Every finding on record at Titonka Care Center

Based on observation, infection control policy and staff interview, the facility failed to initiate a legionella water program for the facility. The facility reported a total census of 21 residents. Findings include: During interview on 4/17/25 at 10:30 AM., with Staff A, Maintenance, was unable to explain what the facility was currently doing to prevent Legionella growth in the facility. Staff A stated he wasn't sure what needed to be done for the legionella water program. Staff A stated the previous Administrator was in charge of the Legionella water program. Staff A stated this person left the facility in June 2024. Staff A stated there has not been any temperatures taken of the hot water system since June of 2024. Staff A stated he does run water down the drains at random times but does not have any documentation of this. Staff A stated the city does test for Legionella. Review of facility provided policy titled Legionella Prevention Policy and Procedure with a date of 1/2/24 revealed Legionella is usually spread through water droplets in the air. Legionella lives in fresh water, but can live in man-made settings if water is not properly maintained. It becomes a problem when small droplets of water contain the bacteria and get into the air and people breath them in. It grows best in building water systems that are not well maintained. The key to preventing Legionnaires ' disease is to make sure that building owners and managers maintain building water systems in order to reduce the risk of Legionella growth and spread. Examples of building water systems that might grow and spread Legionella include: Hot tubs Hot water tanks and heaters Large Plumbing systems Cooling towers (structures that contain water and a fan as part of centralized air-cooling systems for building or industrial processes) Decorative fountains During interview on 4/17/25 9:25 AM the Director of Nursing (DON) reported that maintenance doesn't know what needs to be done for water testing or what needs to be done for Legionella. The DON reported she just got information on what needs to be in the Legionella policy as to what the facility needs to be doing.

Based on facility record review and staff interviews, the facility failed to employ a licensed Administrator. The facility reported a census of 21 residents. Findings include: During an interview on 4/14/25 at 10:31 AM, the Director of Nursing (DON) reported she has applied for Provisional Administrator and has not been approved yet. She reported the prior Administrator had left back in October around 18th-21st but not sure of the date. During an interview on 4/17/25 at 9:11 AM, the DON reported the former Administrator was available by phone if they would need her but she was not employed by the facility and had not been in the building since October 20th. She reported the facility was not actively looking for an Administrator and has not been.

Based on observation, record review, policy review, resident and staff interviews, the facility failed to administer medications per physician orders and failed to accurately record follow up to a medication for 1 of 1 residents reviewed (Resident #9). The facility reported a census of 21 residents. Findings include: Resident #9's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14 indicating intact cognition. The MDS include diagnoses of Seizure disorder or Epilepsy, hypertension and peripheral autonomic neuropathy. The MDS documented Resident #9 was taking anticonvulsant medications during the 7 day look back period. During an observation on 4/15/25 at 7:50 AM, Resident #9 reported to Staff B, Registered Nurse (RN) that her medications from 4/14/25 evening are still in her room on her tray table. Resident #9 reported she must have fallen asleep and the nurse had brought them in but didn't wake her for them so she never took them. Resident #9 reported she knew they were her evening medications because her seizure medication was in it. During an interview on 4/15/25 at 8:00 AM the Assistant Director of Nursing (ADON) reported Staff C, RN was the nurse last evening and that she has Resident #9's medications from last night pointing to the medications on her desk. The ADON reported Resident #9's seizure medication, Tylenol and cold medication is what she had. She reported Staff C should not have left the medications for the resident to take. Review of the Resident #9's April 2025 Medication Administration Record documented the Phenytoin (anticonvulsant for seizures), Tylenol and DayQuil Severe medications were signed that they were taken. It further documented Staff C, RN also did a follow up to the cold medication that was not taken saying it was effective. During an interview on 4/15/25 at 3:10 PM the Director of Nursing (DON) reported Resident #9's last lab for her seizure medication was low so they are rechecking it since the medication was not taken last night. During an interview on 4/17/25 at 9:45 AM the DON reported she was the one who called Staff C, RN about the medications not taken and Staff C, RN reported to the DON she normally doesn't leave the medications in the room and for follow ups to as needed medications such as cough medication the nurse should follow up with the resident to see that it was effective. The facility policy Medication Variance dated 4/16/25 documents the purpose is to manage accountability of the staff involved in the medication system.

Based on clinical record review, staff interview and policy review the facility failed to obtain a bed hold notification for 1 of 2 residents reviewed (Resident #2). The facility reported a census of 21. Findings include: Review of Resident #2's Electronic Healthcare Record (EHR) revealed Resident #2 was in the hospital from [DATE] to 12/9/24. Review for bed hold notification for Resident #2 revealed there was no bed hold form to review for the dates of hospitalization. During interview on 4/16/25 at 1:50 PM the Director of Nursing (DON) stated that they haven't been doing the bed holds. The DON stated she thought they didn't have to do them anymore. The DON stated they don't have a formal form, but they do talk with the families regarding the bed hold. The DON stated they don't have a place to document that. The DON stated she will put this in place. Review of the facility provided policy dated 7/28/2017, titled Bed Hold revealed: The bed hold policy refers to the desire to Hold a resident's bed in cases in which a resident is not in the facility overnight. This could include, but is not limited to situations such as a resident being in the hospital or staying overnight with the family. Private pay residents that choose to hold the bed will be billed for the day at the regular rate. If a private pay Resident decides to not hold the bed and pay the full daily rate, the resident will be considered discharged from the facility and will remove all personal items. Bed hold days for Medicaid eligible residents for temporary absences will be covered as follows: when absent due to hospitalization for a period not to exceed ten days in any calendar month. After ten days, upon the discretion of the facility, the facility may choose to discharge a resident following normal discharge procedure. And when absent overnight for the purpose of visitation or vacation for a period not to exceed eighteen days in any calendar year.

Based on clinical record reviews, staff interviews and policy review, the facility failed to do neurological assessments with unwitnessed falls for 1 of 1 residents reviewed (Resident #1). Resident #1 had 14 falls since May 2024, out of those 14 falls the facility failed to do neurological assessments on 7 of those unwitnessed falls. Findings include: The Minimum Data Set (MDS) dated for 1/23/25 for Resident #1 included diagnoses of Alzheimer 's dementia, anxiety disorder, depression and bipolar disorder. Resident #1's MDS dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 00, indicating severe impaired cognition. The Facility Incident Reports (IR) documented from 7/30/24 to 12/5/24 revealed Resident #1 had unwitnessed falls on these dates 7/30/24, 8/12/24, 8/18/24, 9/21/24, 9/22/24, 10/7/24, and 12/5/24 and the facility failed to do neurological assessments each time. Review of the IR dated 7/30/24 at 8:08 PM revealed Resident #1 had an unwitnessed fall in his room. Resident #1 was found in his room sitting on the floor in front of his recliner. Resident #1 denied hitting his head. The IR revealed neurological assessment completed within normal limits for Resident #1. The facility failed to complete neurological assessments for this fall. Review of the IR dated 8/12/24 at 5:55 PM revealed Resident #1 had an unwitnessed fall in his room. Resident #1 he had slid out of his recliner and was found on the floor. The facility failed to complete neurological assessment for this fall. Review of the IR dated 8/18/24 at 6:50 PM revealed Resident #1 had an unwitnessed fall in the lobby. Resident #1 was found on his knees with his w/c behind him. The facility failed to complete neurological assessment for this resident. Review of the IR dated 9/21/24 at 5:00 PM revealed Resident #1 had an unwitnessed fall in his room. Resident #1 was found on the floor in front of his recliner. Resident #1 denied hitting his head. The facility failed to complete neurological assessment for this resident. Review of the IR dated 9/22/24 at 2:02 PM revealed Resident #1 had an unwitnessed fall in his room. Resident #1 was found on the floor next to his recliner. The facility failed to complete neurological assessment for this resident. Review of the IR dated 10/7/24 at 4:54 PM revealed Resident #1 had an unwitnessed fall in his room. Resident #1 was found sitting on the floor in front of his recliner. The facility failed to complete neurological assessment for this resident. Review of the IR dated 12/5/24 at 5:37 PM revealed Resident #1 had an unwitnessed fall in the hallway. Resident #1 was found sitting on the floor in the hallway. The facility failed to complete neurological assessment for this resident. Review of the facility's policy named Neurological assessment dated [DATE] revealed: The neurological assessments must be completed on any resident with a suspected head injury and all unwitnessed falls. If a resident is alert and oriented and has a BIMS score of 12 or higher, neuro checks do not have to be done if they tell you they did not hit their head and no head injury is noted or suspected. The first neuro check must be done before moving the resident after the fall. Neuro checks must be performed as follows: a. Initial, then every 30 minutes times 3 b. Every hour times 2 c. Every four hours times 2 d. Every eight hours times 2 If any abnormal findings are present, neuro checks must be done more frequently. Notify the primary care physician of the incident/accident as soon as possible. Notify the primary care physician of any abnormal findings immediately. Notify the Director of Nursing (DON) and Administrator of all falls. Document all vital signs from neuro check worksheet into electronic health record. a. File a new assessment (listed as neurological Assessment) for each of the vital signs. b. Save each assessment in the electronic health record with the time that the assessment was done so it matches the time of the vital signs During interview on 4/16/25 at 1:48 PM the Director of Nursing (DON) stated that the expectation is to do neurological assessment when the resident has an unwitnessed fall. During interview on 4/16/25 at 2:30 PM the DON acknowledged and verified the neurological assessments were not completed for these seven falls. The DON stated that five of them were documented as he denied hitting his head, so the DON felt they didn't do the neuro's due to this. The DON stated she knows the facility has not been doing the neuro's like they are supposed to. The DON stated that she has redone the neuro policy as of 4/3/25 and will be educating the staff regarding this.

Based on observations, record review, staff interviews and policy reviews, the facility failed to change and label oxygen tubing for 1 of 1 residents reviewed (Resident #2). The facility reported a census of 21. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 documented diagnoses of heart failure, hypertension (high blood pressure), diabetes mellitus. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. On 4/14/25 at 1:03 PM an observation was made regarding Resident #2's oxygen tubing. The oxygen tubing lacked a date of when it was last changed. On 4/15/25 at 7:30 AM during medication administration Resident #2 reported to the nurse he needed new oxygen tubing because his tubing was hard and made a sore in his nose. Resident #2 told the nurse he wears it every night so needs it changed. On 4/15/25 at 3:55 PM the Director of Nursing (DON) stated it should be on the medication administration sheet (MAR) or the treatment administration sheet (TAR) to give directions to the staff to change the oxygen tubing. Review of the MAR for March and April of 2025 lacked information regarding changing the oxygen tubing or when to change it. On 4/15/25 at 4:05 PM, an interview with Resident #2 revealed he had not had his tubing changed as of yet today. Resident #2 stated he did say something about it this morning to the nurse because the tubing is getting hard and giving him a sore in his nose. Resident #2 stated he didn't think it had changed in the last thirty days. Resident #2 stated he would like to have it changed every two weeks. Observations made at this time, oxygen tubing had not been changed, and continued with no date on it. Review of the undated facility provided policy titled Administration of Oxygen Therapy revealed the purpose is to administer oxygen to prevent or due to hypoxia, to deliver low flow oxygen concentration with nasal cannula, to deliver medium concentration of oxygen by mask, to deliver high humidity to the upper respiratory tract. The policy stated to change water in the humidifier bottle daily and to change the mask, cannula and bottle weekly. Interview with DON on 4/16/25 at 2:29 PM revealed she is not sure how that was missed, it is in the standing orders and should have been pulled over to put on the TAR to give guidance to the staff.

Based on record review, interviews, and policy review , the facility failed to ensure residents whom the facility administered psychotropic medications were monitored for targeted behaviors and failed to utilize non-pharmacological interventions for 1 of 5 residents reviewed (Resident #12). The facility reported a census of 21 residents. Findings include: Resident #12's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognition. The MDS include diagnoses of anxiety, depression and suicidal ideations. The MDS documented Resident #5 was taking anti-anxiety and antidepressant medications during the 7 day look back period Review of Resident #12's Progress Notes documented the resident receiving Lorazepam as needed due to crying and restlessness on 4/12/25 and 4/8/25 but no non-pharmacological interventions were documented prior to giving the medication. Review of Resident #12's Care Plan documented she uses antidepressant and anti-anxiety medications for for anxiety, depression, and suicidal ideations with a goal that she will be free from discomfort or adverse reactions related to anti-anxiety and antidepressant therapy. It directed staff to monitor for side effects and effectiveness of the medications. The Care Plan lacked documentation of targeted behaviors and non-pharmacological interventions for the staff for her anxiety, depression and suicidal ideations. During an interview on 4/16/25 at 2:25 PM the Director of Nursing reported the facility does not know much about Resident #12 to put interventions on the care plan that are non-pharmacological interventions. She reported the facility currently does not have things in place for monitoring the targeted behaviors for Resident #12.

Based on record review and staff interview, the facility failed to report Payroll Based Journal (PBJ) during the 1st quarter of fiscal year 2024. The facility reported a census of 13 residents. Findings include: Review of the PBJ report provided by the Center of Medicare and Medicaid Services (CMS) for Fiscal year (FY) 2024 quarter one, indicated the facility did not submit PBJ data. Review of CMS Submission Report titled PBJ on Demand Final File Validation Report dated 2/12/24 revealed the data file was rejected as the reporting period selected on the upload screen did not match submitted XML. On 4/30/24 at 3:28 PM, the Director of Nursing (DON) reported the previous Business Office Manager (BOM) submitted the PBJ data on 2/12/24 but there was a fatal error and the file was rejected. The DON stated the BOM resigned on 2/14/24 and the error was not followed up on. The DON reported she now has access and was educated on the PBJ process. On 4/30/24 at 5:30 PM, the DON reported the facility did not have a PBJ policy but does now.

Based on observations, staff interviews, and policy review, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents reviewed (Residents #1, #8). The facility failed to complete hand hygiene after removing gloves and did not complete an annual review of the infection control policies/procedures. The facility reported a census of 13 residents. Findings include: 1. Resident #1 ' s Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 06, indicating severe cognitive impairment. The MDS identified Resident #1 was independent with bed mobility and required substantial/maximal assistance with transfers and toileting. Resident #1 ' s MDS included diagnoses of Alzheimer's dementia, non-alzheimer ' s dementia, anxiety, depression, bipolar disorder, and an open wound to the left shoulder. A Physician Order dated 1/16/24 for Resident #1 directed staff to cleanse the left shoulder wound with normal saline, pat dry, apply bacitracin (antibiotic ointment) and ABD (abdominal gauze pad), secure with tape every day and as needed. A Hospital form titled Microbiology Reference dated 4/26/24 documented Resident #1 ' s wound culture from the left shoulder wound revealed organism of Staphylococcus Aureus(gram positive bacteria) was present in the wound. A Physician order dated 4/29/24 directed staff to administer Linezolid (antibiotic) 600 mg (milligrams) one tablet by mouth two times a day for 7 days for an infection to the left shoulder. On 5/1/24 at 9:30 AM, observed Staff A, RN (Registered Nurse) complete a dressing change to Resident #1 ' s left shoulder wound. Staff A set up the wound care supplies on top of a barrier on a tray table which did not include hand sanitizer. Staff A applied a gown before entering Resident #1 ' s room. Staff A washed hands in the room and applied gloves. Staff A removed the old dressing that was not labeled/dated from Resident #1 left shoulder. Staff A removed/discarded gloves and washed her hands with soap and water. Staff A applied a new pair of gloves and took the wound cleanser and sprayed the cleanser on the gauze pads. Staff A cleansed the left shoulder wound two times. After cleansing the wound, Staff A removed/discarded gloves and applied a new pair of gloves without completing hand hygiene. Staff A applied bacitracin ointment to her gloved finger and then proceeded to open up the ABD package and cut the ABD pad in two with a pair of scissors resulting in the ointment being smeared on her gloved hand. Staff A then applied bacitracin directly to the ABD pad and applied it to the wound. Staff A removed/discarded her gloves and applied a new pair of gloves without completing hand hygiene. Staff A took the roll of tape, tore pieces of tape off the roll and secured the ABD pad with the tape to the left shoulder. Staff A acknowledged and verified she did not complete hand hygiene after removing the gloves during the wound care. 2. Resident #8 ' s Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 12, indicating intact cognition. The MDS identified Resident #8 required substantial/maximal assistance with bed mobility. The MDS further documented Resident #8 was dependent on staff for transfers and toileting. The MDS identified Resident #8 had a colostomy (bag that holds stool). Resident #8 ' s MDS included diagnoses of anemia, hypertension, ulcerative colitis (chronic, inflammatory bowel disease), and anxiety. On 04/30/24 at 10:15 AM observed Staff A, RN empty Resident #8 ' s colostomy bag. Resident #8 was sitting on the toilet. Staff A washed hands and applied gloves. Staff A used a graduate to empty stool contents from the colostomy bag. Staff A placed a barrier on the floor to sit graduate on while she cleansed the end of the bag with a incontinent wipe and then placed a clamp on the end of the bag. Staff A removed/discarded gloves, adjusted the resident's brief and applied new gloves without completing hand hygiene. Staff A then took the covered graduate with stool contents outside of the room to be emptied. 3. Review of the Infection Control Policy and Procedures revealed the facility did not review the policies annually. The following policies documented the following dates: a. Standard Precaution Policy- No revised or reviewed date b. Contact Precaution Policy- Revised 2/29/16 c. Airborne Precaution Policy- No revised or reviewed date d. Droplet Precaution Policy- No revised or reviewed date e. Infection Control Program Policy- No revised or reviewed date f. Infection Control Precautions Guidelines Policy- dated 12/2016 g. Infection Control Program Surveillance System- dated 12/2016 h. Pneumococcal Vaccination Policy- dated 12/2016 i. Influenza Vaccination Policy- dated 12/2016 On 5/1/24 at 11:25 AM, The Director of Nursing (DON) reported she would expect hand hygiene to be completed when removing gloves and when going from a dirty to clean task. On 5/1/24 at 3:15 PM, The DON reported the infection control policies were a work in progress and that she tried to review the policies annually. The DON stated the policies are kind of a mess. The DON verified that the Medical Director had not reviewed the infection control policies. The undated facility policy titled Standard Precautions directed staff to complete hand washing immediately after gloves are removed. The policy further documented it may be necessary to wash hands between tasks and procedures on the same resident to prevent cross contamination.

Based on interviews, document review, and facility policy review, it was determined the facility failed to ensure COVID-19 vaccination status and exemptions were monitored and exemptions were obtained and documented for 10 of 51 staff reviewed for COVID-19 vaccination status, including 1 (Registered Nurse [RN] #7) of 6 staff selected for COVID-19 vaccination compliance review. Findings included: A review of the facility's undated policy titled, Employee Vaccination Policy, indicated, Employee vaccination status will be tracked and securely documented for each staff member, including those for whom there is a temporary delay in vaccination and those who requested an exemption. The policy further indicated, The staff member can accept or refuse a COVID-19 vaccine and change their decision. A review of the COVID-19 Staff Vaccination Status for Providers list indicated 10 staff members were not vaccinated; there were no documented exemptions or delays. The list indicated one activity employee, one laundry employee, one housekeeping employee, four certified nursing assistants, and three registered nurses were unvaccinated. The list indicated RN #7, who was one of six staff members selected for the COVID-19 vaccination compliance review, was not up to date with the COVID-19 vaccination boosters and had not been granted an exemption. During an interview on 02/16/2023 at 9:17 AM, the Office Manager (OM) indicated he did not have an exemption for Registered Nurse (RN) #7. The OM indicated RN #7 was supposed to send the exemption in that morning. The OM indicated until about one month ago Team Assist (TA) #9 was responsible for obtaining the exemptions, then it became his responsibility. The OM stated that yesterday, 02/15/2023, he was told if staff were not up to date with vaccinations, then they were required to get an exemption. During an interview on 02/16/2023 at 12:11 PM, the Director of Nursing (DON) indicated the OM was responsible for the exemptions. The DON indicated the OM should have obtained the exemptions once the staff stopped getting the boosters. The DON indicated she was ultimately responsible to make sure it got done or that the OM knew it needed to be done. The DON stated anyone that quit getting the shot should have gotten an exemption. The DON indicated the vaccination binder needed to be updated and needed to be audited to ensure it stayed updated. The DON indicated it was her expectation for the vaccination documentation to be organized and updated. During an interview on 02/16/2023 at 12:19 PM, the Administrator indicated his expectation was the vaccination statuses were kept updated and tracked and that audits were done periodically.

Based on interviews, record review, document review, and policy review, the facility failed to ensure residents were free from staff-to-resident verbal / mental abuse and psychosocial harm for 2 of 2 sampled residents reviewed for abuse, (Residents #1 and #10). Specifically, Certified Nursing Assistant (CNA) #10 verbally abused Resident #1 on 09/13/2022 and was overheard by other staff members but was not removed from the facility until after the CNA verbally abused Resident #10 during the same shift. This had the potential to affect all 23 residents who resided in the facility. Findings included: Review of a facility policy titled, Abuse Prevention and Identification, dated 12/12/2022, specified, Responsibility: All employees of a care facility. Purpose: 1. To protect residents from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion. Abuse - is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, or pain or mental anguish, or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and; psychosocial well-being. This presumes that instances of abuse of all residents, even those in a coma, cause physical harm, or pain or mental anguish. Verbal Abuse - is defined as any use of oral written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Additionally, the policy defined mental abuse included, but was not limited to, humiliation, harassment, threats of punishment, or deprivation. The policy also indicated, The staff will assure that no resident is subjected to abuse through words or deeds of any person. Additionally, the policy indicated, 6. The facility will immediately begin a thorough investigation of the alleged abuse by interviewing the resident, if able to do so, the person reporting the incident or all other persons as appropriate to the alleged incident. 7. To prevent further potential abuse, the facility will reassign, or suspend the alleged perpetrator until the investigation is completed and a determination of the charge has or has not been substantiated. 3. When a report of suspected or alleged abuse is made to a Charge Nurse / Supervisor, the person to whom it is reported will immediately begin the investigation process. 4. To protect the resident during the investigation, the staff member will be immediately reassigned, removed or suspended from the resident's area. A review of a Medical Diagnosis list in Resident #1's electronic medical record revealed the facility admitted the resident with diagnoses that included cerebral aneurysm post-surgical repair, dementia, mood disorder, anxiety disorder, and heart failure. A quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #1 was severely cognitively impaired per a staff assessment for mental status. The MDS indicated the resident required extensive assistance of two or more people for bed mobility, toilet use, and personal hygiene. According to the MDS, the resident was frequently incontinent of bladder and always incontinent of bowel. A review of Resident #1's Care Plan, dated as initiated on 05/24/2021, indicated the resident had an activities of daily living self-care performance deficit related to advanced age and non-weight bearing status. The care plan included an intervention to provide perineal care twice a day and with each incontinent episode. A review of a Medical Diagnosis list in Resident #10's electronic medical record revealed the resident had diagnoses that included dementia, osteoarthritis right hip, difficulty walking, and venous insufficiency. The quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of zero, indicating the resident was severely cognitively impaired. The MDS indicated the resident required extensive assistance of two or more people for toileting and was totally dependent on the physical assistance of two or more people for transfers. Additionally, the MDS indicated the resident was frequently incontinent of bowel and bladder. A review of Resident #10's Care Plan, dated 08/25/2021, indicated the resident was at risk for an activities of daily living performance deficit due to reduced mobility and advanced age. Interventions included providing pericare twice daily and as needed (PRN) for incontinence episodes. Review of a written statement, dated 09/13/2022 and signed by Licensed Practical Nurse (LPN) #13, revealed the LPN was walking down the hall when she overheard CNA #10 getting verbally stern with Resident #1. The statement indicated LPN #13 heard CNA #10 telling Resident #1 to stop crying and you pooped. The LPN's statement indicated CNA #12 (the CNA who was assisting CNA #10 with Resident #1's incontinence care) pulled the LPN aside and reported that the resident was crying due to having been incontinent of bowel, and CNA #10 had yelled at the resident during incontinent care because the resident was crying. The LPN's statement indicated CNA #12 told her that CNA #10 had yelled, You did this all to yourself. Stop crying. You are pushing my limits. You pooped yourself. The statement indicated the LPN immediately notified the Director of Nursing (DON). Additionally, LPN #13's statement indicated CNA #12 came to her again and reported that CNA #12 was awful to another resident. According to the statement, CNA #12 reported that when CNA #10 was right in front of Resident #10, she stated, [Resident] stinks, can't you smell that? [Resident #10] you stink. The statement indicated LPN #13 then pulled CNA #10 aside and told her this behavior was not accepted and told her to leave. Review of a written statement, dated 09/13/2022 and signed by CNA #12, revealed CNA #12 was assisting Resident #1 with CNA #10 and the resident was crying because the resident had soiled him/herself. CNA #12 was trying to comfort the resident when CNA #10 stated, You did this to yourself so stop crying. You're pushing my limits. You pooped yourself. Additionally, the statement indicated CNA #10 was shoving the resident during repositioning. CNA #12's statement indicated a nurse was in the hall and overheard part of the conversation, and CNA #12 pulled the nurse aside to report what had happened. The statement further indicated, Right after that, I assisted [CNA #10] with [Resident #10] and CNA #10 stated the resident, stinks, can you smell that? [Resident #10] you stink. The statement indicated Resident #10, was right there when this happened. I immediately told nurse again. On 02/16/2023 at 8:52 AM, 12:00 PM, and 3:15 PM, the surveyor attempted to contact CNA #10 for a telephone interview and left messages requesting a return call. No return call was received. During an interview on 02/16/2023 at 12:50 PM, the Social Service Director (SSD) stated on the night of 09/13/2022, the charge nurse had called her stating she had been unable to reach the DON. She stated LPN #13 told her CNA #12 had observed/heard CNA #10 making unkind statements to two of the residents. She stated she was in the room when CNA #10 was interviewed on the morning of 09/14/2022 and did not think the CNA provided further information. The SSD stated she spoke with the involved residents and did not think they had concerns. The SSD was unable to provide documentation of interviews with additional residents. The SSD stated when Resident #1 was asked how staff treated them, the resident responded, good. During a telephone interview on 02/16/2023 at 1:43 PM, LPN #13 stated she was walking down the hall past Resident #1's room on 09/12/2022 when she heard CNA #10 say, You did this to yourself, you pooped yourself. She stated CNA #12 (the CNA who was assisting CNA #10) reported to LPN #13 having witnessed CNA #10 making those exact comments to Resident #1. CNA #12 also reported to the LPN that CNA #10 told Resident #10, You stink, can you smell that, you stink. The LPN stated she had not witnessed any prior episodes of abuse by CNA #10. She added that when she contacted the DON immediately after the incident occurred, the DON stated to remove the CNA from the facility immediately. The LPN stated CNA #10 did not return after being sent home that evening. According to LPN #13, neither Resident #1 nor Resident #10 appeared upset. She stated Resident #1 was asleep within an hour after the incident but did act as though something had happened. The LPN stated neither resident would have been capable of expressing their emotions. During an interview on 02/16/23 at 3:19 PM, the DON and the Administrator were asked if the facility determined abuse had occurred. They stated the investigation determined there was probable cause to believe CNA #10 had acted inappropriately, and this was the third time the CNA had caused the facility to have to self-report. They decided to terminate her. According to the DON and Administrator, skin assessments were completed on both residents, and all residents received their weekly skin assessments after the incident occurred. Additionally, the SSD interviewed the cognitively intact residents as part of the facility's investigation. As of the end of the survey on 02/16/2023, the facility had not provided documentation of interviews with cognitively intact residents conducted after the events on the evening of 09/13/2023 were provided. During a telephone interview on 02/16/2023 at 4:41 PM, CNA #12 stated Resident #1 was crying before she and CNA #10 provided incontinent care on the evening of 09/12/2022. She stated CNA #10 told the resident to stop crying because the resident pooped themself, and it was their own fault. CNA #12 added that CNA #10 had also told Resident #10, You stink, can you smell that, you stink. Review of a Staff Coaching document, dated 09/14/2022, revealed CNA #10 was terminated. The section for Reasons for Action indicated, On the evening of 09/13/2022 it was reported that you were verbally inappropriate with two residents, telling one of them one 'you stink' and telling another 'You did this to yourself so stop crying - you're pushing my limits. You pooped yourself. You were also physically rough with one of the above residents. The document indicated being verbally inappropriate as mentioned above was considered verbal abuse and being physically rough with a resident was considered physical abuse. The Corrective Actions included that the allegations were reported to the State Department of Inspections and Appeals (DIA) on the evening of 09/13/2022, and DIA had recommended that CNA #10 be sent home immediately and further recommended that CNA #10 be terminated from employment. Additionally, the document indicated the DIA would complete an investigation and determine if any charges would be brought against CNA #10. CNA #10 did not document a statement in the section of the document designated for Employee Comments. CNA #10 signed the form on 09/14/2022.

Based on observations, facility policy review, resident interviews, and staff interviews the facility failed to properly use isolation precautions while providing care, or delivering meals to Resident #22. Observations of meal trays being passed throughout the facility showed staff not wearing correct isolation precaution equipment and lacked hand hygiene before delivering trays to other residents not in isolation before and after delivering to Resident #22. The findings constituted an immediate jeopardy (IJ) to resident health and safety.The facility failed to ensure the ice cooler was covered when staff weren't present. The laundry room staff failed to follow proper procedures with keeping clean and dirty laundry separated in the laundry room. One staff member purposely exposed their face while talking to a resident by pulling down the face mask and lacked hand hygiene during personal care. The facility reported a census of 22 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #22 identified a Brief Interview for Mental Status (BIMS) score of 14, indicating cognitively intact skills for daily decision making. The MDS documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 8/29/21 at 12:21 p.m., revealed staff delivering room trays. Staff entered Resident #22's room with mask and goggles on to deliver a room tray. Resident #22's room did not have any personal protective equipment (PPE) outside of the door and lacked any signage outside of the room indicating precautions in place. Food was served on normal serving dishes. Staff left the plate for the resident and went to the meal cart without performing hand hygiene then continued down the hallway to the next room to serve meal trays until the cart was empty. The facility reported an admitted [DATE] for Resident #22. Review of the Order Summary Report dated 8/24/21 revealed an admitted [DATE]. Review of the document titled New Staff or Person Being tested dated 8/24/21 revealed Resident #22 was asked, do you have any reason to believe you have been exposed to COVID-19? Resident #22 answered no. Resident #22 was asked, have you been around anyone excluding facility residents, who have tested or was confirmed COVID-19 positive, or were pending testing results for COVID-19? Resident #22 answered no. Resident #22 was asked, do you have any new symptoms including any of the following respiratory symptoms? Cough, shortness of breath, or difficulty breathing. Resident #22 answered no. Resident was tested on [DATE] at 4:40p.m., by Staff H, RN. Resident #22 ' s result of the test was negative. On 8/29/21at 4:30 p.m., an interview with Staff D, Registered Nurse (RN) revealed there was no one in the facility on transmission based precautions (TBP). Staff D, RN revealed Resident #22 was in quarantine but not on TBP because Resident #22 was a new resident in the facility. On 8/29/21 at 4:32 p.m., an interview with Staff E, Certified Nursing Assistant (CNA) revealed there was no one in the facility on TBP at this time. Staff E, CNA revealed if there was a resident on TBP there would be a sign on the outside of the resident ' s door and staff would receive the information from the nursing staff during shift report. On 8/29/21 at 4:32 p.m., an interview with Staff F, CNA, revealed there was no one in the facility on TBP at this time. Staff F, CNA, revealed if there was a resident on TBP there would be a sign on the outside of the resident ' s door and staff would receive the information from the nursing staff during shift report. On 08/29/21 at 5:00 p.m., an interview with the Assistant Director of Nursing (ADON) revealed if someone was on TBP the type of precautions would depend on if it was a skin issue or respiratory issue. The ADON revealed if the precautions were for respiratory, she would expect staff to be using a mask, gloves, goggles, and a gown. There would be red bags for linens and garbage and would communicate with the charge nurse and send an alert out via Point Click Care (PCC) (electronic health charting system). The ADON revealed there is no specific policy relating to COVID-19. On 8/29/21 at 5:01 p.m., an interview with the Team Assistant revealed Resident #22 was tested for COVID-19 on 8/24/21 at 4:30 p.m., by Staff H, RN. Resident #22 ' s result was negative. On 8/29/21 at 5:11 p.m., an interview with the ADON revealed Resident #22 stays in her room due to her being in quarantine. The ADON revealed Resident #22 had not received the COVID-19 vaccine and had refused to receive the vaccination. She is unvaccinated and when she is off of quarantine she will have to wear a mask when she comes out of her room. Facility is going to have the physician, when he comes next, talk to her and see if she is willing to have the vaccination. The ADON stated the resident stated she had an allergic reaction to the flu vaccine and said the resident will not take any further vaccines due to that. The ADON explained staff should be wearing a gown and mask for her care. Review of Resident #22's Progress Notes on 8/29/21 revealed the following: a. Progress Note dated 8/24/2021 at 5:28 p.m., revealed discussion with Resident #22 regarding COVID vaccine. Resident #22 stated she was allergic to the flu vaccine and the doctor told her not to take any vaccines. Resident #22 is agreeable to discuss the COVID vaccine and other vaccines with the physician during recert rounds. Resident #22 prefers to not receive the vaccine at this time. Facility contacted Resident #22's family. Resident #22's family stated if Resident #22 would like the COVID vaccine that is ok with Resident #22's family. b. Progress Note dated 8/26/21 at 1:32 p.m., revealed Resident #22 continued to be in isolation for 14 days due to being a new admit. c. Progress Note dated 8/27/21 at 1:42 p.m., revealed Resident #22 remained in isolation due to being a new admit. d. Progress Note dated 8/29/21 at 2:55 p.m., revealed Resident #22 continued in quarantine. On 8/29/21 at 5:21 p.m., an interview with the Team Assistant revealed currently in the facility unvaccinated staff were being tested two times weekly and residents were tested if they were displaying any symptoms. Observation on 8/29/21 at 5:37 p.m., revealed Resident #22 laying in bed with the bedroom door wide open. Resident #22's room lacked any PPE outside of the room, signage on the door indicating the resident was in isolation or quarantine precautions, and lacked any red bins outside of the room. Observation on 8/29/21 at 6:01 p.m., revealed the ADON educating Staff D, RN and Staff G, LPN in the medication room. Observation on 8/29/21 at 6:05 p.m., revealed staff G, LPN educating Staff E, CNA. Observation on 8/29/21 at 6:09 p.m., revealed Staff G, LPN and Staff E, CNA bringing PPE gowns, gloves and masks out of a hallway to the nurses station. Observation on 8/29/21 at 6:11 p.m., revealed Staff G, LPN and Staff E, CNA bringing a table to the outside of Resident #22's room. Observation of PPE gowns and masks laid on the table outside of Resident #22's room. Observation on 8/29/21 at 6:13 p.m., revealed 2 red garbage bins were brought down to Resident #22's room and placed outside the door of Resident #22's room. Observation on 8/29/21 at 6:14 p.m., revealed Staff G, LPN disinfecting a table with drawers at the nursing station. Staff G, LPN brought down to Resident #22's room and placed outside of the door and removed the current table. Staff G, LPN placed gowns, gloves, and masks into the drawers of the table. Observation on 8/29/21 at 6:19 p.m revealed Staff F, CNA, delivering room trays with gloves on while pushing the food cart down the hallway. Staff F, did not change gloves or perform hand hygiene before delivering a room tray to Resident #12. Staff F moved Resident #12's table and stacked up soiled drinking glasses while in Resident #12's room. Staff F exited Resident #12's room and did not remove gloves or perform hand hygiene before pushing the food cart down the hallway. Staff F did not change gloves or perform hand hygiene before delivering a room tray to Resident #7. Staff F exited Resident #7's room. Staff F did not remove gloves or perform hand hygiene before pushing the food cart to Resident #22's room. Staff F did not change gloves, perform hand hygiene, or apply a gown before entering Resident #22's room. Staff F delivered the room tray to Resident #22 wearing a face mask, goggles and gloves. Staff F moved Resident #22's wheelchair, walker, pulled the tray table over to the resident's location in the room, locked the wheelchair brakes for resident to transfer into the wheelchair, moved the walker for a second time, and assisted Resident #22 into the wheelchair. While Resident #22 was transferring, Resident #22 coughed twice toward Staff F. Staff F then served Resident #22 her meal tray. Staff F exited Resident #22 s room. Staff F did not remove gloves, mask, goggles or perform hand hygiene upon exiting Resident #22's room. Staff F walked down the hallway and used a gloved hand to open a closet door and closed the door again with the gloved hand. Staff F removed soiled gloves and performed hand hygiene before walking down to the kitchen. Staff F returned with a clothing protector and walked into Resident #22's room wearing only a mask and goggles. Staff F applied the clothing protector to the resident then applied gloves. Staff F did not perform hand hygiene before applying gloves. Staff F opened Resident #22's food and then handed Resident #22 her call light and exited Resident #22's room. Once in the hallway Staff F did not remove gloves, mask, goggles, or perform hand hygiene before pushing the food cart to Resident #19's room. Staff F did not change gloves or perform hand hygiene before delivering a room tray to Resident #19. Staff F set the meal tray on a chair in front of Resident #19 and exited Resident #19's room and did not remove gloves or perform hand hygiene before pushing the food cart down the hallway. Staff F did not change gloves or perform hand hygiene before delivering a room tray to Resident #13. Staff F exited Resident #13's room and did not remove gloves or perform hand hygiene before grabbing a clean clothing protector off the food cart. Staff F entered Resident #13's room and handed the clothing protector with gloved hands to Resident #13. Staff F exited Resident #13's room and did not remove gloves or perform hand hygiene before pushing the food cart down the hallway. Staff F removed gloves and performed hand hygiene before entering Resident #3's room. Staff F placed the meal tray on the bedside table and spilled a drink onto the floor. Staff F picked up the cup with bare hands, exited Resident #3's room and placed it beside the clean clothing protectors on the bottom of the food cart. Staff F cleaned up the spill and performed hand hygiene. Staff F entered Resident #3's room applied gloves and took the covering off Resident #3's food. Staff F did not remove gloves or perform hand hygiene before picking up a clean clothing protector off the bottom of the food cart, unfolded it, grabbed another clothing protector, and put the first one back on the pile of clean clothing protectors. Staff F gave a clothing protector to Resident #3 then exited the room and did not remove gloves or perform hand hygiene. Staff F did not change gloves or perform hand hygiene before delivering a room tray to Resident #11. Staff F placed the meal tray on the bedside table. Staff F removed gloves, did not perform hand hygiene, and picked up Resident #11's bed control. Staff F assisted Resident #11 to an upright position and then assisted Resident #11 with a clothing protector and adjusted pillows for positioning. Staff F exited Resident #11's room and did not perform hand hygiene before pushing the food cart down the hallway. Halfway down the hallway Staff F stopped and performed hand hygiene and then pushed the cart to the end of the hallway. Observation on 8/29/21 at 6:38 p.m., revealed the Director of Nursing (DON) providing education on TBP to Staff F, CNA. On 8/30/21 at 8:22 a.m., an interview with Staff H, RN revealed the facility had one resident in isolation. Resident #22 was on COVID precautions since she was a new admission. Observation on 8/30/21 at 8:30 a.m., revealed Resident #22's door cracked open with a sign on the door stating isolation precautions - see nurse please. A further observation revealed 2 red bins outside Resident #22's door as well as a box of gloves laying on top of the 3 drawer table next to the door. On 08/30/21 at 8:40 a.m., an interview with Staff I, Housekeeper, revealed there was a resident on isolation precautions in the building. Resident #22's room was the last room that she cleans. Staff I, Housekeeper, stated that she wears a gown, gloves, mask, and goggles. Staff I, Housekeeper, reported the garbage goes in the bins outside the door. Staff I, Housekeeper, revealed laundry goes in the red bin outside the door as well. On 8/30/21 at 8:47 a.m., an interview with Staff J, CNA, revealed Resident #22 was on isolation precautions due to being a new resident. Staff J, stated she needed to wear full PPE which included a gown, gloves, mask, and goggles. On 08/30/21 at 8:55 a.m., an interview with Resident #22 revealed the staff was wearing some type of covering when they came into her room. Resident #22 did not know what exactly the covering was or what it was for. Observations of disposable containers for meals were noted in the room. On 8/30/21 at 9:00 a.m., an interview with Staff K, Laundry, revealed there was one resident with isolation laundry. All isolation laundry was done last and was bagged in a red bag. Staff K revealed if there was an aide in the room when she was delivering laundry, she has them put it into the resident's room. Otherwise if Staff K needed to enter the room she wears a gown, googles, gloves, and a mask. On 8/30/21 at 9:03 a.m, an interview with Staff L, Maintenance, revealed Resident #22 was on isolation precautions. Staff L stated if he needed to go into the resident's room he would wear a gown, gloves, mask, and goggles. Review of Resident #22's Progress Notes on 8/30/21 revealed the following: a. Progress Note dated 8/29/21 at 10:14 p.m., revealed Resident #22 continued with her 12 day new admission isolation at this time. b. Progress Note dated 8/30/21 at 10:06 a.m., revealed follow-up COVID-19 test completed today. Resident #22 denied any symptoms, and test results were negative. c. Progress Note dated 8/30/21 at 3:37 p.m., late entry for 8/24/21 at 3:26 p.m., revealed COVID test was completed upon admission and documented on a testing form used for staff testing. The results were negative. Observation on 9/1/21 at 11:07 a.m., revealed 4 yellow disposable gowns hanging on the hallway on hooks outside of Resident #22's room. On 9/1/21 at 11:12 a.m., an interview with Staff M, Certified Restorative Aide/Certified Nursing Assistant (CRA/CNA), revealed the gowns in the hallway were the gowns that staff used for the day with the isolation resident. Staff M, CRA/CNA, stated that the gowns looked like they had all been worn and was sure that they were worn for Resident #22. On 9/1/21 at 11:15 a.m., an interview with the Administrator revealed the facility did not have a gown shortage. The Administrator stated the facility had plenty of gowns to use. The Administrator stated the facility staff use the gown for the day and then the facility staff throw them away at the end of the shift. The Administrator stated during their COVID-19 outbreak they would use the same gown for the day and then at the end of the shift they would toss them. The Administrator stated moving forward the facility staff will be using a new gown each time they go into Resident #22's room or any other isolated resdient's rooms. Centers for Disease Control and Prevention website titled,Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, visited 8/29/21, revealed all unvaccinated residents who are new admissions and readmissions should be placed in a 14-day quarantine, even if they have a negative test upon admission. Guidance addressing recommended PPE when caring for residents in quarantine is described in Section: Manage Residents who had Close Contact with Someone with [CONDITION(S)]-CoV-2 Infection revealed Unvaccinated residents who have had close contact with someone with [CONDITION(S)]-CoV-2 infection should be placed in quarantine for 14 days after their exposure, even if [CONDITION(S)] testing is negative. Health care providers caring for them should use full PPE (gowns, gloves, eye protection, and N95 or higher-level respirator). Centers for Disease Control and Prevention website titled, Strategies for Optimizing the Supply of Isolation Gowns, visited 9/1/21 and updated 1/21/21, revealed once PPE supplies and availability return to normal, healthcare facilities should promptly resume conventional practices. Conventional capacity is described as measures consisting of engineering, administrative, and PPE control that should already be implemented in general infection prevention and control plans in healthcare settings. Conventional Capacity Strategies include nonsterile, disposable patient isolation gowns, which are used for routine patient care in healthcare settings, are appropriate for use by health care personnel when caring for patients with suspected or confirmed COVID-19. Review of facility policy titled Pandemic Policy and Procedure updated 8/26/2021 revealed during a pandemic, it is extremely important to practice good hygiene practices. Hand hygiene is critical to controlling the spread of infectious diseases. Practice disinfection of contaminated surfaces, hand hygiene (including alcohol- based hand rubs and hand washing) and respiratory hygiene (cover your cough and wear face masks and shields). During an extreme pandemic, face masks and shields may be required for staff to help stop the spread of the virus. It is imperative that you use proper PPE during a pandemic and use it correctly. This is for the safety of our residents and other staff members. Under the Procedure heading revealed the following steps: a. Certain clinical syndromes and conditions carry sufficiently high risk to warrant the addition of enhanced precautions while a more definitive diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . b. Explain to the resident, type and need for precautions. Educate as to the precautions the resident needs to use. c. Identify the type of precaution with interventions on the resident's care plan and nurse aide care instructions. d. Notify all departments of resident name and type of precautions to use. Identify any special needs required by the specific resident. e. Place a sign outside the resident's room identifying the need to check at the nurse's station prior to entering the room. f. If an isolation- stocked with gloves, gowns, masks, and clear or red bags, is available,place outside the resident's door. Under Hand Hygiene and Gloves section it revealed failure to change gloves between residents is an infection control hazard. 2. Observation on 9/7/21 at 2:40 p.m., the facility ice cart was noted to be in the 100 hallway sitting in the middle of the hallway uncovered. A further observation revealed the ice cart was about ½ full of ice with the ice scoop laying inside the cooler on top of the ice. No staff was present with the ice cooler during observation. On 9/15/21 at 1:43 p.m., an interview with the Administrator revealed he would expect the ice cart to be covered. That's why the facility has a cooler and the ice scoop should not be in the cooler. 3. Observation on 8/30/21 at 9:00 a.m., an interview with Staff K, laundry revealed the laundry comes in and out of the same door. Staff K, laundry revealed the door by the dryer is used to take the soiled laundry in and take the clean clothing out of. Further observation of the laundry room revealed a black fan noted to have brown debris on the front of the fan blowing from the washer towards the clean clothing. Noted a clean clothing covered cart and the dryer was across the room. On 8/31/21 at 11:01 a.m., an interview with the Laundry Supervisor revealed laundry should come in the door by the washer and out the doorway by the dryer. All laundry was washed on the isolation cycle. The Laundry Supervisor revealed the staff should not be using the soiled fan in the laundry room. 4. Observation on 9/7/21 at 1:10 p.m., revealed Staff N, CNA, assisting Resident #4 from the dining room to the shower room. Staff N stated Resident #4 was hard of hearing and Staff N needed to pull her mask down so Resident #4 could read her lips. Staff N did not perform hand hygiene prior to assisting Resident #4. Staff N applied the gait belt to Resident #4 and removed the foot pedals from the wheelchair. Staff N did not perform hand hygiene before assisting Resident #4 into a standing position with the gait belt. Resident #4 stood hanging onto the grab bar while Staff N let go of the gait belt and stood behind Resident #4. Then with bare hand pulled down Resident #4's pants and depends. Staff N did not perform hand hygiene and grabbed onto the portable commode. Staff N assisted Resident #4 into a sitting position on the commode. Staff N did not perform hand hygiene. Staff N locked the brakes on the portable commode, and handed Resident #4 the call light. Staff N then pulled her mask down exposing her nose and mouth to tell Resident #4 to call when she was done. Resident #4 nodded with understanding. Staff N pulled her mask up covering her nose and mouth. Staff N did not perform hand hygiene. Staff N pulled the privacy curtain and stood behind the curtain to provide privacy. Resident #4 pulled the call light and Staff N came from behind the curtain. Staff N, did not perform hand hygiene and applied gloves and assisted Resident #4 to a standing position and provided perineal care for Resident #4. Staff N removed gloves and did not perform hand hygiene before pulling up Resident #4's pants and assisting Resident #4 back into the wheelchair. Staff N did not perform hand hygiene. Staff N placed the wheelchair pedals back on the side of the wheelchair, then placed Resident #4 ' s legs back onto the pedals, opened the privacy curtains, and with a bare hand opened the door. Staff N did not perform hand hygiene before pushing Resident #4 back into her room. Staff N moved Resident #4's bedside table next to her and handed the resident her call light. Staff N pulled down her mask exposing her nose and mouth, then told Resident #4 if she needed something to use her call light. Resident #4 nodded in agreement. Staff N pulled her mask up covering her nose and mouth. Without completing hand hygiene, Staff N walked to the shower room and performed hand hygiene then applied gloves to empty the portable commode. On 9/7/21 at 1:28 p.m., an interview with the Administrator revealed there are no residents with special communication needs in the facility. On 9/8/21 at 6:57 p.m., an interview with the DON revealed the facility did not have any residents that staff should be taking their masks down to speak to. The DON revealed there are some who are hard of hearing but staff should not be taking their masks down to talk to the residents. The DON expects staff to keep their masks up at all times. The DON stated she expects staff to be washing their hands prior to assisting residents and wearing gloves when doing care with residents. The DON also stated she expects the staff to wash their hands after removing gloves. Centers for Disease Control and Prevention website titled, Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic, visited 9/7/21 and updated 2/23/21, revealed Healthcare Personnel (HCP) should wear well-fitting source control (use of well-fitting face masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing) at all times while they are in the healthcare facility. The website further revealed, if worn properly a facemask helps block respiratory secretions produced by the wearer from contaminating other persons and surfaces. Review of facility policy titled Infection Control Precautions Guidelines dated 12/16 revealed transmission based precautions are used for residents who are known to be, or suspected of being infected or colonized with infectious agents, including pathogens that require additional control measures to prevent transmission. The standard approaches, as defined by the CDC for transmission-based precautions will be used. Guidelines for transmission-based precautions (isolation) include the following, to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order for transmission will specify the type of isolation and reason for isolation. The duration will depend on the organism involved. Review of facility policy titled Infection Control Program undated revealed Preventing the Spread of Infection, the facility will require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. Review of the facility policy titled Hand Washing Techniques undated revealed the procedure is to wash hands before and after resident contact, after contact with a source of microorganisms (body fluids and substances, mucous membranes, non intact skin, inanimate objects that are likely to be contaminated, and after removing gloves. Under the heading Gloves revealed gloves should be used for hand-contaminating activities. Gloves should be removed and hands washed when such activity is completed, when the integrity of the gloves is in doubt and between residents. Gloves may need to be changed during care of a single resident for example moving from one procedure to another. Disposable gloves should be used only once and should not be washed for reuse. The facility was notified of the IJ on 8/29/21 per phone call at 5:50 PM and given the IJ template at 6:00 PM. The facility provided education to the staff of the need for Transmission Based Precautions for newly admitted residents who are unvaccinated for COVID-19. Staff were educated on the appropriate PPE when going into a residents room that may potentially have COVID-19. PPE supplies and sign posted outside resident room as a reminder of how to don and doff PPE. Staff were educated on the use of hand sanitizer. Education provided on the need for disposable serving dishes used for residents on transmission based precautions. The immediate jeopardy was removed on August 29, 2021 after the surveyor verified implementation of the removal plan. The scope and the severity was lowered to a F.

Based on clinical record review, policy review and staff interview the facility failed to develop comprehensive care plans for 4 of 16 residents reviewed for comprehensive care plans (Resident #1, #4, #5 and #7). The facility reported a census of 22 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed Resident #1 had taken anti-anxiety medication and diuretic medication the last 7 out of 7 days during the review period`. Review of the Care Plan with a revised date of 6/7/21 lacked any documentation pertaining to the residents usage and side effects to watch for with diuretic medication and interventions to use prior to giving anti-anxiety medication. 2. The MDS assessment dated [DATE] for Resident # 5 identified a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impairment. The MDS documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed Resident #5 had taken antibiotic medication and opioid medication the last 7 out of 7 days during the review period. Review of the Care Plan with a revised date of 8/26/21 lacked any documentation of opioid pain medication usage and side effects to watch for with opioid medications and prophylactic antibiotic usage. 3. The MDS assessment dated [DATE] for Resident # 7 identified a BIMS score of 15 indicating no cognitive impairment. The MDS documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed Resident #7 had taken opioid medication the last 7 out of 7 days during the review period. Review of the Care Plan with a revised date of 8/26/21 lacked any documentation of opioid pain medication usage and side effects to watch for with opioid medications. 4. The MDS assessment dated [DATE] for Resident #4 identified a BIMS score of 10 indicating moderate cognitive impairment. The MDS documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed Resident #4 required extensive assist of 2 staff for toileting. Observation on 9/7/21 at 1:10 p.m., revealed Staff N, CNA, assisting Resident #4 from the dining room to the shower room. Staff N applied the gait belt to Resident #4 and removed the foot pedals from the wheelchair. Staff N assisted Resident #4 into a standing position with the gait belt. Resident #4 stood hanging onto the grab bar while Staff N let go of the gait belt and stood behind Resident #4. Then with bare hand pulled down Resident #4's pants and depends and grabbed onto the portable commode. Staff N assisted Resident #4 into a sitting position on the commode. Staff N locked the brakes on the portable commode, and handed Resident #4 the call light. Staff N then pulled her mask down exposing her nose and mouth to tell Resident #4 to call when she was done. Resident #4 nodded with understanding. Staff N pulled her mask up covering her nose and mouth. Staff N pulled the privacy curtain and stood behind the curtain to provide privacy. Resident #4 pulled the call light and Staff N came from behind the curtain. Staff N applied gloves and assisted Resident #4 to a standing position and provided perineal care for Resident #4. Staff N removed gloves and did not perform hand hygiene before pulling up Resident #4's pants and assisting Resident #4 back into the wheelchair. Staff N placed wheelchair pedals back on the side of the wheelchair, then placed Resident #4's legs back onto the pedals, opened the privacy curtains, and with a bare hand opened the door. Staff N pushed Resident #4 back into her room. Staff N moved Resident #4's bedside table next to her and handed the resident her call light. Review of Resident #4's Care Plan dated 8/26/21 revealed for toileting assistance Resident #4 required 2 caregivers in the shower room to stand at the grab bar, place the commode or shower chair behind her. The bedpan is used for as needed toileting. Review of the Care Area Assessment Worksheet revealed staff is to toilet Resident #4 in the shower room where she uses the garb bar to pull herself up with assistance. On 9/9/21 at 9:02 a.m., an interview with the Assistant Director of Nursing (ADON) revealed the care plans should have the information about medications and side effects listed in them. The ADON revealed there is no policy on care plans. On 9/15/21 at 1:43 p.m., an interview with the Administrator revealed he would expect the care plans to be followed.

Based on observations, policy review and staff interviews, the facility failed to discard expired medications and ensure proper labeling for medications in 1 of 1 medication carts and 1 of 1 medication storage room observed. The facility reported a census of 22. Findings include: Observation on 8/30/21 at 2:51 p.m., revealed the medication cart contained the following medications stored and ready for use: a. Resident #10's Senna 8.6 mg tablet with an open date of 8/13/21 lacked a proper label on the bottle to identify medication as Resident #10's. b. Resident #11's bedtime [MEDICATION(S)] with an open date of 7/30/21 and discard date of 8/26/21. c. Resident #19's bottle of Tums with a piece of paper taped onto the bottle with Resident #19's name. The bottle lacked proper labeling and had an expiration date of July 2021. d. Resident #22 1. Open bottle of aspirin 81mg lacked a proper label on the bottle to identify medication as Resident #22's. 2. Open box of [MEDICATION(S)] AD 2 mg tablets lacked a proper label on the bottle to identify medication as Resident #22's. 3. Open bottle of [MEDICATION(S)] 4mg lacked a proper label on the bottle to identify medication as Resident #22's. 4. Open bottle of acetaminophen 500mg lacked a proper label on the bottle to identify medication as Resident #22's. In addition, the observation of the medication storage room revealed the following expired medications stored and ready for use and medications lacking the the proper label to identify medication as a residents: a. Resident #5 1. Milk of Magnesia with an expiration date of 10/13/20. 2. Ready to use enema with an expiration date of 10/13/20. b. Resident #16's ready to use enema with an expiration date of 3/15/21. c. Resident #10's oral [MEDICATION(S)] suspension with a discard date of 6/30/21. d. Resident #2's fast acting dairy aid contained 66 tablets with an expiration date of 1/21. e. Resident #3 1. Open bottle of [MEDICATION(S)] lacked a proper label on the bottle to identify medication as Resident #3's. 2. Open bottle of acetaminophen 500mg tablets lacked a proper label on the bottle to identify medication as Resident #3's. 3. Open bottle of Nature made D3- 2000 iu lacked a proper label on the bottle to identify medication as Resident #3's. f. Resident #23 passed away on 6/15/21 per facility report. The following medications were in the medication room ready for use: 1. [MEDICATION(S)] and [MEDICATION(S)] with an expiration date of 11/28/20 with seven vial opens. 2. 4 unopened packages of [MEDICATION(S)] and [MEDICATION(S)] expired 1/13/21 with 2 vials open. 3. Unopened bottle of 90 capsules of tamsulosin 0.4 mg. 4. 2 unopened bottles of 100 count multivitamin with minerals. 5. Open bottle of multivitamin with minerals. 6. Unopened bottle of 100 count [MEDICATION(S)] SL 0.4mg. 7. Unopened bottle of 90 count Losartan/HCTZ 100/12.5 mg. 8. 6 unopened bottles of 60 count [MEDICATION(S)] 400 mg. 9. Open bottle of [MEDICATION(S)] tablets. 10. Unopened bottle of [MEDICATION(S)] 50 mg tablets. 11. Unopened bottle of acetaminophen 325mg. 12. Unopened bottle of [MEDICATION(S)] 40mg . 13. Open bottle of [MEDICATION(S)] 5mg. 14. Open bottle of Calcium/D3 tablets. 15. Open bottle of [MEDICATION(S)] 300 mg capsules. 16. Open bottle of [MEDICATION(S)] 1000mg. Review of facility policy titled Medication Labeling and Storage, undated revealed labels should be typewritten and firmly affixed to the outside of the container. The label of the residents unit dose medications should contain: resident's name, resident's room number and bed number, name of medication and direction for use. Containers having no labels are destroyed in accordance with state and federal laws. On 8/30/21 at 3:29 p.m. an interview with the Director of Nursing revealed she would not expect the facility to have expired medications and unlabeled medications in the medication carts or the medication rooms.

Based on facility record review and staff interviews, the facility failed to ensure the facility's Dietary Service Manager had the required qualifications in the absence of a full-time dietitian. The facility reported a census of 22 residents. Findings include: On 8/29/21 at 11:55 a.m., an interview with the Dietary Manager (DM) revealed she did not have her Certified Dietary Manager certification. She is currently enrolled in the class and had recently received an extension for the completion of the class. The facility reported a hire date for the DM of 2/11/2019. A document titled Director of Dietary Services with a revised date of 12/2/94 revealed the DM requirements include completion of a state approved food service supervior's course and the DM assumes responsibility for overall dietary department compliance with governmental regulation and sanitation requirements. On 9/9/21 at 10:58 a.m., an interview with the Administrator revealed the DM should have her certification.

Based on observations, staff interviews, and facility policy reviews the facility failed to have sanitizable cutting boards, ensure food was stored and prepared under sanitary conditions and ensure that food was served under sanitary conditions. The facility identified a census of 22 residents. Findings include: 1. An initial kitchen tour conduct on [DATE] at 11:11 a.m., revealed the following observations: a. Open gallon of Blue Bunny ice cream in the freezer with no open date. b. Open bag of chicken chunks in the freezer with no open date. c. Open container of sour cream with no open date. d. Sliced yellow cheese in saran wrap with no open date. e. Open jar of better than bouillon with no open date and best by date of [DATE]. f. Open container of freeze dried chive with no open date and use by date of ,d+[DATE]. g. Open box of baking soda with no open date. h. Open bag of walnut halves and pieces with no open date and use by date of [DATE]. i. Open gallon of 1% milk with no open date. j. Freezer labeled Unit 1 freezer revealed the freezer to have approximately ½ inch of ice and frost build up on the top of the freezer, the top and bottom of the first shelf and the top and bottom of the third shelf in the freezer. k. 5 cutting boards, showed visible deep grooves, discoloration and a fuzzy surface on all boards. l. 2 chest deep freezers revealed ice build up around all 4 edges of the freezer. m. Dinner plates, small plates and bowls noted to have chips in the edges of the dishes. n. Clear plastic food covers noted to have cracks, and chips in the top opening. 2. Observation on [DATE] at 12:01 p.m., revealed Staff A, Dietary Cook serving the main dining room plates. Staff A, Dietary Cook picked up a breadstick with a bare hand and placed it onto the plate and the plate was served to a resident. Staff A, Dietary Cook continued to the next plate without sanitizing or wearing gloves and served the next resident. Staff A, Dietary Cook continued to do this for 7 residents until Staff B, Dietary Aide (DA) came into the kitchen and laid a set of tongs on the breadsticks for Staff A, Dietary Cook to use to serve. Staff A, Dietary Cook finished serving breadsticks with the tongs to the remaining residents. 3. Observation on [DATE] at 12:14 p.m., revealed room trays in the kitchen on the serving cart with pineapple upside down cake on the trays with a scoop of whip topping uncovered. Staff B, DA pushed the room tray cart out of the kitchen into the hallway uncovered. Staff B, DA finished loading room tray carts and called for nursing staff to let them know room trays were ready. Pineapple upside down cake with whip topping continued to be uncovered. Observation at 12:18 p.m., revealed room trays being pushed down the hallway with no cover over the pineapple upside down cake with whipped topping. Observation on [DATE] at 12:21 p.m., revealed a cart leaving the kitchen with pineapple upside down cake with whip topping on leaving the kitchen uncovered. The cart was pushed down the hallway and into the dining room where the dessert was served to each resident in the dining room. Observation on [DATE] at 12:26 p.m., revealed room trays being served in the 200 hallway with the pineapple upside down cake with whip topping uncovered on the cart and a tray being served to a resident in their room with no covering. Review of the facility policy titled Food Storage revealed all items must be covered, labeled, and dated. All foods that have been opened and partially used shall be dated and sealed before returning to a food storage area. Store all open packages in closed and labeled containers. Defrost freezer on a regular basis to maintain proper functioning. Review of the facility policy titled Sanitary Conditions, undated, revealed food that is transported to the resident needs to be covered to maintain temperature and protect from other contaminants. On [DATE] at 11:55 a.m., an interview with the Dietary Manager (DM) revealed food should be labeled with open dates and there should not be any expired food in the kitchen. The freezers should have been defrosted but she had gotten behind on defrosting the 3 freezers. She revealed that she agrees the dishes, cutting boards and clear plastic food covers are unable to be sanitized due to the chips, cracks and surfaces of the items. On [DATE] at 12:46 p.m., an interview with the Administrator revealed Staff A, Dietary Cook should not have used her bare hands to put the breadstick onto the plate and the dessert should have been covered for the room trays.

Based on record review and interview, the facility failed to have the minimum amount of required persons for their quarterly Quality Assessment and Assurance (QAA) by not having the Medical Director present to the meeting on 3/26/21. The facility reported a census of 22. Findings include: A document entitled QA Signature Page dated 3/26/2021 had no signature for the Medical Director. During interview on 9/9/21 at 12:05 PM the Assistant Director of Nursing (ADON) stated she did not know why the facility didn't do QAA during the months prior. He was here every 60 days and we were talking with him throughout, we just don't have record of it.

Based on personnel file reviews, facility policy review and staff interviews the facility failed to obtain an evaluation by the Department of Human Services (DHS) prior to hire to determine if an employee with a criminal history could work in the facility for 1 of 5 current employees sampled (Staff C). The facility identified a census of 22. Findings include: The personnel file for Staff C, dietary, documented a hire date of 8/6/2015. The Single Contact License and Background Check(SING) dated 7/27/2015 indicated a possible criminal hit for Staff C, which required the Department of Criminal Investigation (DCI) to clarify if the prospective employee did or did not have a criminal history. The personnel record lacked the documentation that further research from DCI had been completed. On 9/9/21 at 10:59 a.m., an interview with the Administrator revealed the background check for a possible criminal hit for Staff C was not completed. The Administrator revealed the facility was going to run another SING check immediately. On 9/9/21 at 11:16 a.m., the facility completed a SING check on Staff C. The SING dated 9/9/2021 indicated a possible criminal hit for Staff C which required the DCI to clarify if the prospective employee did or did not have a criminal history. Review of facility policy titled Abuse Prevention and Identification Screening and Reference Review with a revised date of 5/24/2017 revealed the facility will complete a criminal background check per standardized rules promulgated prior to hire. The result of the check will be kept by the Administrator or the Human Resource Department. Upon satisfying that the individual is eligible for hire upon completion of the reference check, nurse aide or licensor status and criminal background checks, the facility may continue the hiring process. Negative findings in checks conducted will make an individual ineligible for hire until the area of concern is clarified. On 9/9/21 at 11:26 a.m., an interview with the Administrator revealed Staff C, is currently not working and Staff C, dietary will not be working until DCI completes their review.

Based on record review and staff interview, the facility failed to provide 3 of 3 residents discharged from skilled level of care (LOC) with the required forms for Medicare Liability Notices and Beneficiary Appeals at least 48 hours before discharge from care (Resident #6, Resident #12, and Resident #21). The facility reported a census of 22 residents. Findings Include: 1) Review of the clinical record for Resident #6 revealed the resident had Skilled Services starting on 3/19/21 and services ended on 3/26/21. The form was signed by Resident #6's Power of Attorney (POA) on 3/27/21, the day after skilled services had ended. 2) Review of the clinical record for Resident #12 revealed the resident had Skilled Services starting on 5/27/21 and ending on 6/9/21. On form CMS- Resident #12 chose option 2 stating she wanted services and acknowledges that Medicaid won't be billed. The signature on this form was dated 5/27/21 when she began services. 3) Review of the clinical record for Resident #21 revealed the resident had Skilled Services starting on 3/3/21 and services ended on 3/19/21. The form was signed by Resident #21 on the end date of 3/19/21. Interview with the Assistant Director of Nursing (ADON) revealed that they were aware of the problem and had a self-correction form. Since the time of correction, they have not had anyone come off skilled care. The Self-Identification form revealed the problem was identified on 7/16/21.

Based on clinical record review and staff interview the facility lacked a discharge summary including a recapitulation of a resident's stay for 1 of 1 resident reviewed for discharged , (Resident #6). The facility reported a census of 22 residents. Findings include: The electronic chart in Point Click Care (PCC) revealed Resident #6 was discharged with personal belongings, inventory sheet was signed, vital signs were taken, skin was intact, lungs were clear and discharged to another facility by personal vehicle with family. PCC also revealed that report was called to receiving nursing home and medications were returned to pharmacy. Documentation lacked activities of daily living (ADL), communication, behavior patterns, diagnoses, activities, routines, and nutritional status. During interview on 9/8/21 at 10:36 AM the Administrator stated all they had for recapitulation of stay was the discharge summary.

Based on resident record review, staff interview and facility record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one resident, (Resident #13). The facility reported a census of 31 residents. Findings include: According to the Minimum Data Set with assessment reference date 6/16/17 Resident #13 had a BIMS score of 10, moderately impaired cognitive skills for daily decision making, and had [DIAGNOSES REDACTED]. Resident #13 was frequently incontinent of bowel and bladder. The Nurses Notes dated 6/28/17 had a late entry for 6/27/17 that documented while on an activity outing to Smith Lake Staff C Registered Nurse (RN) and the Activity Director attempted to transfer Resident #13 to the toilet with gait belt. As the resident was being pivoted her knees gave out and the resident was slowly lowered to the floor between the toilet and wheelchair with legs flexed and weight on her left hip, not sitting on her ankles or feet. The resident complained of pain but did not holler out in extreme pain. A full assessment was not done as not able to due to the residents position. The resident did move bilateral legs with minimal pain. Staff C, the activity director and the maintenance man positioned a hoyer sling under the resident and she was assisted up and positioned in the wheelchair. The resident did not complain of pain during the transfer. The resident was wheeled in her wheelchair to the shelter house and ate lunch and took her medication. The resident sat quietly with no complaints of pain. At 1:00 p.m. the resident returned to the facility and was taken to her room. Staff C reported the incident to the Charge Nurse. An assessment of the resident legs was completed with no bruising,swelling redness or deformity noted. At 6:20 p.m. the resident stated she felt sick and did not want her supper. The residents husband took her back to her room and staff transferred her to bed via hoyer lift. A registered nurse assessed the resident at 7:00 p.m. and found a large bruise to the right lower leg and a slightly swollen left ankle, warm and tender to the touch and red/pink in color. At 7:30 p.m. the resident was transferred by ambulance to the hospital. At 11:30 p.m. the hospital called and the resident was being transferred to another hospital to see an orthopedic doctor. The History and Physical Final Report dated 6/29/18 noted the resident had a left distal tibia and fibula fractures. The X-rays were discussed with the patients family and conservative treatment recommended due to the patient being non-ambulatory and concerns with poor bone quality and wound healing. The family and patient were in agreement and the resident was placed into a well padded plaster cast. A Therapy Alert dated 8/5/16 noted Resident #13 was a hoyer lift for all transfers. Resident #13's Care Plan with target goal date of 6/26/17 included the intervention; care giver assist of 2 for repositioning and hoyer transfers. During interview on 9/18/18 at 11:40 a.m. Staff C stated she was out with activity at Smith Lake. She helped take Resident #13 to the bathroom with the Activity Director. During pivot transfer the resident stopped bearing weight and they lowered her to the floor easily with gait belt. She does not recall her complaining of pain. She did an assessment as able, doesn't think she saw anything. Staff C had Maintenance staff come in and the three of them lifted Resident #13 into the wheelchair, she could not recall if they used a sling or gait belt with this transfer. She did not recall any complaints of pain with that transfer. When returned to the facility she reported to the charge nurse what happened and that the resident should be assessed. Staff C did not recall how the resident transferred prior to incident at the lake, she works at the facility prn, maybe two times a month. During interview on 9/18/18 at 1:10 p.m. the Activity Director stated Resident #13's family saw the outing on the activity calendar and thought it would be a good idea for the resident to go. The resident had gone on other outings but not any that long. This was fishing and lunch then to return to the facility. The resident had been saying over and over she had to go to the bathroom, the nurse (Staff C) made the decision to pivot transfer into the bathroom. They used a gait belt and the two of them stood her up and when they were pivoting her she kept saying I can't stand, the resident stopped bearing any weight and they put here down easily. It was so long ago but does not recall her complaining of any pain, just remembered her saying over and over that she could not stand when they were pivoting her. She did not think the resident was assessed until they returned to the facility. At this time they were trying to figure out how to get her up off the floor, the resident was able to straighten out her legs. The Maintenance Man came and helped them. They completely lifted her up and placed in her in the wheelchair. Then they went and ate lunch. The resident did not appear uncomfortable. They came back to the facility after the meal. She told facility staff what happened and the charge nurse assessed here. The Activity Director stated she did wonder to her self what they would do if the resident needed to go to the bathroom when they were out but did not say anything to anyone. She does not usually work on the floor and does not routinely transfer Resident #13. Review of facility records showed Staff C and the Activity Director were issued verbal counseling on 6/27/17 for not following resident #13's Care Plan for transfers. During interview on 9/18/18 at 1:30 p.m. the Administrator stated Resident #13 went on the activity because her husband wanted her to go. The facility had asked their daughter and she agreed if her Dad wanted her to go she should go. He stated he does not think the thought of toileting the resident out of the facility was even thought about. During interview on 9/19/18 at 8:15 a.m. the ADON stated at the time of the incident the facility did not have a policy in place for residents requiring hoyer transfers and going out of facility for activities. The facility provided a policy titled Resident Outings created (MONTH) 28, (YEAR), to ensure: a. Resident's safety on planned outings. b. Ensure resident's needs are met and Care Plans followed during planned outings.