. During an observation on 6/19/24, at 11:54 a.m., CNA 3 exited the resident's room and began to don personal protective equipment (PPE, equipment, such as gowns and gloves, to protect against spread of infection) to enter Resident 43's room. During an observation on 6/19/24, at 12:13 p.m., CNA 3 was in the middle of cleaning up Resident 43. Linens, hygienic wipes and chucks (disposable barriers to protect linen) soiled with feces was visible. During a concurrent observation and interview on 6/19/24, at 2:50 p.m., with Resident 43, Resident 43 was in bed with the covers on. Resident 43 stated she waited 45 minutes before CNA 3 came in to help. Resident 43 stated she often had to wait this long to get changed and was disappointed and tired of being upset about the long waits. During an interview on 6/19/24, at 3:01 p.m., with RN 1, RN 1 stated certified nursing assistants (CNA) were expected to help each other answer call lights and to immediately help a resident according to their scope of practice. RN 1 stated if a CNA was unable to help the resident immediately, the CNA was expected to ask another CNA or licensed nurse to help. RN 1 stated licensed nurses could also help change a resident. During an interview on 6/19/24, at 3:17 p.m., with the Director of Staff Development (DSD), the DSD stated CNAs were expected to answer call bells and assist the resident with their request immediately and if they could not they should ask other CNAs or staff to help. The DSD stated any staff can answer a call bell and should assist within the scope of their practice. The DSD stated it was unacceptable for a soiled resident to wait 45 minutes before getting cleaned up. During an interview on 6/20/24, at 12:50 p.m., with the Director of Nursing (DON), the DON stated the number one rule was nursing staff were expected to answer call lights when they see them and to assist residents immediately which included getting water or cleaning up a resident. The DON stated it was unacceptable for a soiled resident to wait 45 minutes before getting cleaned up. During a review of facility policy and procedure (P&P) titled, Call light answering, dated 7/2012, the P&P indicated staff answer the light/bell within a reasonable time .respond to the request .leave the resident comfortable .if you are unable to assist, explain to the resident and notify the charge nurse for further instruction.

Based on interview and record review, the facility failed to provide appropriate safety measures and adequate supervision to prevent one of two residents (Resident 1) from rolling out of bed and falling on the floor during a bed linen change. The failure to provide sufficient staff or adequate measures to prevent a dependent resident from rolling off the bed during a bed linen change, which resulted in Resident 1 being transported to the emergency department for evaluation after the fall caused a brief loss of consciousness and a headache which lasted over a week. Findings: A review of Resident 1 ' s Admission Record, printed 4/10/24, indicated Resident 1 was admitted to the facility in 2017 with diagnoses of multiple sclerosis (MS, a chronic condition that affects the brain and spinal cord) and paraplegia (paralysis of the legs and lower body caused by spinal injury or a disease). A review of Resident 1's Minimum Data Set (MDS, resident assessment tool used to provide care), dated 2/2/24, indicated Resident 1 had clear speech, was able to be understood, and was able to understand others, and had impairment to both sides of the upper and lower extremities. The MDS indicated Resident 1 required substantial/maximal assistance (The helper does more than half the effort of lifting or holding trunk or limbs.) for all activities of daily living (eating, dressing, hygiene, bathing) including transfers between surfaces and moving/changing position in bed. A review of Resident 1's Nursing Progress Notes, dated 2/27/24, at 10:02 p.m., Registered Nurse 1 (RN 1), the progress notes indicated on 2/27/24, at 9:07 p.m., Resident rolled out of bed (between bed and window) during incontinent care. Resident .complained of headache . During a telephone interview on 4/11/24, at 11:36 a.m., with RN 1, RN 1 stated while working in another resident ' s room, Certified Nursing Assistant 1 (CNA 1) called RN 1 to join CNA 1 in Resident 1 ' s room. RN 1 stated upon entering Resident 1 ' s room, RN 1 saw Resident 1 lying on the floor next to the left side of the bed. RN 1 stated CNA 1 said Resident 1 rolled off the bed while CNA 1 was changing the bed linen. During a telephone interview on 4/16/24, at 8:30 a.m., with CNA 1, CNA 1 stated CNA 1 had turned Resident 1 to a left side-lying position on the left side of the bed, with Resident 1 ' s right leg crossed over the left leg while CNA 1 completed a bed linen change. CNA 1 stated Resident 1 rolled off the bed when CNA 1 was on the right upper side of the bed securing the top right corner of the fitted sheet. During a concurrent observation and interview on 4/29/24, at 10:45 a.m., with Resident 1, Resident 1 lay awake in a bed positioned with about a one foot gap between the bed and a free-standing shelving unit which abutted the bedroom wall. Resident 1 stated CNA 1 had been changing the linen on the bed and had turned Resident 1 to the left side with CNA 1 ' s hand against Resident 1 ' s back. Resident 1 stated CNA 1 had pushed against Resident 1 ' s back with enough force to cause Resident 1 to fall off the bed onto the floor between the bed and the shelving unit. Resident 1 stated during the fall the back of Resident 1 ' s head hit something which caused a brief loss of consciousness at the time of the fall and a headache that lasted about two weeks. Resident 1 stated the headache at the time of the fall was so severe Resident 1 had gone to the emergency room for evaluation. A review of Resident 1 ' s Hospital Discharge Summary, dated 2/28/24, indicated, Primary Diagnosis: Traumatic injury of head . fall from bed, three (3) feet (ft) high, and complained of left sided pain with a headache. Patient loss consciousness and was sent to the hospital for further evaluation. All scans were negative for fracture (broken bone) or bleeding. Patient sent back to Skilled Nursing Facility (SNF) for continued medical care. Will follow up with labs and monitor .Assessment and Plan: Fall Precautions in place . A review of the facility ' s policy and procedure (P&P) titled, Falls and Fall Risk, Managing, undated, indicated, .Staff may identify interventions related to the resident ' s specific risks and causes in the attempt to reduce falls and minimize complications from falling .a fall is defined as: Unintentionally coming to rest in the ground, floor, or other lower level, but not as a result of an overwhelming external force .An episode where a resident lost his or her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered, a fall. A fall without injury is still a fall .

Based on interview and record review, for one of two sampled residents (Resident 1), the facility failed to ensure Resident 1's clinical record was accurately documented when Resident 1's right heel ulcer was documented in the Treatment Administration Record (TAR) as a right lower leg ulcer. This failure had the potential to result in uncoordinated care. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was admitted on [DATE] with diagnoses that included pressure ulcer (localized damage to one or more layers of the skin and/or underlying soft tissue usually over a bony prominence) of the right heel. During a review of Podiatry (branch of medicine devoted to the study, diagnosis and treatment of foot and ankle) Progress Notes dated 8/8/23, the Podiatry Progress Notes indicated Resident 1 presented to the podiatry clinic for follow-up visit for right medial (towards the middle/center) heel wound. The Progress Notes indicated current wound care as wet to dry, posterior splint, and heel wedge. During a concurrent interview and review with Treatment Nurse (TN) 1 on 9/12/23 at 12:10 p.m., Resident 1's TAR for July 2023 was reviewed , the TAR indicated Resident 1's right heel wound treatment as: cleanse right heel wound with normal saline (NS, a solution used to cleanse wounds during wound dressing changes), gently pat dry, pack wound with black foam, cover with drape, change every Monday, Wednesday and Friday and as needed if soiled or dressing is displaced. TN 1 stated Resident 1's right heel received Negative Pressure Wound Therapy (NPWT, a therapeutic technique using suction pump, tubing, and dressing to remove excess drainage and promote healing in acute or chronic wounds). During a review of Resident 1's TAR for August 2023, the TAR indicated the same treatment with NPWT was provided on the right heel until 8/4/23. The TAR for August 2023 also indicated the NPWT was discontinued on 8/5/23. Resident 1's TAR did not indicate a wound treatment for the right heel, after NPWT was discontinued, from 8/6/23 to 8/9/23. During a concurrent interview and review with Director of Nursing (DON) on 9/12/23 at 1 p.m., Resident 1's Order Summary Report and TAR for August 2023 were reviewed. DON stated the wound that was indicated in Resident 1's August 2023 TAR as right lower leg (everything between the knee and the ankle) was incorrect. DON stated the wound care was meant for Resident 1's right heel because Resident 1 did not have any wound on the right lower leg. Resident 1's August 2023 indicated body audit was done daily in the morning for skin observation. DON stated the licensed staff who did the body audit had to make the correction if needed rather that to just sign anything that was not accurate. DON stated this mistake was a good learning opportunity for licensed staff to maintain accurate documentation. During a review of the facility's policy and procedure (P&P) titled Skin Management Guidelines dated February 2022, the P&P indicated, documentation of wound evaluation should include wound location.

Based on observation, interview, and record review, the facility failed to provide necessary treatment and services for one of three residents (Resident 1), when nursing staff failed to: 1. Notify the physician or respond to Resident 1 ' s request for transfer to the acute care hospital when Resident 1 had a change of condition and asked for assistance. 2. Monitor blood oxygen as ordered for shortness of breath and provide oxygen as needed. (Oxygen saturation is a measurement of oxygen in the blood, expressed as a percentage, with 100 percent the maximum value of oxygen saturation.) 3. Administer pain medications per physician order and care plan, as needed. These failures resulted in untreated pain, emotional distress, and delayed recognition and treatment of Resident 1 ' s emergency medical condition of a pulmonary embolism. (A condition where a blood clot develops in a blood vessel in the body, becomes dislodged, travels to the lungs and blocks blood flow through a blood vessel, causing damage, potentially fatal damage, in the lungs and to the body.) Findings: During a review of Resident 1 ' s Minimum Data Set (MDS, a resident assessment tool used to guide care), dated 3/29/23, the MDS indicated Resident 1 had a score of 15 on the Brief Interview for Mental Status exam (BIMS, The Brief Interview for Mental Status is a scoring system used to determine the resident ' s cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) The MDS indicated Resident 1 required extensive assistance from two people for bed mobility and had not left his bed during the seven-day look-back period. The MDS indicated Resident 1 had diagnoses of peripheral venous insufficiency (impaired blood circulation in the extremities) and lymphedema (excessive fluid outside the blood vessels in body tissues causes swelling of the effected parts). During a review of Resident 1 ' s physician Order Summary Report, dated active April 2023, the Summary Report indicated the following orders: Start date 4/19/23: start oxygen at 2 Liters per minute for shortness of breath (SOB), chest pain, or oxygen saturation less than 90%, and notify physician; Start date 4/19/23: monitor vital signs, and oxygen saturation every 4 hours to monitor for COVID-19; Start date 4/7/23: hydrocodone-acetaminophen 10-325 milligrams (mg), (A combination medication of 325 mg of acetaminophen and 10 mg of hydrocodone. Hydrocodone is a narcotic pain medication. Narcotics are medications subject to regulations enforced by the U.S. Drug Enforcement Agency due to a potential for abuse and dependence.), give one tablet by mouth every 6 hours for pain; Start date 4/7/23: hydrocodone-acetaminophen 10-325 mg, give two tablets, by mouth every 6 hours as needed for moderate pain; Start date 3/25/23: hydromorphone hydrochloride (a narcotic pain medication) 2 mg, one tablet by mouth every 4 hours as needed for pain. During a review of Resident 1 ' s care plan for Pain, dated 3/16/23, the care plan indicated Resident 1 had pain due to a recent surgery, chronic low back pain, and peripheral neuropathy (nerves located outside of the brain and spinal cord are damaged and cause weakness, numbness and pain, usually in the hands and feet). Care plan interventions included: report nonverbal expressions of pain such as moaning, striking out, grimacing, crying, thrashing, change in breathing; administer pain medication per physician orders; notify physician if pain frequency/intensity was worsening or if current pain regimen was ineffective. During a concurrent observation and interview on 6/1/23 at 10:45 a.m., Resident 1 sat upright while he lay in bed. Resident 1 stated he had been in and out of the hospital in the past four months and was so weak he was unable to stand, walk, or even hold items in his hands. Resident 1 stated on one occasion he had gone to the hospital after he woke during the night around 3:30 a.m. with horrendous chest pain. Resident 1 stated he yelled for assistance and Certified Nursing Assistant 1 (CNA 1) came to his room. Resident 1 stated he told CNA 1 he could not breathe, and CNA 1 said, You ' re breathing, and shut his door. Resident 1 stated he was helpless, weak, desperate, in pain, and could not breathe. Resident 1 stated he yelled multiple times he wanted to go to the hospital and he was worried because staff were not helping him. Resident 1 stated his cell phone was out of reach, but he used voice activation to call Emergency Medical Service (EMS) and be transported to the hospital. Resident 1 stated the hospital diagnosed him as having a serious blood clot and saved his life, all because he had called EMS himself, not the facility. During an interview and concurrent record review on 6/2/23 at 2:09 p.m., with LVN 1, Resident 1 ' s nursing notes were reviewed. LVN 1 stated the first time she had cared for Resident 1 he had called 9-1-1 and gone to the hospital. LVN stated other staff had told her Resident 1 had a frequent behavior of yelling. LVN 1 stated she had done a visual check and administered Resident 1 ' s ordered as needed pain medications, but Resident 1 continued to complain of pain. LVN 1 was unable to provide documentation the physician had been notified when Resident 1 ' s pain continued even after administration of pain medications. LVN 1 stated she had not called 9-1-1 for Resident 1. During a review of Resident 1 ' s progress notes dated 4/25/23 at 07:06 a.m., by Licensed Vocational Nurse 1 (LVN 1), the progress notes indicated LVN 1 had noted a Change of Condition, (COC). The COC notes indicated Resident 1 had started to complain of chest pain at 5:45 a.m. and kept yelling and cursing, and complaining he couldn ' t breathe. The notes indicated Resident 1 called 9-1-1, and was taken to the hospital by Emergency Medical Transport at 7:10 a.m. During a review of Resident 1 ' s Medication Administration Record (MAR), dated April 2023, the MAR indicated Resident 1 ' s pain levels on 4/25/23 were two at 12 a.m. and one at 6 a.m. During a review of Resident 1 ' s Controlled Drug Records, the Controlled Drug Records indicated Resident 1 last received one hydromorphone tablet on 4/24/23 at noon, and two Hydrocodone-Acetaminophen 10-325 tablets on 4/25/23 at 1 a.m. During an interview and concurrent record review on 6/30/23 at 4:10 p.m., with the Director of Nursing (DON), Resident 1 ' s progress notes, Medication Administration Record (MAR), and Weights and Vital Signs Summary (records of heart rate, respiratory rate, blood pressure, temperature, and blood oxygen saturation) were reviewed. The DON stated when Resident 1 complained of pain and shortness of breath, the policy and procedure would have been to assess Resident 1 ' s vital signs, pain level, and oxygen saturation, give oxygen if the saturation was low, and call the physician. The DON was unable to provide documentation that Resident 1 ' s oxygen saturation was monitored on 4/25/23, or that oxygen was provided to Resident 1. The vital signs recorded on 4/25/23 at 6:29 a.m. indicated a blood pressure: 129/60, pulse: 68, respiration:18 and temperature: 97.8 degrees Fahrenheit. The DON stated Resident 1 should not have needed to call 9-1-1 himself. During a review of Resident 1 ' s emergency medical services [Ambulance company] report, Patient Care Report, dated 4/25/23, the Report indicated the request for transport was received on 4/25/23 at 6:53 a.m. and the ambulance arrived at Resident 1 ' s bedside at 7 a.m. The Report indicated Resident 1 ' s vital signs at 7 a.m. as heart rate of 113, respirations of 28, blood pressure of 164/64, and oxygen saturation of 87%. The Report indicated Resident 1 complained of difficulty breathing, and sharp, right-sided chest pain, with increased pain with deep breaths. The Report indicated the ambulance crew administered supplemental oxygen with improvement in Resident 1 ' s oxygen saturation but Resident 1 remained in distress during transport to the acute care hospital. During a review of Resident 1 ' s ED notes, dated 4/25/23 at 07:27 a.m., the ED notes indicated Resident 1 was anxious and complained of sharp, tight, continuous pain in his right chest, at a level of ten (on a scale of zero to ten, with ten the worst possible pain). The ED notes indicated a computed tomography (CT, a type of X-ray study) scan indicated Resident 1 had a pulmonary embolism. During a review of Resident 1 ' s emergency department (ED) History and Physical (H&P), dated 4/25/23, the H&P indicated Resident 1 ' s chief complaint was right-sided chest pain upon awakening. During a review of the facility ' s policy and procedure (P&P), titled, Pain Management Guidelines, dated 11/2021, the P&P indicated, Pain is evaluated and documented .whenever there is a change in condition, using an appropriate pain scale, determined by nursing .using a numeric rating scale used for patients whose cognitive functioning ranges from intact to mildly or moderately impaired .patients are asked to choose a number from 0 (indicating no pain) to 10 (indicating worst pain imaginable) .alternative scale for patients who are alert and oriented and unable to utilize the Numeric Rating Scale are to use descriptors: no pain, mild pain, moderate pain, severe pain, very severe horrible pain .

Based on observation, interview, and record review, the facility failed to ensure Resident 1 ' s narcotics were recorded on both the controlled substances sheet and Medication Administration Record (MAR). This failure to follow facility policy resulted in prevention of accurate reconciliation of controlled substances. Findings: During a review of Resident 1 ' s Minimum Data Set (MDS, a resident assessment tool used to guide care), dated 3/29/23, the MDS indicated Resident 1 had a score of 15 on the Brief Interview for Mental Status exam (BIMS, The Brief Interview for Mental Status is a scoring system used to determine the resident ' s cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) The MDS indicated Resident 1 required extensive assistance from two people for bed mobility and had not left his bed during the seven-day look-back period. The MDS indicated Resident 1 had diagnoses of peripheral venous insufficiency (impaired blood circulation in the extremities) and lymphedema (excessive fluid outside the blood vessels in body tissues causes swelling of the effected parts). During a review of Resident 1 ' s care plan for Pain, dated 3/16/23, the care plan indicated Resident 1 had pain due to a recent surgery, chronic low back pain, and peripheral neuropathy (nerves located outside of the brain and spinal cord are damaged and cause weakness, numbness and pain, usually in the hands and feet). Care plan interventions included: report nonverbal expressions of pain such as moaning, striking out, grimacing, crying, thrashing, change in breathing; administer pain medication per physician orders; notify physician if pain frequency/intensity was worsening or if current pain regimen was ineffective. During a review of Resident 1 ' s physician Order Summary Report, dated active April 2023, the Summary Report indicated the following orders: Start date 4/7/23: hydrocodone-acetaminophen 10-325 milligrams (mg), (A combination medication of 325 mg of acetaminophen and 10 mg of hydrocodone. Hydrocodone is a narcotic pain medication. Narcotics are medications subject to regulations enforced by the U.S. Drug Enforcement Agency due to a potential for abuse and dependence.), give one tablet by mouth every 6 hours for pain; Start date 4/7/23: hydrocodone-acetaminophen 10-325 mg, give two tablets, by mouth every 6 hours as needed for moderate pain; Start date 3/25/23: hydromorphone hydrochloride (a narcotic pain medication) 2 mg, one tablet by mouth every 4 hours as needed for pain. During an interview and concurrent record review on 6/2/23, at 2:09 p.m., with LVN 1, Resident 1 ' s nursing notes were reviewed. LVN 1 stated the first time she had cared for Resident 1 he had called 9-1-1 and gone to the hospital. LVN 1 stated she had done a visual check and administered Resident 1 ' s ordered as needed pain medications, but Resident 1 continued to complain of pain. During a review of Resident 1 ' s MAR, dated April 2023, the MAR indicated no hydrocodone-acetaminophen or hydromorphone hydrochloride was administered to Resident 1 on 4/25/23. During a review of Resident 1 ' s Controlled Drug Records, the Controlled Drug Records indicated Resident 1 last received one hydromorphone tablet on 4/24/23 at noon, and two Hydrocodone-Acetaminophen 10-325 tablets on 4/25/23 at 1 a.m. During a review of the facility ' s policy and procedure (P&P), titled, Medication Administration: Medication Pass,, dated 6/2021, the P&P indicated for controlled/narcotic medication to circle initials on MAR and document refusal on back side of MAR and to circle initials on Controlled Substance Charting Record and document refusal and to notify physician. The policy titled, Omnicare, a CVS Heat company, dated 4/2022, indicated the facility routinely reconcile the number of doses remaining in the package to the number of doses recorded on the Controlled Substance Verification Shift Count Sheet, to the medication administration record. Cross reference. See also F600.

Based on observation, interview and record review, the facility failed to ensure one of 3 sampled residents, Resident 1, was checked for a blood glucose level and administered insulin medication before eating breakfast as ordered by the physician. This failure had the potential for Resident 1 to further elevate her blood glucose level and cause undesirable symptoms or a life-threatening complication such as coma (unconscious state). Findings: During an interview on 3/30/23, at 11:50 a.m., Resident 1 stated her blood glucose remained high and was not checked by a nurse all morning. Resident 1 stated her blood glucose was high before eating breakfast and was not administered insulin (hormone that helps your body use sugar for energy). Resident 1 stated she wears a device that registers her glucose results to her cellphone. Resident 1 stated her current blood glucose result is 229 and was concerned she was not going to receive insulin before lunchtime. Review of the most recent Quarterly Assessment, Minimum Data Set (MDS-a standardized assessment tool that measures health status), dated 1/28/23, indicated Section B: Speech - B0600=Speech Clarity=0. Clear speech, B0700=Makes Self Understood=0. Understood, and Section C: Cognitive Patterns - C0500 BIMS (Brief Interview for Mental Status) Score: 15 = cognitively intact. Review of the physician order dated 12/10/22, it indicated Humalog injection solution 100 unit/ml (Insulin Lispro). Inject as per sliding scale: if 70 - 120 = 0 units; 121 - 150 = 2 units; 151 - 200 = 4 units; 201 - 250 = 6 units; 251 - 300 = 8 units; 301- 350 = 10 units; 351 - 400 = 12 units and notify MD, subcutaneously before meals and at bedtime for Diabetes Mellitus (DM, a condition when blood sugar is elevated). During an interview on 3/30/23 at 1:10 P.M., RN 1 stated she administered insulin 8 units for breakfast and 6 units for lunch. Review of the document, titled Location of Administration Report , dated 3/1/2023 thru 3/31/2023, it indicated Scheduled Time: 03/30/23 07:00 A.M., Administration Time: 03/30/23 11:00 A.M., Administered by: RN 1, Route: subcutaneously (injection), Location of Admin: Arm - right. Another record, titled Weights and Vitals Summary , it indicated the date: 3/30/23 , time: 11:00 and blood glucose: 266 . During an interview on 3/30/23 at 2:35 p.m., RN 1 stated she was called to work today and arrived late, after 9:00 a.m. RN 1 stated the previous nurse did not update her of Resident 1's immediate needs. RN 1 stated she noticed the insulin order was not signed off on the MAR for 7:00 A.M., this meant insulin was not given to Resident 1. RN 1 stated the nurse who was there at 7:00 A.M. should have verified the blood glucose and administered the insulin prior to breakfast meal. RN 1 stated Resident 1 informed her of a blood glucose level: 266 and verified the result registered on Resident 1's cellphone. RN 1 stated she administered 8 units of insulin because Resident 1 still wanted it. When asked What happens when insulin is not given prior to meal? RN 1 stated the resident will become hyperglycemic and experience dizziness. During an interview on 3/30/23 at 2:41 P.M., certified nurse assistant (CNA)1 stated, Resident 1 checks her own blood glucose. CNA 1 stated Resident 1 usually tells her about needing insulin before breakfast then CNA 1 informs the nurse. CNA 1 stated Resident 1 ate when the breakfast tray was served this morning, Resident 1 did not say anything about wanting insulin. CNA 1 stated Resident 1 would experience shaking, sweat and possibly throwing up if blood glucose is very high. During an interview on 3/30/23 at 2:55 P.M., the Director of Nursing (DON) stated RN 2 was the covering nurse who is supposed to verify Resident 1's blood glucose and administer insulin. DON stated insulin administration should not be delayed. During an interview on 4/12/23 at 10:18 A.M., RN 2 stated Resident 1 usually asks for her insulin to be administered because she eats at different times. RN 2 stated if she administered insulin to Resident 1, she recorded it in the chart immediately. RN 2 stated she does not remember the details for 3/30/23 and confirms that Resident 1 is a reliable source, though forgetful at times. RN 2 stated she makes notations in the progress notes to explain administering outside the prescribed time. Review of the policy and procedure, Medication Administration: Medication Pass , dated 06/2021, indicated to administer medication in accordance with frequency prescribed by physician -within 60 minutes before or after prescribed dosing time and according to specific procedure, such as oral, topical, injection, etc.

Based on observation, interview and record review, the facility failed to follow infection control policies and procedures for two (Resident 1 and Resident 2) of two sampled residents when Resident 1 and 2's oxygen tubing were not labeled or dated and Resident 1 ' s nebulizer (process of transforming liquid medications into a fine spray (aerosol) or mist, which can then be carried into the respiratory system through inhalation) tubing and mask were left exposed to air when not in use. This deficient practice had the potential to transmit infectious microorganisms and increase the risk of infection for Residents 1 and 2. Findings: During a review of Resident 1's Admission record, printed on 11/2/22, the admission record indicated Resident 1 was originally admitted to the facility on [DATE]. During a concurrent observation and interview on 11/2/22 at 12:25 p.m., with Registered Nurse (RN) 1, Resident 1 ' s oxygen tubing and nebulizer tubing ' s were not labeled or dated. RN 1 stated the nebulizer tubing's were exposed to air and it should be covered in a bag when not in use to prevent infections. RN 1 further stated it is important to label and date them to identify when the tubing's were last changed. During a review of Resident 1 ' s, Order summary report, the doctor ' s orders indicated Resident 1 had a medical diagnosis of Chronic obstructive pulmonary disease (COPD- is a chronic inflammatory lung disease that causes obstructed airflow from the lungs and causes breathlessness). The order indicated Resident 1 had an order for continuous oxygen of 2 Liters per minute via nasal cannula (oxygen tubing that provides air through the nose) continuously. Resident 1 also had orders for nebulization [ipratropium- albuterol inhalation solution 0.5-2.5 mg/3ml (breathing medication)] every 4 hours for shortness of breath. During a review of Resident 2 ' s Admission record, printed on 11/2/22, the admission record indicated Resident 2 was originally admitted to the facility on [DATE]. During a concurrent observation and interview on 11/2/22 at 12:37 p.m., with RN 1, Residents 2 ' s oxygen tubing's were observed. RN 1 stated Resident 2 ' s oxygen tubing did not have any label or date on them. During a review of Resident 2 ' s, Order Summary, the order summary indicated Resident 2 had an order for oxygen administration at 2 liters per minute via nasal cannula for shortness of breath, chest pain and oxygen saturation less than 90 %. During an interview on 11/2/22 at 12:55 p.m., with Unit manager (UM) 1, UM 1 stated oxygen tubings and nebulizer tubings are changed every week and should be labeled with resident ' s name and dated. UM 1 stated this process is in place so tubings are not used for other residents and to identify when it was last changed to prevent infection. During an interview on 11/2/22 at 3:45 p.m., with Director of Nursing (DON), DON stated for a resident using oxygen or nebulizer, the tubings should be labeled and dated as it gives cues when it should be changed and control infections. DON stated it is important to hold oxygen or nebulizer tubings in a clean bag when not in use to prevent infection. During a review of the facility ' s Policy and Procedure (P&P) titled, Oxygen administration, dated 06/2021, the P&P indicated, Completion of procedure; . 2. When oxygen not in use, store oxygen tubing and nasal cannula or mask in separate, labeled plastic bag.

Based on interview and record review for one of three sampled residents (Resident 1), the facility failed to ensure Resident 1 maintained acceptable parameters of hydration and nutrition when Resident 1's decreased in meal intake was not identified and interventions were not implemented in a timely manner. In addition, Resident 1's input and output was not monitored, and nutritional supplement was not provided as ordered by the physician This failure resulted in Resident 1 sustaining a 13% weight loss. Resident 1 was transferred to the acute care hospital for dehydration and Lactic Acidosis (lactic acid build up in the bloodstream) Findings: During a review of Resident 1's Admission Record Report (ARR), ARR indicated Resident 1 was admitted to the facility on [DATE] and tested positive for Covid 19 disease (a disease caused by a virus which causes mild to serious symptoms and may cause death) on 6/20/20. During a review of Resident 1's General Progress Notes (GPN), dated 7/7/20, GPN indicated Resident 1 was transferred to acute care hospital on 7/7/20. During a review of the Minimum Data Set (MDS, an assessment tool used to guide care) dated 6/26/20, indicated Resident 1 required staff's assistance for set up and supervision during meals. During a review of Resident 1's Care plan titled, Nutritional Status as evidence by potential weight loss related to inadequate oral intake . dated 5/27/20 indicated that the facility will provide diet as ordered and review weights and notify the physician and responsible party of the significant weight change During an interview on 1/31/22 at 1:35 p.m., with Director of Staff Development (DSD), DSD stated, Resident 1 was not eating and drinking sufficient amounts for Resident 1's pressure ulcer (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) to heal. During a review of Resident 1's Documentation Survey Report (DSR) Jun, Dated June 2020, indicated Resident 1 generally ate: 6/1/20 6/15/20 50% to 75% of meals and 6/16/20 6/29/20 0% to 25% of meals. During a review of Resident 1's DSR Jul, dated July 2020, indicated as follows regarding the percentage of meals Resident 1 ate: 7/1/20 0% of breakfast, 7/2/20 0% of breakfast, 7/3/21 refused breakfast, 0 % lunch, and 40% dinner, 7/5/20 0% for breakfast, 7/6/20 50% for breakfast, 25% for lunch, and 50% for dinner and 7/7/20 50% for breakfast and lunch. Review of the progress notes from 6/16/20 through 7/3/20 indicated there was no progress notes regarding Resident 1's decrease in meal intake until 7/3/20. A review of Resident 1's Nursing Progress Notes (NPN), dated 7/3/20, NPN indicated, .pt [patient] does not have much appetite consumed less than 25% of meals. staff continues to encourage fluids while awake . During a review of Resident 1's NPN, dated 7/4/20, NPN indicated, .pt. does not have much appetite consumed less than 25% of meals. staff continues to encourage fluids while awake . During a review of Resident 1's NPN, dated 7/6/20, NPN indicated, Alert and verbally responsive . encourage fluid and meal intake . eat10% breakfast, 10% lunch, 25% dinner .wt (164.6 lbs) . assessed by M.D. During a review of Resident 1's Order Summary Report (OSR), dated 5/21/20 7/7/20, OSR indicated, Weekly weight every day shift every Mon was ordered on 5/22/20 and Weekly weight every shift every Mon for monitoring was ordered on 6/1/20. During a review of Resident 1's Weights and Vitals Summary (WVS), indicated Resident 1 weighed 182.2 lbs on 5/22/20, 189.2 lbs on 6/17/20 (Wednesday), and Resident 1 was next weighed on 7/6/20 (Tuesday), and weighed 164.6 pounds, a total of 24.6 lbs. (13%) weight loss within 20 days. During a review of Nutrition Assessment (NA), dated 5/27/20, NA indicated, .Encourage protein intake r/t [related to] wound healing. Plan/Monitor: . continue to review wt [weight] trends, labs, and PO [by mouth] intake RD [Registered Dietitian] to f/u [follow up] PRN [as needed] Goal: Experience no significant wt [weight] changes. During a review of Resident 1's medical record, no additional Nutrition Assessments were found. During an interview on 2/8/22, at 9:30 a.m., with Registered Dietician (RD), RD stated, the registered dietician obtained information regarding Resident 1 in daily meetings with nursing staff and by reading Resident 1's chart. RD stated, if Resident 1 was ordered for strict I&O and weekly weights, and these were not done as ordered, the dietician should notify the doctor and nursing staff. RD stated, the dietician should have addressed issues regarding not eating and drinking adequate amounts. RD stated, Resident 1 should have been assessed monthly and more often, as needed, based on Resident 1's condition. RD stated, dietician, along with nursing, followed I&O, weights, and pressure ulcer status to assess the resident's condition and make recommendations, which the doctor would review and order if agreed. During a review of Resident 1's OSR, dated 5/21/20 7/7/20, indicated, strictly monitor I&O (measure amount of liquid taken in and amount of liquid put out by resident) every shift for COVID 19, was ordered on 6/22/20. During a review of Resident 1's medical record (MR), MR revealed no recording of I&O, no recording of the amount of liquid Resident 1 took in and the amount of liquid he put out. During a review of Resident 1's Order Summary Report dated 5/21/2 7/7/20, indicated Resident 1 had the following orders: 1. 5/30/20 Low Sodium Cardiac Diet, Dysphagia, Mechanically Altered texture 2. 5/27/20 House shake two times a day with breakfast and lunch 3. 6/22/20 Strictly monitor input and output every shift During a review of Resident 1's Documentation Survey Report, dated June 2020, indicated the following dates and tasks were blank: For the section Document Amount of Meal Taken: 6/3/20 breakfast and lunch, 6/12 lunch, 6/14 lunch, 6/19 breakfast and lunch, 6/20 dinner, 6/21 breakfast, lunch, and dinner, 6/25/ dinner, 6/26 lunch and dinner, 6/27 lunch and dinner, 6/28 breakfast, lunch, and dinner, 6/29 dinner, and 6/30/20 dinner. For the section Nutritional Supplement: 6/3/20 8 am and noon, 6/12 noon, 6/19 8 am and noon, 6/21 8 am and noon, and 6/28/20 8 am and noon. For the section HS (bedtime) Snack 6/20/20, 6/21, 6/22, 6/24, 6/25, 6/26, 6/27, 6/28, 6/29, and 6/30/20, For the section Hydration/Fluids Offered: 6/3/20 day shift and night shift, 6/7 night shift, 6/15 night shift, 6/21 night shift, 6/22 night shift, 6/24 night shift, 6/25 evening shift, 6/26 evening shift, 6/27 evening shift, 6/28 evening and night shift, 6/28 day, evening and night shifts, and 6/30/20 evening shift. During a review of Resident 1's Documentation Survey Report, dated July 2020, indicated staff had not charted for the following dates and tasks: For the section Document Amount of Meal Taken: 7/1/20 lunch and dinner, 7/2 lunch and dinner, 7/4 breakfast, lunch, and dinner, and 7/5/20 lunch and dinner For the section Nutritional Supplement: 7/4/20 8 am and noon, and 7/5/20 at 12 noon For the section Hydration/Fluids Offered: 7/1/20 evening shift, 7/3 night shift, 7/4 day and evening shifts, 7/5 day and night shifts, and 7/6/20 night shift For the section HS (bedtime) Snack: 7/1/20, 7/2, 7/4, and 7/5/20. During a review of MD Progress note, dated 6/29/20, indicated, Continue encourage p.o [by mouth]. During a review of Resident 1's Nursing Progress Notes, dated 7/7/20, indicated, patient transported via gurney to go to [acute care hospital] r/t related to] patient failure to thrive. pt not eating or drinking fluids, patient appears to be fatigue and has a persistent wet non productive cough, pt sent per MD order . During a review of Resident 1's acute care hospital Discharge Summary Note (DS), dated 7/7/20, indicated Resident 1 was admitted to the hospital from the facility with significant dysphagia (difficulty swallowing), moderate protein calorie malnutrition, adult failure to thrive syndrome (a decline in older adults resulting in poor nutrition, weight loss, inactivity, depression and decreased functional ability), septic shock (a widespread infection causing organ failure and dangerously low blood pressure), [CONDITION(S)] (a high concentration of sodium in the blood usually caused by not drinking enough water) and COVID 19 positive. Review of the Clinical Notes section indicated Resident 1 had . LACTIC ACIDOSIS (7/7/2020) potentially due to poor oral intake with recent 30# weight loss and associated dehydration markedly dry mucous membranes on exam .being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] During a telephone interview on 2/8/22, at 12:57 p.m., with Director of Nursing (DON), DON stated, the doctor ordered strict I&O for Resident 1. DON stated, the liquids given to resident should have been recorded in milliliters (a measurement of volume. One milliliter was one thousandth of a liter.) DON stated, the number of times Resident 1 urinated should also have been recorded. DON stated, no documentation of I&O was in Resident 1's chart. DON stated, I&O would have shown the staff whether Resident 1 had sufficient fluids or was dehydrated. DON stated, Resident 1's charting should have been complete, so any change of condition could have been picked up and treated. During a telephone interview on 4/28/22 at 10:54 a.m., with DON, DON stated, the expectation was all doctor's orders were to be followed. DON stated, staff's failure to record Resident 1's I&O and weigh Resident 1 weekly may have contributed to his worsened condition. DON stated, the expectation was for staff to assess Resident 1, any change in his condition, and base his care on his condition.

Based on interview and record review, the facility failed to maintain infection control program for five of five sampled residents (Residents 1, 2, 3 , 4 and 5), when the facility failed to identify and monitor the prevalence of Scabies (a contagious, intensely itchy skin condition caused by a tiny, burrowing mite) in the facility and interventions to mitigate the spread of infection was not implemented. This failure resulted in cross contamination and Residents 2, 3 ,4 and 5 contracted scabies. Findings: During a review of Resident 1's My Transition Home (MTH), dated 1/8/20, indicated Resident 1 was admitted to the facility on [DATE]. During a review of Resident 1's General Progress Notes (GPN), dated 1/11/20, GPN indicated Resident 1 was discharged on [DATE]. During a review of Resident 1's Admission Record Report indicated Resident 1 was re admitted to the facility on [DATE] from the acute care hospital. During an interview on 7/19/21, at 4:47 p.m., with Resident 1's family member (FM) 2, FM 2 stated, Resident 1 was admitted to the facility twice. FM 2 stated, Resident 1 developed a rash on his back a short time after Resident 1 was discharged from the first admission, the rash spread on Resident 1's body and was subsequently diagnosed as scabies. FM 2 stated, Resident 1's scabies spread to Resident 1's wife. During an interview on 1/31/21, at 1:35 p.m., with Director of Staff Development (DSD), DSD stated, four residents were treated with [MEDICATION(S)] (a medication used to treat scabies, which is a contagious, intensely itchy skin condition caused by a tiny, burrowing mite and is usually transmitted by skin to skin contact) for scabies during Resident 1's first admission to the facility. DSD stated, scabies infection can appear two or more weeks after exposure. During a review of Resident 1's acute care hospital's H&P Notes (History and Physical, H&P), dated 5/19/20, H&P indicated, Of note, he was diagnosed with scabies by Derm [Dermatologist- a doctor who specializes in conditions involving the skin, hair, and nails] and prescribed two rounds of treatment with [MEDICATION(S)] [skin cream used to treat scabies] and a topical steroid cream. During a review of Resident 2's General Progress Note (GPN), dated 12/31/19 at 2:20 p.m., indicated .pt noted with rash on arms back and abdomen, MD notified and ordered permethrim cream 5% tonight and repeat in 7 days . During a review of Resident 2's GPN dated 12/31/19 at 11:35 p.m., GPN indicated, .Administered permethrim cream 5% during bedtime . During a review of Resident 2's Order Entry (ORD), dated 12/31/19, indicated, .[MEDICATION(S)] Cream 5 % .Apply to: neck to toe . During a review of Resident 3's ORD, dated 12/12/19, indicated, .[MEDICATION(S)] Cream 5% .Apply to: all over body except face . During a review of Resident 3's ORD, dated 1/16/20, ORD indicated, .[MEDICATION(S)] Cream 5% . Apply to: all over body except face . During a review of Resident 3's Progress Note, dated 12/12/19, indicated, Call to daughter to notify of changes to treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 4's ORD, dated 12/12/19, ORD indicated, [MEDICATION(S)] Cream 5% . Apply to: body . For (indications for USE) scabies . During a review of Resident 4's Progress Notes (PN), dated 12/12/19, indicated, 12 10 2019 Rashes noted on skin (abdomen, arms, back of knees). Pt c/o [complained of] itching . During a review of Resident 4's PN, dated 12/12/19, indicated, . Resident went for Dermatology appointment today. Dr . diagnosed resident with scabies During a review of Resident 5's ORD, dated 1/18/20, indicated, [MEDICATION(S)] Cream 5% . Apply to: neck to toes . For (indications for use) rash . During a review of Resident 5's General Progress Note (GPN), dated 1/20/2020, GPN indicated, pt treated with permetherin cream 1/18/20 . During an interview on 4/28/22 at 12:52 p.m., with DSD, DSD stated she did not find documentation showing the facility implemented an infection prevention and control program during December 2019 and January 2020, when Resident's 2, 3, 4, and 5 were treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of the facility's policy and procedure (P&P) titled, Infection Control Manual: Chapter 3, Disease Specific Guidelines, dated 7/2021, the P&P indicated, Scabies is an infection of the skin by the human itch mite . the most common symptoms of scabies are intense itching and a pimple like skin rash. The scabies mite usually is spread by direct, prolonged, skin to skin contact with a person who has scabies. Institutions, such as nursing home . are common sites of scabies infections. Section 1 Infectious Process indicated Infection control is an increasingly important aspect of healthcare for both patients and employee prevent route of transmission by direct or indirect contact with handwashing, disinfection and sterilization techniques, isolation of infected patients and contagious employees not working . During a review of the facility's policy and procedure (P&P) titled, Infection Control Manual: Chapter 7, Surveillance, dated 7/2021, the P&P indicated, Infections that should be considered in a routine surveillance program include those that: demonstrate limited transmissibility and limited preventability such as . skin infections . Further review indicated the Surveillance Criteria for Skin, Soft Tissues, and Mucosal Infection included Scabies.

Based on observation, interview, and records review, the facility failed to follow infection control practices to prevent spread of infection in the facility during a novel Coronavirus Disease (COVID-19 - a mild to severe respiratory (lung) illness) outbreak (an occurrence of disease greater than expected at a particular time and place) when the following were observed: 1. The facility's surveillance system (monitoring of the spread of disease to establish patterns of disease progression) including mapping (tracking tool used to identify outbreaks and for disease prevention and control), and tracking (summary information of persons who may be associated with an outbreak) were not completed to accurately monitor progression of COVID-19 outbreak in the facility that resulted in failure to properly cohort residents who tested positive with COVID-19. 2. The facility did not assign dedicated staff for caring for COVID-19 residents and Persons Under Investigation (PUI - residents being isolated and observed for Covid 19 symptoms and waiting for Covid 19 testing results). 3. Two facility staff members did not follow guidelines for donning and doffing of PPE when entering and exiting COVID-19 designated units. 4. COVID-19 positive residents were roomed with PUI residents and multiple doors of resident bedrooms were left open. These cumulative failures to follow transmission-based precautions resulted in widespread outbreak of COVID-19 cases at the facility including 54 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, and 54), and 33 staff members (Certified Nursing Assistants (CNA) 1, 2 , 3 ,4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, Registered Nurse (RN) 1, 2, 3, 4, 5, 6, Licensed Vocational Nurse (LVN) 1, 2, 3, 4, 5, Housekeeping (HSK) 2 , 3, Rehabilitation Staff 1, 2, Unit Manager (UM), and Admission Coordinator (AC)) who worked at the facility. Two residents died (Resident 2 and 32) in the facility of COVID 19. The Administrator, Director of Nursing (DON), Infection Preventionist (IP), and Housekeeping Supervisor (HS) were verbally notified of the Immediate Jeopardy (IJ) on [DATE] at 3:37 p.m. The facility failed to implement infection control interventions that would prevent the spread of COVID-19. Through observation, interviews with the staff members and record reviews of the facility's documents, the facility showed they initiated the plan of action through in-services of employees regarding infection control. The IJ was abated during an on-site visit on [DATE] at 2:11 p.m. Findings: 1. During an interview with the Administrator on [DATE] at 10:10 a.m., the Administrator stated the facility had a total of 54 cumulative cases of residents and 32 cumulative cases of staff tested positive for COVID-19 as of [DATE]. Of the 54 total cumulative residents who tested positive with COVID-19, 47 residents were in the facility, five residents (Residents 1, 12, 13, 18 and 53) were transferred to the acute hospital for further treatment, and two residents (Resident 2 and 32) expired at the facility due to COVID-19 During an interview and record review with the Infection Preventionist on [DATE] at 11:00 a.m., the IP was unable to show mapping was completed. The IP was not able to provide the number of residents who were PUI or positive for COVID-19. The spreadsheet did not include exhibited symptoms of residents who were symptomatic, nor did it list the residents who were roommates of residents who tested positive with COVID-19. A review of the facility's Infection Control Manual titled, Surveillance dated ,[DATE] indicated, Infection Detail Report: This report provides a comprehensive look at the patients who have infections, their room numbers, the onset date, admitted , whether it is an Healthcare Associated Infections (HAI) or Community Acquired (CA), types of infection, symptoms . When reviewing this report, it is important to look at each column to identify trends and commonalities. Look at the room number to see if infections are within close proximity, on the same hall, in the same room or on the same unit .Look at the type of precautions implemented . Identify trends. Further review of the untitled and undated spreadsheet revealed a cumulative total of 54 residents were tested positive with COVID-19 from [DATE] through [DATE]. Of the 54 total cumulative positive cases, five residents (Residents 1, 12, 13, 18 and 53) were sent out to acute care hospital, one resident (Resident 14) was transferred to non-acute care facility, and two expired (Resident 2 and 32) at the facility. The spreadsheet did not indicate the dates of transfer for Residents 1, 12, 13, 18 and 53), nor the date when Resident 2 and 32 expired. During a record review of an undated facility document titled, Employee Tracker the reflected 31 facility staff (Certified Nursing Assistants (CNA) 1, 2 , 3 ,4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, Registered Nurse (RN) 1, 2, 3, 4, Licensed Vocational Nurse (LVN) 1, 2, 3, 4, 5, Housekeeping (HSK) 2 , 3, Rehabilitation Staff 1, 2, Unit Manager (UM), and Admission Coordinator (AC)) were tested positive from COVID-19 between the dates of [DATE] through [DATE]. During a concurrent interview with IP on [DATE] at 11 a.m., IP stated the document did not include the cumulative total of 33 facility staff. The employee tracker did not include RN 5 and 6 who were reported COVID-19 positive as of [DATE]. During an interview with the DON on [DATE] at 11:00 a.m., and review of the facility's document titled, Daily Staffing record dated [DATE] through [DATE], the staffing record revealed licensed staff were assigned to care for residents in wings of COVID 19 positive residents, PUI's, and COVID 19 negative residents. The DON stated staff who tested positive for COVID-19 were providing care to COVID-19 positive, PUI and COVID-negative units in the facility. A review of the Centers for Disease Control and Prevention (CDC) published guidelines titled Preparing for COVID-19 in Nursing Homes, dated [DATE] indicated, Background: Given their congregate nature and resident population served (e.g., older adults often with underlying chronic medical conditions), nursing home populations are at high risk of being affected by respiratory pathogens like COVID-19 .As demonstrated by the COVID-19 pandemic, a strong infection and control program is critical to protect both residents and health care personnel. 2. During a concurrent interview and record review with the DON and Regional Director of Operations (RDO) on [DATE] at 11:45 A.M., the DON explained Building A and Building B, each have COVID-19 units. During an observation and facility floor plan review on [DATE] at 12 noon with DON and RDO, a resident (Resident 51) who tested positive for COVID-19 on [DATE] and a PUI resident (Resident 59) were sharing a room , and a resident (Resident 50) who tested negative for COVID-19 and a PUI resident (Resident 56) were sharing a room. According to the facility's undated policy and procedure titled, Designation of Space Antechamber or COVID-19 Airborne Isolation, Patients with confirmed [DIAGNOSES REDACTED]. 3. During an observation outside the facility main entrance on [DATE] at 10:40 a.m., Occupational Therapist 1 (OT 1) who was wearing PPE including; N95 mask, face shield, gown, gloves, and shoe coverings, exited from the building using an outside emergency door in Building B wing 3. OT 1 walked across the parking lot, entered a car, and proceeded to walk back inside the building using the same doorway she exited. During the facility tour observation and interview with DON on [DATE] at 12:00 p.m., Building A and Building B were observed each with COVID-19 units. DON stated COVID-19 hallways each have antechamber units covered in plastic barriers with zipper. The first plastic barrier serves as the entry and exit where staff don and doff their PPE, while the second plastic barrier was an entry and exit to the wing of the COVID-19 units. DON stated the emergency exit doors in each of the COVID-19 units should not be used to enter or exit the building. During an observation on [DATE] at 12:30 p.m., Housekeeper 1 (HSK 1) was observed entering Building B from the outside parking lot using the emergency exit door leading to the COVID-19 unit hallway. HSK 1 did not perform hand hygiene and did not wear PPE upon entry to the COVID-19 unit hallway. HSK 1 walked down the hallway passing by 12 resident rooms housing COVID-19 positive residents, HSK 1 entered the plastic barrier to the antechamber donning and doffing area. A review of the facility's undated policy and procedure titled, Designation of Space Antechamber or COVID-19 Airborne Isolation Unit (CAIU) indicated Personnel need to wash their hands before touching zipper wall and entering antechamber, Personnel need to enter chamber and securely close zipper, Personnel are to wash hands after closing first barrier wall zipper, Don PPE. Enter unit from antechamber. Securely close zipper on second barrier wall after leaving antechamber .When preparing to leave the unit, perform hand hygiene before touching zipper to first barrier wall entering antechamber. Securely zip barrier wall closed. Doff PPE and wash hands. Exit the antechamber through the second zipped wall. Securely zip barrier wall closed. Perform hand hygiene before proceeding to any other area of the facility. 4. During an observation and interview with the DON on [DATE] at 12:00 p.m., rooms [ROOM NUMBERS] doors were left open. DON immediately closed the doors in room [ROOM NUMBER], and room [ROOM NUMBER]. DON stated the rooms of residents who tested positive for COVID-19, and residents who were considered PUI's should always have their door closed. During an observation and interview with Staff 2 on [DATE] at 12:30 p.m. in Building B emergency exit door, HSK 1 parked the housekeeping cart in front of room [ROOM NUMBER] adjacent to room [ROOM NUMBER]. Both rooms were observed to have left open. A review of the CDC's undated guidance titled, Transmission-Based Precaution indicated In settings where Airborne Precautions cannot be implemented due to limited engineering resources, masking the patients and placing the patients in private room with the door closed will reduce the likelihood of airborne transmission.

Based on interview and record review, the facility failed to recognize symptoms of dehydration, and take action to monitor and prevent dehydration for one (1) of three sampled residents. Resident 1 developed nausea and vomiting, decreased appetite, and was taking a diuretic medication ([MEDICATION NAME] - used to increase the excretion of excess water from the body), which put her at risk for dehydration. Resident 1 experienced two episodes of lowered blood pressure, an indication of possible dehydration, and the physician was not notified. In addition the facility failed to implement its Hydration Practice Guide Flowchart, to monitor for possible signs and symptoms of dehydration. These failures resulted in Resident 1 being hospitalized for [REDACTED]. Findings: During a review of the clinical record on 5/4/16, for Resident 1, the history and physical showed she was admitted to the facility 4/10/16 with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 4/17/16 showed Resident 1 had severe mental impairment and required extensive assistance (staff has to complete part of the activity) for activities of daily living and supervision (requires staff oversight, encouragement or cueing) for eating. Medication records for Resident 1 showed the doctor ordered [MEDICATION NAME] 20 milligrams once a day for treatment of [REDACTED]. Interventions included report signs and symptoms of dehydration, [MEDICAL CONDITION] (low blood pressure), or dizziness. The April 2016 MAR for Resident 1 showed blood pressure readings of 98/70 on 4/29/16 and 92/46 on 4/30/16. The physician's orders [REDACTED]. There was no documented evidence that Resident 1's physician was notified of these blood pressure readings. During an interview with the Director of Nurese (DON) on 7/22/16 at 1 p.m. she could not find any documented evidence that the physician was notified of the lowered blood pressure. Nursing progress notes dated 4/27/16 at 3:49 p.m. showed Resident 1 had vomited and was complaining of abdominal pain. The physician was notified and orders received for [MEDICATION NAME] 4 milligrams (medication to treat nausea and vomiting) every 4 hours as needed for nausea or vomiting. Medication administration records (MAR) for April and May showed Resident 1 received [MEDICATION NAME] for nausea once on 4/27/16, twice on 4/30/16, once on 5/1/16, and once on 5/2/16. The amount of meals consumed by Resident 1 were documented on 4/27/16 as 75% for breakfast, 25% for lunch and dinner. On 4/28/16 the amount of meals consumed were 50% for breakfast, no documentation of lunch intake and 0 intake of dinner. On 4/29/16 Resident 1 consumed 25% for breakfast , 25% for lunch and 0 for dinner. On 4/30/16 Resident 1 ate 25% of breakfast and 25% of dinner. The amount consumed for lunch on 4/30/16 was not documented. On 5/1/16 it was documented Resident 1 ate 50% of each meal. On 5/2/16 it was documented that Resident did not eat any of her meals. Progress notes written by Registered Nurse 1 (RN 1) dated 5/2/16 2:34 p.m., indicated at around 1 p.m. that day Resident 1 complained of nausea and abdominal pain. RN 1 gave Resident 1 [MEDICATION NAME] at 1:29 p.m. to help treat these symptoms. The progress note indicated Resident 1's Responsible Party wanted the resident to go to the emergency room (ER). The progress note showed, Informed MD (medical doctor) that instead of discharge tomorrow will discharge today, MD agreed. There was no documentation that RN 1 assessed Resident 1's vital signs, hydration status or her abdominal pain. During an interview with RN 1 on 6/2/16 at 11:37 a.m., she stated Resident 1's Responsible Party wanted Resident 1 to go to the emergency room . She stated Resident 1 had been throwing up four days ago. During an interview with Resident 1's physician (MD 1) on 6/16/16 at 3:35 p.m., he stated he had last seen Resident 1 on 4/20/16. The facility's policy and procedure titled Hydration Practice Guide Flowchart dated 2012, indicated residents should be monitored for changes in hydration status and if there is a change, a Hydration Evaluation Form should be completed. A review of the clinical record on 5/4/16 for Resident 1 did not show a Hydration Evaluation form. During an interview with the facility's Director of Nursing (DON) on 7/6/16 at 11:55 a.m., she stated a Hydration Evaluation Form was not completed for Resident 1 after she had complaints of nausea, vomiting and epigastric (upper central region of the abdomen) pain. During a review of the emergency room record at the acute hospital, the arrival information showed Resident 1 arrived in the ER at 1:30 p.m. on 5/2/16. The ER physician notes indicated resident appeared significantly dehydrated with poor skin turgor (sign used to assess fluid loss), pain level 7 out of a possible 10 (severe pain), her creatinine was elevated (sign that kidneys are not working well) and complained of a persistent cough. The ER physician noted Resident 1 required admission for intravenous (through a vein) hydration, antibiotics and treatment for [REDACTED]. Resident 1 was discharged from the hospital on [DATE].