HENDERSON HEALTH & REHABILITATION CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a clean, sanitary, comfortable, and homelike environment for 1 of 8 residents (Resident #2) in that:<BR/>1. <BR/>Resident #2's window, window blinds, and floor around his bed were soiled with visible dust, dirt, debris, and smudges.<BR/>2. <BR/>Resident #2's bed sheets and pillowcase had scattered brown stains on them.<BR/>This failure placed residents residing in the facility at risk for a diminished quality of life and a diminished clean, homelike environment.<BR/>The findings include:<BR/>Review of Resident #2's undated face sheet revealed he was a [AGE] year-old male readmitted to the facility on [DATE] with a primary diagnosis hemiplegia and hemiparesis following cerebral infarction of left non-dominate side (weakness or paralysis on one side of the body) and secondary diagnoses of cognitive or emotional deficit and aphasia (impaired ability to comprehend or formulate language).<BR/>Review of a quarterly MDS assessment dated [DATE] indicated Resident #2 had a BIMS score of 3 which indicated severe cognitive impairment and he required total assistance with oral hygiene, toileting hygiene, shower/bathing, lower body dressing, putting on/taking off footwear, and personal hygiene; he required maximum assistance for upper body dressing; he required setup and clean up assistance with eating. He was always incontinent of bowel and bladder.<BR/>A comprehensive care plan revised on 10/03/24 indicated Resident #2 exhibited verbal and physical aggressive behaviors with interventions in place including approaching and speaking to resident in a calm manner, clearly explaining all daily care activities, and early intervention when resident behaviors were escalating. Resident #2 had a history of violent behaviors and had hit staff at the facility on multiple occasions. The same comprehensive care plan included a revision on 12/05/25 which indicated Resident #2 had an ADL self-care performance deficit related to contracture of left hand, limited range of motion in upper and lower extremities, and hemiplegia/hemiparesis.<BR/>An observation on 3/24/25 at 11:36 AM of Resident #2's room revealed there were scattered brown stains on his sheets and pillowcase. The window in his room had green and brown smudges on the glass and the window blinds had an accumulation of dust on them. The floor around his bed had an accumulation of dirt and debris.<BR/>During an interview on 3/24/25 at 11:36 AM, Resident #2 said facility staff did change his bed linens and clean his room, but not daily.<BR/>During an interview on 3/24/25 at 11:45 AM Housekeeper C said all resident rooms were cleaned every day. She said the daily cleaning consisted of cleaning the restroom, wiping down all surfaces, sweeping and mopping the floors, and taking out the trash. She said she doesn't always clean behind resident beds or underneath them because she would need help to move the beds away from the wall. She said Resident #2 never exhibited any violent behaviors that interfered with housekeeping staff's ability to clean his room, and his room had already been cleaned today.<BR/>An observation on 3/25/25 at 9:00 AM Resident #2's room revealed what appeared to be the same soiled bed linens and pillowcase on his bed. The floor, window, and window blinds appeared to have not been cleaned from previous observation. <BR/>During an interview on 3/25/25 at 9:45 AM Housekeeper D said every resident room was cleaned daily and a daily cleaning included wiping down all surfaces, sweeping and mopping floors, and taking out the trash. Housekeeper C said she had enough time to complete all assigned duties and no resident behaviors had ever affected her ability to clean their rooms. <BR/>During an interview on 3/25/25 at 10:05 AM, CNA E said the facility had been having problems running out of clean linens in the morning. She said sometimes she had to delay changing bed linens until laundry staff washed more linens. <BR/>During an interview on 3/25/25 at 10:30 AM, EVS Manager said housekeepers were expected to clean each resident's room daily, which consisted of taking out the trash, wiping down all surfaces, and sweeping and mopping floors. She said, additionally, each housekeeper was assigned one room daily to be deep cleaned. She said a deep clean was cleaning everything in the room and it was also done for new resident admissions. She said CNAs were bringing soiled linens to the laundry room too late in the day to be washed and ready for the next morning, because laundry staff left at 2:00 PM. She said linens were provided late some days, but there was always clean linen available to accommodate resident needs.<BR/>During an interview on 3/25/25 at 11:00 AM, the ADON said the facility had identified an issue with their laundry processing. The ADON said CNAs recently changed to a 12-hour shift, and left at 6:00 PM instead of 2:00 PM. She said CNAs were waiting until the end of their shift to bring linens to the laundry room and laundry staff left at 2:00 PM. The ADON said she wasn't satisfied with the quality of housekeeping services, and administration was in discussion with the company they were contracted with.<BR/>An observation on 3/25/25 at 3:00 PM of Resident #2's room revealed what appeared to be the same soiled bed linens and pillowcase on his bed. The floor, window, and window blinds appeared to have not been cleaned from the initial observation. <BR/>During an interview on 3/25/25 at 3:00 PM, Resident #2 said staff had helped him change his clothing that day, but his linens had not been changed in a few days.<BR/>During an interview on 3/25/25 at 4:30 PM, the ADM said the facility had identified there was an issue with their laundry processing. She said CNAs were not emptying linen barrels early enough in the day to provide laundry staff time to wash them. The ADM said CNAs had been instructed to empty linen barrels earlier in the day. She said the facility always had clean linens available to accommodate resident needs.<BR/>Review of a policy dated May 2003 titled Housekeeping Standards indicated the following:<BR/> .The facility will provide a clean and sanitary living environment for the physical and emotional wellbeing of the resident .<BR/>And<BR/> .Daily cleaning schedules will be followed to provide a clean, safe, sanitary environment for residents, staff and visitors .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of a face sheet dated 03/02/2023 indicated Resident #131 was an [AGE] year-old female who admitted on [DATE] with the diagnoses of respiratory failure, pneumonia, related to Covid 19, Covid 19 virus, and major depressive disorder.<BR/>Record review of Resident #131's electronic medical record on 02/28/2023 revealed the MDS assessment, the comprehensive care plan, and the baseline care plan were not completed.<BR/>During an interview and observation on 03/02/2023 at 8:51 a.m., the ADON was the nurse for Resident #131. The ADON was informed by Resident #131 that she had not been bathed since she admitted on [DATE]. The ADON said Resident #131 would have a bath/shower today. The ADON said the nurses were responsible for ensuring the baths were completed. The ADON said the bath sheets were removed from use when the facility went to all electronic. The ADON said they no longer used the paper bath sheets and the computer documentation did not indicate a resident had a bath only the assistance required for bathing. <BR/>During an interview on 03/02/23 at 10:14 a.m., CNA H said the bath schedule was done by room numbers. CNA H said if a resident was in the room by themselves then they were considered being in the A bed. CNA H said Resident #131 had refused her shower today but was given a bed bath. CNA H said Resident #131 received her bath on the 2:00 p.m. - 10:00 p.m. shift.<BR/>Record review of an undated bath sheet provided by the ADON on 03/02/2023 indicated Resident #131 would receive her showers on Monday-Wednesday-Friday on the 2:00 p.m. to 10:00 p.m. shift.<BR/>Record review of Resident #131's ADL flow sheets did not reveal any refused bathing or showering.<BR/>3)Record review of a face sheet dated 03/02/2023 indicated Resident #74 was an [AGE] year-old female who admitted on [DATE] with the diagnoses of spondylolisthesis (disorder of which a bone vertebra slips forward onto the bone below), eating disorder, and high blood pressure. <BR/>Record review of an admission MDS dated [DATE] indicated Resident #74 was usually understood and usually understood others. The MDS indicated Resident #74 BIMS score was a 13 indicating she was cognitively intact. The MDS indicated Resident #74 required extensive assistance of one staff with bed mobility, transfers, locomotion, toilet use, personal hygiene, and bathing. The MDS indicated Resident #74 was frequently incontinent of bowel and was not on a toileting plan. <BR/>During an observation and interview on 02/27/2023 at 10:08 a.m., revealed Resident #74 was lying in her bed leaning to the left side. Resident #74's room smelled of foul-smelling bowel movement at the doorway. Resident #74 said she had been incontinent of bowel since right before breakfast. Resident #74 said she was still lying-in bed with an incontinent episode at this time. Resident #74 said she refused therapy because she was waiting to be changed. Resident #74 said she had to eat with bowel movement in her brief and bed.<BR/>During an observation on 02/27/2023 at 10:16 a.m., revealed CNA C entered Resident #74's room and answered the call light. Resident #74 made CNA C aware she needed her brief changed. CNA C left the room and obtained the needed supplies. During the incontinent care Resident #74's brief had overflowed with liquid bowel movement. Resident #74 had liquid stool was up her abdomen past her umbilicus (belly button) and up her low back. Resident #74's back of her shirt was saturated with liquid stool as well. <BR/>During an interview on 03/03/2023 at 2:30 p.m., CNA OO said on 02/27/2023 Resident #74 activated her call light during breakfast. CNA OO said she did not change Resident #74 because the regulation (state regulation) said changing of briefs during breakfast was cross contamination. CNA OO said she was aware Resident #74 had a bowel movement.<BR/>During an interview on 03/03/2023 at 11:00 a.m., the DON said no one should eat their meal with an incontinent episode. The DON said it was a dignity issue. The DON said Resident #74 should have been changed prior to her having her breakfast.<BR/>During an interview on 03/03/2023 at 11:15 a.m., the Interim Administrator said she did not expect anyone to eat their meals with soiling in their briefs. The Interim Administrator said leaving someone with a soiled brief on could cause skin problems, loss of dignity, and make a resident not want to eat. <BR/>During an interview on 03/03/2023 at 11:00 a.m., the DON said the CNAs were responsible for the bathing and the nurses for ensuring the baths were completed. <BR/>During an interview on 03/03/2023 at 11:15 a.m., the Interim Administrator said the baths/showers should be monitored using the electronic computer system. The Interim Administrator said again this was monitored in the morning meetings with the corporate tools (morning meeting tool used to audit). The Interim Administrator said the previous administrator failed to implement the tools the corporate tools. The Interim Administrator said not bathing could make a resident feel good because they may not smell good. <BR/>Record review of the facility's policy, Resident Showers, dated 02/11/2022, indicated .the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation, and help prevent skin issues as per current standards of practice . 1. Residents will be provided showers as per request or as per shower schedule .<BR/>Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene were provided for 3 of 4 residents (Residents #280, #74 and #131) reviewed for ADL care.<BR/>The facility failed to ensure Resident #280 was routinely showered/bathed.<BR/>The facility failed to ensure Resident #131 was routinely showered/bathed.<BR/>The facility failed to ensure Resident #74's brief with bowel incontience was changed prior to her morning meal.<BR/>These failures could place residents at risk of not receiving care/services, decreased quality of life impacting their loss of dignity.<BR/>Findings included:<BR/>1. Record review of Resident #280's face sheet, dated 03/02/23, indicated an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included fracture of right femur, history of falling, asthma, anxiety, and osteoporosis (condition in which bones become weak and brittle). <BR/>Record review of Resident #280's comprehensive care plan, dated 02/28/23, indicated she had an ADL self-care performance deficit and was at risk for not having her needs met in a timely manner. The care plan interventions included to provide shower, shave, oral care, hair care, and nail care per schedule and when needed. <BR/>Record review of the admission MDS, dated [DATE], indicated Resident #280 was usually understood and usually understood others. The MDS revealed Resident #280 had a BIMS score of 10, which indicated she had moderately impaired cognition. Resident #280 required limited assistance with transfers, dressing, toileting, and personal hygiene. Resident #280 required extensive assistance with bed mobility and locomotion. She was totally dependent on staff for bathing.<BR/>During an interview on 02/27/23 at 10:12 a.m., Resident #280 was in her room with family member present at bedside. Resident #280 said she had only received one shower since she admitted on [DATE]. Resident #280's family member agreed with Resident #280's statement and indicated that was correct. <BR/>During an interview on 03/01/23 at 08:11 a.m., Resident #280 said had not received another shower since the one she received Sunday (02/26/23).<BR/>Record review of Resident #280's ADL flow sheets did not reveal any refused bathing or showering.<BR/>During an interview on 03/01/23 at 10:32 a.m., CNA U said the showers were completed as per the shower sheet that was posted at the nurse's station. CNA U said shower schedule was as follows:<BR/>Monday, Wednesday, Friday- Morning shift women on A beds.<BR/>Monday, Wednesday, Friday- Evening shift women on B beds.<BR/>Tuesday, Thursday, Saturday- Morning shift men on A beds.<BR/>Tuesday, Thursday, Saturday- Evening shift men on B beds.<BR/>CNA U said they do not have shower sheets that they complete. CNA U said they document on the POC where they indicate if the resident received a shower. CNA U said there was not a place in the POC to indicate if a resident did not receive a shower or bath. CNA U said she would notify the charge nurse for any resident refusals. CNA U said she did not care for Resident #280.<BR/>During an interview on 03/01/23 at 10:40 a.m., RN G said the showers were done as per the schedule that was posted at the nurse's station. RN G said Resident #280 had indicated to him that she had been having problems receiving a bath. RN G said he instructed the nurse aide to give Resident #280 a shower on Sunday (02/26/23). RN G said he had notified the ADON regarding the issues Resident #280 was having receiving her showers or baths. RN G said there was usually only one aide on that hall and that there needed to be at least two aides for residents to receive the care they needed. <BR/>During an interview on 03/01/23 at 10:57 a.m., the ADON said they were in the middle of implementing the shower sheets again. The ADON said she was not aware of Resident #280 issues receiving a shower.<BR/>During an interview on 03/02/23 at 10:14 a.m., CNA H said the bath schedule was done by room numbers. CNA H said if a resident was in the room by themselves then they were considered being in the A bed. CNA H said she had given Resident #280 a bed bath one time. CNA H said the reason Resident #280 did not receive a shower was because when Resident #280 admitted to the facility, she had a wound thing on her hip and Resident #280 did not want to get the wound wet. CNA H said if a resident did not receive a bath or shower, N/A was checked on the POC. <BR/>During an interview on 03/02/23 at 10:28 a.m., the ADON said she expected showers or baths to be done according to the shower schedule unless the resident refuses. The ADON said if a resident refuses their shower, the aide was responsible for notifying the charge nurse. The ADON said the charge nurse was responsible of charting the refusal, notifying the family and physician if necessary. The ADON said the charge nurses were responsible of ensuring the baths were being completed as scheduled. The ADON said by not providing the showers as scheduled the resident was at risk for skin breakdown, dignity issue, or infection. <BR/>During an interview on 03/02/23 at 11:34 a.m., Resident #280 said she had not received a bed bath. Resident #280 said when she had the wound vac to her right hip the aides said they could give her a bed bath, but one was never provided. Resident #280 said the only shower she had received was the one that was provided to her on Sunday (02/26/23).<BR/>During an interview on 03/03/23 at 10:50 a.m., the DON said she expected the aides to follow the shower schedule and expected all the residents to be provided with a shower or bath depending on their preference. The DON said if a resident was to refuse their shower or bath, the aide was to notify the charge nurse so they could go talk to the resident as to why they refused. The DON said by not receiving a bath as scheduled the resident was at risk for skin problems, increased infection, and poor hygiene. The DON said she was responsible, as well as the charge nurse, to ensure the showers or baths were being completed as scheduled.<BR/>During an interview on 03/03/23 at 11:05 a.m., the Interim Administrator said she expected the showers or baths to be completed as scheduled. The Interim Administrator said by not receiving showers or baths the resident was at risk for not feeling well and a risk for infection. The Interim Administrator said the DON was responsible for ensuring the baths or showers were completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an environment that was free of accident hazards for 1 of 6 residents reviewed for accidents hazards. (Resident #130)<BR/>The facility failed to implement a fall intervention when Resident #130 said he fell on [DATE] to prevent Resident #130 from falling on 02/27/2023.<BR/>These failures could place residents at risk for falls and falls with serious injury. <BR/>Findings included:<BR/>Record review of a face sheet dated 03/02/2023 indicated Resident #130 was an [AGE] year-old male who admitted on [DATE] with the diagnoses of stroke, heart attack, heart failure, and diabetes. <BR/>Record review of a baseline care plan dated 02/23/2023 documented by the ADON indicated Resident #130 had self-care performance with personal hygiene, toileting, dressing and bathing. The base line care plan indicated Resident #130 was alert but cognitively impaired. The base line care plan indicated Resident #130 was at risk to fall with the goal will not sustain a fall related injury by utilizing fall precautions through next review date. The Fall care plan indicated an intervention would be to provide assistance to transfer and ambulate as needed.<BR/>Record review of a comprehensive care plan dated 02/23/2023 and revised on 03/01/2023 indicated Resident #130 had a potential to falls related to high blood pressure medications, gait problems, and incontinence. The goal was he would not sustain a fall related injury by utilizing the fall precautions. The interventions included anticipate his needs, educate resident/family/caregivers on safety reminders, encourage socialization, encourage activities, anticipate needs by placing items close to him, and attempt to determine cause of past falls. The comprehensive care plan did not address a bed alarm.<BR/>Record review of the most recent MDS dated [DATE] indicated Resident #130 usually understands and was usually understood. Resident #130 BIMS score was 12 but he required cueing to recall. The MDs indicated Resident #130 had difficulty focusing his attention and was easily distracted. The MDS indicated Resident #130 required limited assistance of one staff with bed mobility, transfers, walking, locomotion, dressing, toileting, personal hygiene, and extensive assistance of one staff for bathing. The MDS indicated Resident #130 was incontinent occasionally of bladder and frequently of bowel. The MDS indicated Resident #130 had one fall with an injury.<BR/>Record review of a fall risk dated 02/23/2023 indicated Resident #130 scored a 14 indicating he was at moderate risk to fall. The fall risk indicated Resident #130 had a history of multiple falls in the last six months. The fall risk assessment indicated Resident #130 could not recall the season, where he was, the location of his room or the names of the staff. The assessment failed to assess his gait.<BR/>Record review of a nurse's note dated 02/26/2023 at 11:30 a.m., RN G wrote Resident #130's family was visiting today and informed the RN supervisor and staff nurse of Resident #130 reporting he had a fall last night and got himself back to bed and did not report to anyone. RN G documented there was new discoloration around the right eye of Resident #130.<BR/>Record review of an incident report dated 02/26/2023 indicated Resident #130 reported a fall last night. The daughter's statement indicated she reported Resident #130 said he fell against his wheelchair. The immediate action taken on the incident report indicated a head-to-toe assessment was completed with noted old bruises to trunk with yellow discoloration. Slight bruising noted to the right peri-orbital area (surrounding the eye).<BR/>Record review of a progress note documented by LVN V dated 02/27/2023 at 9:59 p.m., indicated Resident #130 was found on his buttocks on the floor between the bed and wheelchair. LVN V documented Resident #130 said he was trying to get in his chair. LVN V documented there were no injuries. LVN V indicated the bed was in low position and he had his call light in his hand. LVN V indicated she provided re-education. <BR/>Record review of the consolidated physician's orders indicated Resident #130 had a bed alarm ordered on 02/28/2023 two days after he reported to his family, he fell and sustained bruising to his right eye. <BR/>Record review of the electronic medical record dated February 2023 indicated Resident #130 had a physician's order for a bed alarm when in bed, monitor every shift for falls beginning on 02/28/2023 at 6:00 p.m. The medical record did not indicate a nurse completed this task; the space was blank.<BR/>During an observation and interview on 03/01/2023 at 4:10 p.m., Resident #130 was lying in bed. Resident #130 had deep purple peri-orbital (around the eye) bruising. Resident #130 said he did not know he had bruising to his right eye. Resident #130 denied falling.<BR/>During an interview on 03/03/2023 at 11:00 a.m., the DON said the care plan should be updated with fall interventions as they occur to prevent another fall or risk for injuries. The DON said the nursing team was responsible for putting interventions in place.<BR/>During an interview on 03/03/2023 at 11:30 a.m., the Interim Administrator said interventions should be put in place with each fall to prevent the next fall. The Interim Administrator said not putting an intervention in place could result in a serious injury.<BR/>Record review of an Investigation of Incidents and Accidents policy dated 12/03/2020 indicated the resident environment will remain s free of accident hazards as possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This included: identifying hazards and risks, evaluating, and analyzing hazards and risk, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Implementation of Interventions-using specific interventions to try to reduce a resident's risk from hazards in the environment. This process included: Ensuring interventions were put into action.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to secure all drugs and biologicals in locked compartments, including the storage of schedule II-V medications in separately locked, permanently affixed compartments, permitting only authorized personnel to have access for 4 of 6 medication carts. (Stations #1, #2, #3, and #4)<BR/>The facility failed to ensure only authorized personnel had access to the facility's medication carts containing narcotics. <BR/>The facility failed to ensure medication carts with narcotics, were kept double locked.<BR/>These failures could place residents at risk of drug diversion and misuse of medication.<BR/>Findings included: <BR/>During an observation on 01/31/23 at 05:02 AM, two medication carts located near Nurse's station 1 were unattended and the outer lock was open.<BR/>During an interview on 01/31/23 at 5:02 AM, LVN A said both carts should be locked because they contained narcotics and should be under double lock.<BR/>During an observation on 01/31/23 at 5:13 AM, a medication cart located near Nurse's station 3 was unattended and unlocked.<BR/>During an interview on 01/31/23 at 5:15 AM, LVN B said the cart should be always locked because there were narcotics in the cart. LVN B said during the night shift LVN B and LVN A share the keys to the medication cart because not all the medications were in each cart. <BR/>During an observation and interview on 01/31/23 at 5:20 AM, the cart 3 was locked. When asked to open the cart, LVN B said she did not have the key and used her hand to pat the top of the notebook on top of the cart looking for the keys. LVN B said she must have left them in her jacket and walked toward Station 3. LVN A walked toward the cart and said she had the keys. LVN A handed the keys to LVN B. LVN B unlocked the cart showing narcotics inside the cart. <BR/>During an interview on 01/31/23 at 5:21 AM, LVN A said she normally left the keys inside the narcotic count book on top of the medication cart. LVN B said she sometimes left the keys in the book. <BR/>During an interview on 01/31/23 at 6:20 AM, the ADON said all narcotics should be stored under double lock according to facility policy. The ADON said carts should be secured any time they were unattended, and keys should never be left on top of the cart. The ADON said the facility had some recent drug diversions.<BR/>During an observation 02/02/23 at 5:11 AM, Station 4 medication cart was locked. Two sets of keys were on top of the cart in plain view. Surveyor approached the cart, NA A, looked at Surveyor, reached for the keys and pulled her hand back rapidly. Surveyor walked to station 3, the cart was locked. Surveyor turned around and went back to the cart on station 4 the keys were no longer on the cart. <BR/>During an interview on 02/02/23 at 5:14 AM, NA A said LVN C motioned for her to get the keys when she saw the surveyor coming. When asked how she knew LVN wanted her to get the keys, NA said, Because she was standing down the hall in front of room [ROOM NUMBER] and pointed to the cart and felt of her pockets. NA A said she should not have keys to the medication cart. <BR/>During an interview on 02/02/23 at 5:15 AM, LVN C said it was a mistake to leave the keys on top of the cart. LVN C said normally she does not leave the keys. LVN C said the keys on top of the cart were for the medication cart and the nursing cart for Hall 1. LVN C said she motioned for NA to move her cart.<BR/>During an observation and interview on 02/02/23 at 5:15 AM, Surveyor asked LVN C to unlock the nursing cart on Station 1. LVN C felt her pockets and said, I don't have the keys. NA A must have them. LVN C asked NA A for the keys. LVN C got the keys from NA A, opened the Nurse's cart on Station 1 revealing 20 containers of narcotics in the cart. <BR/>During an observation on 02/02/23 at 5:25 AM, station 2 medication cart was unlocked inside a room next to the nurses' station. LVN D walked into the unlocked room.<BR/>During an interview on 02/02/23 at 5:26 AM, LVN D said she was just around the corner restocking the other cart. LVN D said she left the cart unlocked when she took supplies to the other cart that was in the hallway, just around the corner. <BR/>During an observation on 02/02/23 at 5:26 AM, LVN D opened the Narcotic lock box for station 2 and seven cards of narcotics were inside the box. <BR/>Record review of a policy titled medication storage dated 01/20/21 showed .1. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication room) under proper temperature controls. B. Only authorized personnel will have access to the keys to locked compartments . 2. Narcotics and Controlled Substances: a. Scheduled II drugs and back-up stock of Schedule III, IV and V medications are stored under double-lock and key. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections were maintained for 4 of 6 residents reviewed for communicable disease (Resident #'s 41, 45, 54, and 74) and 1 of 12 months reviewed for infection control tracking and trending (January 2023).<BR/>The facility failed to initiate transmission-based precautions with the onset of the diagnosis of shingles F(painful rash with blisters) for Resident #45. <BR/>The facility failed to initiate transmission-based precautions with the onset of and ongoing of diarrhea for Resident #74. <BR/>CNA C failed to change gloves and washing her hands during incontinent care and prior to exiting Resident #74's room. <BR/>The facility failed to separate the linen from the rooms with communicable infections from the general linen for Resident #'s 45 and 74. <BR/>The facility failed to test Resident #41 for Clostridium Difficile (Inflammation of the colon caused by bacteria) when he had chronic diarrhea. <BR/>The facility failed to document tracking and trending of infection and antibiotic use for January of 2023. <BR/>LVN F failed to remove soiled gloves after obtaining Resident #50's blood sugar and he failed to perform hand hygiene before donning clean gloves.<BR/>The facility failed to ensure LVN D did not use a dirty cloth to clean Resident #54's catheter during catheter care. <BR/>The Infection Preventionist allowed RN G to work with a temperature of 102.2. <BR/>An Immediate Jeopardy (IJ) situation was identified on 02/28/2023 at 4:47 p.m. While the IJ was removed on the 03/03/2023 at 1:21 p.m., the facility remained out of compliance at an actual harm with a scope of widespread with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. <BR/>This failure could place residents at risk for being exposed to shingles, and diarrhea related to clostridium difficile (bacteria causing diarrhea to life-threatening damage to the colon. <BR/>Findings included:<BR/>1) Record review of a face sheet dated 03/02/2023 indicated Resident #45 was an [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of heart failure, depression, malnutrition, and high blood pressure. <BR/>Record review of the consolidated physician's orders dated 02/01/2023 indicated Resident #45 was did not indicated contact isolation was ordered.<BR/>Record review of the consolidated physician's orders dated 03/01/2023 indicated Resident #45 had Acyclovir 800 milligrams 5 times daily for 5 days for possible shingles started on 03/01/2023. Resident #45 had Clindamycin 300 milligrams three times a day for cellulitis x 7 days started on 02/28/2023 and Doxycycline Monohydrate 100 mg twice a day for cellulitis until 03/07/2023. Resident #45 was also ordered Gentamicin Sulfate Ophthalmic ointment 0.3% 1 application in right eye two times a day for infection x 7 days to start on 02/28/2023.<BR/>Record review of the comprehensive care plan dated 11/09/2022 failed to indicate Resident #45 had shingles involving his face, and right eye. The comprehensive care plan did not address isolation precautions. <BR/>Record review of the most recent Significant change MDS dated [DATE] indicated Resident #45 was usually understood and usually understands. Resident #45 required large print to read. The MDS indicated Resident #45's BIMS score was 11 indicating he had moderately impaired cognition. The MDS indicated during the assessment period Resident #45 did not reject care. The MDS indicated Resident #45 required extensive assistance of one staff with bed mobility, dressing, toilet use, personal hygiene, and with bathing Resident #45 required total assistance of one staff member. Resident #45 was incontinent of bowel and bladder. <BR/>Record review of Resident #45's February 2023 electronic medication record indicated he received Acyclovir 800 milligrams one tablet three times a day for shingles for 7 days started on 02/20/2023 and completed on 02/27/2023. Resident #45 was ordered Ofloxacin Ophthalmic Solution 0.3% one drop to the right eye 4 times daily for 5 days starting on 02/20/2023. Acyclovir 800 milligrams was restarted on 02/28/2023, Ofloxacin Ophthalmic Solution 0.3% instill one drop in right eye at bedtime for 7 days started on 2/27/2022, and Doxycycline 100 milligram give one tablet twice daily for 7 days started on 02/28/2023 after surveyor intervention. <BR/>Record review of a nursing note dated 02/20/2023 at 10:12 a.m., LVN G wrote the physician was notified regarding Resident #45's redness, swelling, and matter to his right eye.<BR/>Record review of a nursing note dated 02/20/2023 at 10:54 a.m., LVN G wrote he received new orders for Acyclovir 800 milligrams three times a day for 7 days, ofloxacin 0.3% one drop in right eye four times a day for 5 days, appointment with an ophthalmologist and check a HSV ig M level.<BR/>Record review of a nursing note dated 02/20/2023 at 8:34 p.m., LVN M wrote monitoring for edema every day and night shift, with the right side of Resident #45's face/eye with edema with the MD aware with labs ordered.<BR/>Record review of a nursing note dated 02/21/2023 at 1:03 a.m., LVN M wrote right side of Resident #45's face/eye continues with edema and redness, and Resident #45 denied pain. LVN M noted Resident #45's son would like to see if the facility ophthalmologist could see resident #45 instead of having to be transferred out of the facility. <BR/>Record review of a nursing note dated 02/22/2023 at 9:08 a.m., LVN O indicated Resident #45 continued the Acyclovir eye drops to his eye every night, continued to assess for pain, discomfort, and changes.<BR/>During an observation on 02/27/2023 at 12:17 p.m., Resident #45 was lying in his bed. He had scabbing appearing areas to his right eye and forehead. Resident #45's right eye is scabbed closed he could not open it on command. There were no isolation precautions posted on Resident #45's room.<BR/>During an interview on 02/27/2023 at 12:26 p.m., CNA N said Resident #45 had not been on any isolation precautions. CNA N said she regularly cares for Resident #45 and has floated to other halls to help. CNA N said she had questioned the DON as to why Resident #45 was not on any type of isolation because CNA N said shingles were contagious. CNA N said she floated to work on other halls. CNA N said Resident #45 did not eat any of his noon meal because he was hurting from the shingles.<BR/>During an interview on 02/27/2023 at 8:55 a.m., the DON said the nurses had not realized Resident #45 required isolation. The DON said the nurses did not make her aware of a case of shingles. The DON said Resident #45 should have been placed on contact isolation. The DON said the risk for unvaccinated and residents who had not had chicken pox as a child were at risk of having shingles. The DON said she was unaware Resident #45 had an order to see an ophthalmologist related to his right eye. The DON said they facility eye physician had already made rounds around February 9th or the 10th. The DON said she had not contacted the mobile eye physician or the son with a plan to have Resident #45's right eye examined. The DON said shingles in the eye could result in vision loss for Resident #45. The DON said she was the infection preventionist for the building. The DON said she was unsure how Resident #45's infection of the shingles as missed because she said the nurse managers log the infections and review the orders in morning meeting. <BR/>Record review of a nurse note dated 02/28/2023 at 1:06 p.m., indicated Resident #45 was administered a tramadol 50 milligram tablet for pain.<BR/>During an interview on 02/28/2023 at 3:11 p.m., LVN P said CNA N asked why Resident #45 was not on isolation if he had shingles. LVN P said she asked the DON to explain why Resident #45 was being treated for shingles why was he not on isolation. LVN P said the DON said Resident #45 should have been on isolation. LVN P said she had worked February 19, 2023, through February 23, 2023. LVN P said Resident #45's eye was much worse. LVN P said no one had contacted the physician for Resident #45's worsening shingles. LVN P said Resident #45 had not been on isolation for the shingles, but he should have been to prevent the spread to other residents. <BR/>During an interview on 02/28/2023 at 3:26 p.m., the medical director said she was unaware of Resident #45's right eye condition with shingles covering the entire eye lid and the right eye would not open. The medical director said she was unaware Resident #45 had not seen an eye specialist related to the shingles to the right side of the face and eye. The medical director said she expected the facility to obtain an appointment promptly due to the risk of blindness with ocular shingles. <BR/>During an observation and interview on 02/28/2023 at 3:45 p.m., LVN P applied a warm compress to Resident #45's right eye. LVN P asked Resident #45 to open his right eye, and he could not open the eye at all. Resident #45 said his right eye was hurting and LVN P immediately stopped and said she would administer a pain medication. LVN P said she would notify the physician. Resident #45 now had isolation signs and PPE outside of the room.<BR/>Record review of a nurses note dated 02/28/2023 at 12:57 p.m., Resident #45 had an appointment scheduled for March 2, 2023, at 3:15 p.m. The note indicated Resident #45's son was notified of the appointment related to shingles to the right eye. <BR/>Record review of a nurse note dated 02/28/2023 at 8:03 p.m., the ADON wrote Resident #45's family was notified of the lab results of the Herpes Simplex IgM result of 0.66 and the new order received from the physician for Clindamycin 300 mg one three times and day and discontinue the acyclovir. <BR/>Record review of a nurse note dated 02/28/2022 at 8:21 p.m., the DON wrote Resident #45's isolation was discontinued for shingle precautions and indicated Resident #45 had a new diagnosis of cellulitis and with a new medication ordered. The new order was Clindamycin 300 mg one capsule three times a day for 7 days. <BR/>Record review of a nurse note dated 02/28/2023 at 11:08 p.m., LVN B wrote Resident #45 was administered gentamycin eye drops. LVN B wrote Resident #45 face was red and swollen with blisters and scabs.<BR/>During an interview on 02/28/2023 at 8:55 a.m., the DON said the nurses did not realize Resident #45 required isolation for the shingles. The DON said Resident #45 should have been placed on contact isolation. <BR/>During an interview on 02/28/2023 at 10:07 a.m., the Interim Administrator said she was unaware of Resident #45 having shingles. The Interim Administrator said shingles should be isolated in so not to spread to other residents.<BR/>Record review of Resident #45's March 2023 electronic medical record indicated he had Gentamicin Sulfate Ophthalmic Ointment 0.3% instill one application in the right eye two times a day for 7 days starting on 03/01/2023, Ofloxacin Ophthalmic Solution 0.3% instill one drop in right eye at bedtime for 7 days starting on 02/27/2023; Doxycycline monohydrate 100 milligrams one capsule twice daily for cellulitis until 03/07/2023; and Clindamycin 300 mg one capsule by moth three times a day for cellulitis for 7 days; and Acyclovir 800 milligrams one tablet by mouth 5 times a day for 5 days for possible shingles starting on 03/01/2023. <BR/>Record review of a nurse note dated 03/01/2023 at 1:24 a.m., LVN B documented Resident #45 had a diagnosis of cellulitis, day 2 of isolation, acyclovir was discontinued, day 2 of 7 on ofloxacin and gentamicin eye drops, day 3 of 7 on doxycycline with no adverse reactions. The note indicated Resident #45 had redness, swelling, and scabs to his face with warm compresses used.<BR/>During an interview on 03/01/2023 at 8:34 a.m., the Regional Corporate Nurse said after digging deeper the lab result for an IgM level was 0.66 which was negative. The Regional Corporate Nurse said Resident #45 was negative for shingles but was being treated for cellulitis. <BR/>During an observation and interview on 03/01/2023 at 9:18 a.m., Resident #45 said his right eye was hurting. Resident #45 had a very minimal opening between his eye lids and there was yellow stingy material in the opening. Resident #45's isolation precautions remained removed. <BR/>During an interview on 03/01/2023 at 2:57 p.m., the medical director indicated initially Resident #45's rash appeared to be shingles. The medical director indicated the IgM test (antibody test for an infection) was negative. The medical director said she would complete a PCR HSV and VSV, and place Resident #45 back on isolation. The medical director said she would order a PCR HSV and VSV (testing for Herpes simplex virus and varicella simplex virus) because the test would be the most accurate test according to CDC recommendation.<BR/>Record review of a nurses note dated 03/01/2023 at 6:10 p.m., LVN G placed Resident #45 back on isolation precautions further pending laboratory results. <BR/>Record review of a nurses note dated 03/01/2023 at 6:24 p.m., ADON wrote she notified the Resident #45's son of the new orders to restart Acyclovir 800 milligrams five times daily x 5 days, PCR HSV and VZV lab (laboratory test for herpes simplex and varicella zoster), and reinstate the isolation precautions. <BR/>Record review of an incident report dated 03/02/2023 at 3:30 p.m., indicated Resident #45 slid from his wheelchair to the floor. The ADON wrote there were no injuries noted but Resident #45 was sent to the emergency room.<BR/>Record review of an After Visit Summary dated 03/02/2023 indicated Resident #45 was provided instructions related to shingles and minor head injury. The summary indicated his diagnoses included an unspecified fall, facial contusion, and herpes zoster (shingles). The educational material included in the Visit Summary report indicated:<BR/>*If the shingles affects your eye the doctor may cover your eye with a bandage<BR/>*Infections of the eye and the skin around the eye were other health problems to treat<BR/>*To prevent the shingles do not share towels, go swimming, or play contact sports with people who have shingles if you never had chicken pox.<BR/>*Do not touch or scratch your rashes, if you do wash your hand afterwards.<BR/>2) Record review of a face sheet dated 03/02/2023 indicated Resident #74 was an [AGE] year-old female who admitted on [DATE] with the diagnoses of spondylolisthesis (disorder of which a bone vertebra slips forward onto the bone below), eating disorder, and high blood pressure. <BR/>Record review of a Baseline care plan dated 01/24/2023 at 8:39 a.m., the ADON did not document Resident #74 had a recent history of Clostridium Difficile (infection of the colon from bacteria), diarrhea, or isolation precautions needed for on-going symptoms. <BR/>Record review of the comprehensive care plan dated 02/07/2023 indicated Resident #74 was at risk for Covid 19 infection but did not mention Clostridium Difficile or the need for isolation precautions. <BR/>Record review of an admission MDS dated [DATE] indicated Resident #74 was usually understood and usually understands. The MDS indicated Resident #74 BIMS score was a 13 indicating cognitively intact. The MDS indicated Resident #74 required extensive assistance of one staff with bed mobility, transfers, locomotion, toilet use, personal hygiene, and bathing. The MDS indicated Resident #74 was frequently incontinent of bowel and was not on a toileting plan. <BR/>Record review of the February 2023 electronic medical record indicated Resident #74 received Colestipol 1 gram twice daily for treating diarrhea since 01/24/2023, lactobacillus capsule one capsule by mouth twice daily, and Lomotil 2.5-0.025 milligrams one tablet every 6 hours as needed for diarrhea since 01/24/2023. The electronic medical record indicated Resident #74 had 8 doses in the month of February and two doses were unknown if effective. <BR/>Record review of a nursing progress note dated 01/24/2023 documented by LVN T indicated Resident #74 was post Clostridium Difficile .<BR/>Record review of a nursing progress note dated 01/31/2023 at 1:22 a.m., indicated LVN V administered Lomotil for diarrhea, but the medication was ineffective. The note did not indicate the physician was notified.<BR/>Record review of a nursing progress note dated 01/31/2023 at 12:24 p.m., LVN F documented Resident #74 was administered Lomotil for diarrhea.<BR/>Record review of a skilled nurses note dated 02/01/2023 at 12:48 a.m., indicated Resident #74 was post Clostridium Difficile.<BR/>Record review of a progress note dated 02/01/2023 at 1:30 a.m., indicated Resident #74 was administered Lomotil for diarrhea by LVN M. <BR/>Record review of a nursing note dated 02/03/2023 at 5:40 a.m., LVN T documented an administration of Lomotil for diarrhea was provided to Resident #74. <BR/>Record review of a nurses note dated 02/04/2023 at 3:32 a.m., LVN R documented Resident #74 was post clostridium difficile. <BR/>Record review of a nurses note dated 02/04/2023 at 3:32 a.m., LVN R documented Resident #74 was post clostridium difficile.<BR/>Record review of a nurses note dated 02/06/2023 at 8:37 a.m., indicated LVN S documented Resident #74 was post clostridium difficile. <BR/>Record review of a nurses note dated 02/06/2023 at 11:18 p.m., LVN T documented Resident #74 required the administration of Lomotil for diarrhea. <BR/>Record review of a nurses note dated 02/07/2023 at 11:40 p.m., LVN T documented Resident #74 required Lomotil administration related to diarrhea. <BR/>Record review of a nurses note dated 02/15/2023 at 9:42 p.m., LVN T documented Resident #74 required administration of Lomotil for diarrhea.<BR/>Record review of a nurses note dated 02/24/2023 at 12:54 a.m., indicated Resident #74 continued to have been monitored for diarrhea none noted on this shift. <BR/>Record review of a nurses note dated 02/25/2023 at 6:41 a.m., LVN T indicated Resident #74 had 3 diarrhea bowel movements with Lomotil given and effective at present. The note indicated Resident #74's peri area was very red.<BR/>Record review of a nurses note dated 02/25/2023 at 6:43 p.m., LVN B documented Resident #74 required Lomotil for diarrhea and the medication was effective. <BR/> During an observation on 02/27/2023 at 10:08 a.m., Resident #74 said her brief needed changing due to having a very large diarrhea bowel movement. Resident #74 was assisted to activate her call light for assistance. CNA C answered the call light and left the room. CNA C returned with bed linen and incontinent care supplies. CNA C washed her hands then initiated care to Resident #74. CNA C opened Resident #74's brief, then wiped down the left side of her groin, and then across Resident #74's abdomen. CNA C removed her gloves and applied new gloves. Then CNA C took a roll of trash bags and unrolled a bag for use with the same gloves on. CNA C removed gloves and washed her hands. She returned to Resident #74 applied new gloves then removed the soiled brief. CNA C touched the wipe bag and obtained more wipes to cleanse Resident #74's buttocks. CNA C dropped the new brief on the floor. CNA C removed her soiled gloves, opened Resident #74's door and exited the room without washing her hands. CNA C returned to the room with a new brief. CNA C then washed her hands and laid the new brief on top of soiled linen she had rolled up underneath Resident #74. CNA C touched the foot of the bed and moved the bed out to walk around the bed to provide care. CNA C then walked to end of the bed, moved the bed back against the wall and continued with the care. CNA C removed her gloves and donned more gloves applying a barrier cream to Resident #74's buttocks. Resident #74's room had no isolation signs posted or PPE (personal protective equipment).<BR/>Record review of a nurses note dated 02/27/2023 at 5:55 p.m., LVN F documented Resident #74 made the statement she thought she needed to return to the hospital due to the ongoing diarrhea. LVN F documented he informed Resident #74 he had a stool sample waiting for pickup. <BR/>During an interview on 02/28/2023 at 7:47 a.m., CNA C said she made a lot of mistakes with incontinent care. CNA C said she should have closed Resident #74's blind, should have washed hands with glove changes. CNA C said Resident #74 has had diarrhea since she admitted . <BR/>During an interview on 02/28/2023 at 7:51 a.m., the Housekeeping Supervisor said she was unaware there were residents with possible Clostridium Difficile. The housekeeping supervisor said for Clostridium Difficile there was a special tablet to add to the water for cleaning of these rooms. The housekeeping supervisor said she was also unaware of Resident #74 or Resident #45 having communicable disease processes requiring special laundry procedures. The housekeeping supervisor said when the laundry receives linen in the yellow bags the laundry personnel would be alerted to wash this linen separate from the general linen. <BR/>During an interview on 02/28/2023 at 3:26 p.m., the Medical Director said Resident #74 had Clostridium Difficile in the recent past. The Medical Director said she was not notified Resident #74 had on-going diarrhea since admission. The Medical Director said Resident #74 could be a carrier of Clostridium Difficile. The medical director said Resident #74 could still be infectious up to 6 weeks and should have been isolated to prevent the spread of a potential reinfection. The Medical Director said she was unaware Resident #74 was the neighbor to a resident who had non-Hodgkin's lymphoma (cancer of lymphatic system) and recently had a stem cell transplant.<BR/>Record review of a nurses note dated 02/28/2023 at 4:00 p.m., the Marketer QQ documented the medical director was notified of ongoing loose stool and ongoing since admission. The note indicated Marketer QQ notified the medical director of the negative C-diff lab test prior to admission on [DATE] and Resident #74 having Lomotil as needed. The note indicated a new order was received for Imodium 2 mg three times daily until C-diff test returns negative. <BR/>During an interview on 03/01/2023 at 10:58 a.m., LVN S said Resident #74's stool sample result was not back.<BR/>During an observation on 03/01/2023 at 9:18 a.m., Resident #74 was in the therapy gym with other residents present. Resident #74's room had isolation precautions signs and PPE available. <BR/>During an interview on 03/01/2023 at 11:17 a.m., LVN S said if Resident #74 does have clostridium difficile she was told the germ would be contained in her brief. LVN S agreed Resident #74 was incontinent of stool.<BR/>During an interview on 03/01/2023 at 11:30 a.m., the occupational therapist assistant said she checked with LVN S and was advised Resident #74 although on isolation precautions could come to the gym for therapy.<BR/>During an interview on 03/01/2023 at 11:36 a.m., the DON said Resident #74 should have not been allowed in the therapy gym increasing the risk to spread the communicable disease. <BR/>During an observation on 03/02/2023 at 9:48 a.m., Resident #74's neighbor next door had a sign placed beside her entrance indicating she was now in enhanced barrier precautions. The sign indicated everyone must:<BR/>*Clean hands before entering room<BR/>*All personnel must wear gloves, gown, with high care activities such as dressing, bathing, showers, and transfers<BR/>*Changing linen<BR/>*Providing hygiene<BR/>*Changing brief/toileting<BR/>*Device care<BR/>*Wound care.<BR/>This was determined to be an Immediate Jeopardy (IJ) situation on 02/28/2023 at 4:47 p.m. The Interim Administrator and the Regional Corporate Nurse was notified. The Administrator was provided with the IJ template on 02/28/2023 at 4:58 p.m.<BR/>The following Plan of Removal submitted by the facility was accepted on 03/03/23 at 1:21 p.m. and included the following:<BR/>Immediate Action:<BR/>*On 02/27/2023 Resident #45 was placed in contact isolation<BR/>*On 02/28/2023 Resident #74 was placed in contact isolation<BR/>*On 02/28/2023 Resident #45 was removed from contact isolation per physician's order, related to a negative Herpes Simplex IGM test on 02/21/2023, Medical Director ordered Acyclovir treatment which was administer per physician's order<BR/>*On 03/01/2023 after Medical Director spoke to the survey team, the Medical Director ordered Resident #45 to be placed back in isolation, restart Acyclovir, and PCR (Polymerase chain reaction) testing for HSV (herpes simplex virus) and VZV (varicella-zoster virus).<BR/>*On 03/01/2023 Resident #45 was placed back on contact isolation<BR/>*On 02/28/2023 Regional Nurse Consultant completed an assessment of resident #74 to validate Resident had no negative outcome from alleged improper peri-care.<BR/>Facility's plan to ensure compliance quickly:<BR/>*On 02/28/2023 DON/designee began training on Transmission Based Precautions to guide the center on when and what precautions to take to prevent transmission of pathogens base on mode of transmission including linen handling, storage, and sanitation for residents with presumed or confirmed infections, with all staff on duty. This education was completed on 02/28/2023with 20 of 89 staff trained. On 03/01/2023 at 2:00 p.m., no staff will be allowed to work until his education was completed.<BR/>*The DON/Designee was responsible for ensuring residents were placed on appropriate isolation precautions.<BR/>*On 03/01/2023 the DON was provided 1:1 education on Transmission Based Precautions to guide the center on when and what precautions to take to prevent transmission of pathogens based on mode of transmission, on monitoring, tracking, trending of infections by Regional Nurse Consultant. <BR/>*On 03/01/2023 an additional 8 staff were trained prior to working<BR/>*Again, no staff would be allowed to work until the education had been completed<BR/>*On 03/01/1023 DON/designee began performing Hand Hygiene Skills Validation with Nurse Assistants. The skill competencies were completed on 02/28/2023 at 10:00 p.m., with 19 of 89 staff trained. NO staff would be allowed to work until the skills competency was completed.<BR/>*On 03/01/2023 DON/designee began performing Hand Hygiene Skills Validation with all staff with an additional 39 of 89 staff trained.<BR/>*On 02/28/2023 DON/designee began performing Peri-Skills Validation with Nurse Assistants. The skills competencies were completed on 02/28/2023 at 10:00 p.m. with 11 of 29 Nurse Assistants trained. No Nurse Assistants would be allowed to work until the education was completed. <BR/>*On 03/01/2023 DON/designee began performing Peri-Skills Validation with Nurse assistants with an additional 10 of 29 staff trained.<BR/>*On 03/01/2023 housekeeping staff completed deep thorough cleaning/disinfection of resident #'s 45, 74, and 1 other identified resident's room. The cleaning included halls and common areas. <BR/>Quality Assurance:<BR/>*Medical Director was notified on 02/28/2023 at 8:00 p.m. of the Immediate Jeopardies.<BR/>*On 03/01/2023 an Ad Hoc QAPI meeting was conducted to discuss identified issues and to develop plan for sustaining compliance. <BR/>In-services Conducted:<BR/>Transmission Based (Isolation) Precautions dated 10/24/2022 indicated it was the policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' mode of transmission. For training and quick referencing purposes a summary of precautions was contained at the end of the policy.<BR/>Airborne Precautions refer to actions taken to prevent or minimize the transmission of infectious agents/organisms that remain infections over long distances when suspended in air.<BR/>Contact precautions refer to measures that were intended to prevent transmission of infectious agents which were spread by direct or indirect contact with the resident or the resident's environment.<BR/>Droplet precautions refer to actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions.<BR/>Transmission-based precautions (aka Isolation Precautions) refer to actions implemented in addition to standard precautions that were based upon the means of transmission (airborne, contact, and droplet) in order to prevent or control infections. <BR/>Policy Explanation and Compliance Guidelines:<BR/>1.Facility staff will apply Transmission-Based Precautions, in addition to standard precautions, to residents who were known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission.<BR/>2.The facility would use standard approaches, as defined by the CDC, for transmission-based precautions: airborne, contact, and droplet precautions. The category of transmission-based precautions will determine the type of personal protective equipment to be used.<BR/>3.When implementing transmission-based precautions, the facility will consider the following: <BR/>a. The identification of resident risk factors <BR/>b. The provision of a private room .<BR/>c. Cohorting .<BR/>d. sharing a room with a roommate with limited risk factors.<BR/>4. Residents on transmission-based precautions should remain in their rooms except for medically necessary care.<BR/>5. High touch objects and environmental surfaces should be cleaned and disinfected with an EPA-registered disinfectant .<BR/>6. Prompt recognition of need<BR/>Type and Duration of transmission-based precautions recommend for selected infections and conditions:<BR/>Clostridioides difficile formerly Clostridium difficile requires contact precautions, for the duration of the illness and hand hygiene with soap and water.<BR/>Herpes zoster (shingles) requires airborne (if disseminated), contact I if resident was immunocompromised, standard (if localized).<BR/>Validation Checklist Hand Hygiene:<BR/>*Necessary supplies present<BR/>*Water turned on with clean, dry towel; temperature adjusted for comfort<BR/>*Soap applied to hands<BR/>*Hands rubbed together vigorously with antimicrobial soap<BR/>*Friction applied to all surfaces of the hands and fingers<BR/>*Hand hygiene activity continued for 20-30 seconds<BR/>*Hands rinsed thoroughly under running water<BR/>*Hands kept lower than level of wrist during procedure<BR/>*No contact with the inside of the sink<BR/>*Stood away from sink to prevent splashing of uniform/clothing<BR/>*Hands dried thoroughly with paper towels<BR/>*Clean, dry paper towels used to turn off faucet<BR/>*Towels discarded into trash receptacles<BR/>*Alcohol gel used as adjunct<BR/>*Understands the use of gloves and when they were to be used<BR/>*Appropriate use of alcohol-based products.<BR/>Validation Checklist Perineal Care:<BR/>*Reviewed plan of care<BR/>*Gathered needed supplies<BR/>*Summoned for assistance if needed<BR/>*Knock and gained permission to enter resident's room<BR/>*Identified self, explained the procedure, provided privacy and asked permission to proceed<BR/>*Set up needed supplies on the bedside stand in easy reach<BR/>*Positioned the bed at a comfortable working position<BR/>*Washed hands correctly<BR/>*Avoided over exposure of resident while placing linens in proper place<BR/>*Filled wash basin half full of water<BR/>*Donned appropriate personal protective equipment<BR/>*Placed waterproof pad under resident if necessary<BR/>*Followed correct procedure for removing fecal material<BR/>*Performed correct procedure for female<BR/>*Performed correct procedure for male<BR/>*Followed infection control protocol<BR/>*Placed call-light device within easy reach of the resident<BR/>*Cleaned wash basin and returned to storage area<BR/>*Cleaned bedside stand<BR/>*Returned the door and blinds open if resident desired<BR/>*Recorded/reported appropriate data<BR/>*Maintained clean technique and observed any isolation precautions.<BR/>Monitoring included:<BR/>During Interviews on 03/03/2023 from 3:08 p.m. until 3:54 p.m., the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the IJ by:<BR/>Interview with the DON indicated she was [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to implement their policy to ensure the residents, or their responsible party, received education of the benefits and risks, or potential side effects of Covid -19(a severe acute respiratory syndrome ) immunizations, receipt of Covid-19 immunizations, or the residents did not receive the Covid-19 immunizations, due to medical contraindication, or refusal, for 74 of 74 residents living in the facility and 5 of 5 residents who were reviewed for immunizations (Resident #11, Resident #35, Resident #52, Resident #56 and Resident #57)<BR/>The facility failed to document, in Resident #11, Resident #35, Resident #52, Resident #56 and Resident #57 medical records, having had received education, whether by self or with their responsible party, of the benefits and risk, and potential side effects, of the Covid-19 immunization, receipt of the of the Covid-19 immunization, or having had not received the Covid-19 immunization due to medical contraindication or refusal.<BR/>This failure could place residents at risk of not being informed of complications and potential adverse health outcomes. <BR/>Findings included: <BR/>Record review of a facility face sheet dated 5/14/25 for Resident #11 indicated that she was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: pain in right hip, altered mental status and repeated falls. <BR/>Record review of a physician order summary report dated 5/14/25 for Resident #11 indicated that she had no orders for Covid vaccination.<BR/>Review of a document titled, immunization audit report dated 5/13/2025, revealed Resident # 11 and/or her representative was not offered the Covid-19 vaccine since 01/19/21 The document indicated no education given. <BR/>Record review of a facility face sheet dated 5/14/25 for Resident #35 indicated that she was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: chronic pain, atrial fibrillation (rapid heart rate) and anorexia (no desire to eat).<BR/>Record review of a physician order summary report dated 5/14/25 for Resident #35 indicated that she had no orders for Covid-19 vaccination.<BR/>Review of a document titled, immunization audit report dated 5/13/2025, revealed Resident #35 and/or her representative was not offered the Covid vaccine on admission and the document indicated there was no education given to Resident #35. <BR/>Record review of a facility face sheet dated 5/14/25 for Resident #52 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: anemia (low blood volume), atrial fibrillation (rapid heart rate) and anorexia (no desire to eat).<BR/>Record review of a physician order summary report dated 5/14/25 for Resident #52 indicated that she had no orders for Covid-19 vaccination.<BR/>Review of a document titled, immunization audit report dated 5/13/2025, revealed Resident #52 and/or her representative was not offered the Covid-19 vaccine since 01/03/21. The document indicated there was no education given to Resident #52 or a representative. <BR/>Record review of a facility face sheet dated 5/14/25 for Resident #56 indicated that she was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: atrial fibrillation (rapid heart rate), weakness and chronic cough.<BR/>Record review of a physician order summary report dated 5/14/25 for Resident #56 indicated that she had no orders for Covid-19 vaccination.<BR/>Review of a document titled, immunization audit report dated 5/13/2025, revealed Resident # 56 and/or her representative was not offered the Covid-19 vaccine since 07/22/22. The document indicated there was no education given to Resident #56 or a representative. <BR/>Record review of a facility face sheet dated 5/14/25 for Resident #57 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: pain, weakness, and lack of coordination. <BR/>Record review of a physician order summary report dated 5/14/25 for Resident #57 indicated that he had no orders for Covid-19 vaccination.<BR/>Review of a document titled, immunization audit report dated 5/13/2025, revealed Resident #57 and/or her representative was not offered the Covid-19 vaccine. The document indicated there was no education given to Resident #57 or a representative. <BR/>During an interview on 5/14/2025 at 8:45 am, the DON said she was the Infection Preventionist for the facility. The DON could not provide documentation of any resident (74 residents in the facility) education for Covid immunization refusals. DON said the facility had no form for declination to be used when the resident or representative refused and there was no refusal scanned into the electronic system for residents that indicated they had been education on benefits or risks of the covid vaccine. She said there was no documentation of education provide after refusal of Covid vaccination for any resident in the facility. The DON said she would be responsible going forward to ensure that residents were educated on immunizations and providing documentation. She said residents could be at risk of not knowing what they were refusing if they were not provided education. The DON said residents could be at risk of contracting infections, severe respiratory problems and even death if they were not properly educated and did not receive vaccinations. DON said they would be providing education and have consent/declination forms signed going forward.<BR/>During an interview on 5/14/2025 at 9:00 am, the Administrator said there was no documentation of education provide after refusal of Covid vaccination for any of the 74 residents in the facility. She said the facility had not provided covid vaccinations or education on Covid vaccinations in the last two years due to no interest and refusal of the residents or families. The Administrator said the DON was responsible for immunizations and going forward residents will be provided education regarding benefits and risks. Administrator said that residents and families could possibly not have the knowledge to make informed decisions concerning covid vaccinations if risks and benefits were not provided. <BR/>Record Review of a facility policy titled Infection Control Program dated 10-24-2022 indicated .<BR/>COVID-19 Immunization :<BR/>a. <BR/>Residents and staff will have the opportunity to receive the COVID-19 vaccination, and change their decision based on current guidance.<BR/>b. <BR/>Residents and staff will be screened prior to offering the vaccination for prior immunization, medical precautions, and contraindications to determine candidacy for the vaccination.<BR/>c. <BR/>Education about the vaccine, risks, benefits, and potential side effects will be given to residents or resident representatives and staff prior to offering the vaccine.<BR/>d. <BR/>Documentation will reflect the education provided and details regarding whether or not the resident or staff received the vaccine.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 8 (Resident #1) reviewed for dignity in that:<BR/>CNA A spoke to Resident #1 in a loud and harsh tone while attempting to assist the resident out of bed.<BR/>This failure placed residents in the facility at risk of diminished quality of life, and loss of dignity and self-worth. <BR/>Findings Include:<BR/>Review of Resident #1's undated face sheet revealed he was a [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of heart failure and secondary diagnoses of shoulder pain, low back pain, and muscle wasting (loss of muscle mass due to disuse or nerve problems). <BR/>Review of a quarterly MDS assessment dated [DATE] indicated Resident #1 had a BIMS score of 12 which indicated moderate cognitive impairment, and he required total assistance with toileting, putting on/taking off footwear; he required maximum assistance with showering/bathing and lower body dressing; he required moderate assistance with upper body dressing; he required setup assistance with personal and oral hygiene; he required no assistance eating. He was occasionally incontinent of bladder and frequently incontinent of bowel.<BR/>A comprehensive care plan revised on 9/26/24 indicated Resident #1 had an ADL self-care performance deficit and Resident #1 did not always like to change his clothing daily or shower when scheduled. Interventions were in place to provide ADL care as needed, encouraging resident to participate to the fullest extent possible, and praising resident when attempts were made. <BR/>A comprehensive care plan revised on 9/30/24 indicated Resident #1 had impaired cognition and was at risk for further decline related to encephalopathy (group of conditions that cause brain dysfunction) and dementia (altered cognition). Interventions were in place including explaining all procedures to resident and stopping and returning later if resident becomes agitated during care.<BR/>During an interview on 3/24/25 at 12:21 PM, Resident #1 said CNA A came into his room and told him he needed to get up and out of bed. Resident #1 said he told CNA A he did not want to get up right then, and CNA A replied that he had to get up and then pulled his blanket off him. Resident #1 said the CNA attempted to assist him to his feet by pulling his legs over to the side of the bed and he told her again that he did not want to get up yet. Resident #1 said CNA A said, We don't play around here in loud and harsh voice and left the room.<BR/>During an interview on 3/24/25 at 12:30 PM, Resident #3, who was Resident #1's roommate, said he remembered CNA A coming into their room on the morning of the incident. He said CNA A yelled at Resident #1 and told him he had to get out of bed. He said he did not remember CNA A pulling Resident #1 out of bed or jerking his leg. <BR/>During an interview on 3/24/25 at 12:40 PM, Resident Representative said the facility notified him of the incident, and he accompanied Resident #1 to a meeting with the ADM. He said Resident #1 told the ADM he didn't think CNA A should be fired, but he did not want CNA A to be allowed in his room anymore.<BR/>Attempted a telephone interview on 3/24/25 at 1:00 PM with CNA A. An automated voice recording indicated the correct number was reached and there was no voicemail box setup.<BR/>During an interview on 3/24/25 at 3:10 PM, MA B said she went into Resident #1's room to check Resident #3's vital signs in preparation of a medication pass. MA B said she heard Resident #1 tell CNA A he did not want to get up and CNA A responded you need to get up or I'll get in trouble in a loud and harsh-sounding tone of voice. MA B said she left the room to get Resident #3's medication, and when she returned, Resident #1 was seated in his wheelchair dressing himself; CNA A was not in the room.<BR/>During an interview on 3/25/25 at 11:00 AM, the DON said there was nothing in CNA A's background checks or job performance that indicated a risk to residents in the facility. She said CNA A was a large woman with a loud voice and she could have been intimidating to some residents, but there had been no previous allegations of mistreatment from any resident in the facility against CNA A.<BR/>Second attempted telephone interview on 3/25/25 at 3:45 PM with CNA A. An automated voice recording indicated the correct number was reached and there was no voicemail box setup.<BR/>During an interview on 3/25/25 at 4:00 PM, the ADM said CNA A had nothing in her background or job history that indicated a concern for resident safety. She said there had been no allegations of abuse or neglect against CNA A from any resident before this incident. She said CNA A was suspended while the facility investigated the allegation, and the decision was made to terminate CNA A based off MA B's witness statement. The ADM said CNA A was too direct and did not respect Resident #1's personal choice and that would not be tolerated at the facility. She said all CNAs were trained and expected to fully explain all care being provided and encourage residents to participate in care. <BR/>Review of facility policy titled Promoting/Maintaining Resident Dignity last reviewed on 2/16/20 indicated all staff involved in providing resident care will promote and maintain resident dignity by .personal choices will be considered when providing care and services to meet the resident's needs and preferences . and .speak respectfully to residents .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a clean, sanitary, comfortable, and homelike environment for 1 of 8 residents (Resident #2) in that:<BR/>1. <BR/>Resident #2's window, window blinds, and floor around his bed were soiled with visible dust, dirt, debris, and smudges.<BR/>2. <BR/>Resident #2's bed sheets and pillowcase had scattered brown stains on them.<BR/>This failure placed residents residing in the facility at risk for a diminished quality of life and a diminished clean, homelike environment.<BR/>The findings include:<BR/>Review of Resident #2's undated face sheet revealed he was a [AGE] year-old male readmitted to the facility on [DATE] with a primary diagnosis hemiplegia and hemiparesis following cerebral infarction of left non-dominate side (weakness or paralysis on one side of the body) and secondary diagnoses of cognitive or emotional deficit and aphasia (impaired ability to comprehend or formulate language).<BR/>Review of a quarterly MDS assessment dated [DATE] indicated Resident #2 had a BIMS score of 3 which indicated severe cognitive impairment and he required total assistance with oral hygiene, toileting hygiene, shower/bathing, lower body dressing, putting on/taking off footwear, and personal hygiene; he required maximum assistance for upper body dressing; he required setup and clean up assistance with eating. He was always incontinent of bowel and bladder.<BR/>A comprehensive care plan revised on 10/03/24 indicated Resident #2 exhibited verbal and physical aggressive behaviors with interventions in place including approaching and speaking to resident in a calm manner, clearly explaining all daily care activities, and early intervention when resident behaviors were escalating. Resident #2 had a history of violent behaviors and had hit staff at the facility on multiple occasions. The same comprehensive care plan included a revision on 12/05/25 which indicated Resident #2 had an ADL self-care performance deficit related to contracture of left hand, limited range of motion in upper and lower extremities, and hemiplegia/hemiparesis.<BR/>An observation on 3/24/25 at 11:36 AM of Resident #2's room revealed there were scattered brown stains on his sheets and pillowcase. The window in his room had green and brown smudges on the glass and the window blinds had an accumulation of dust on them. The floor around his bed had an accumulation of dirt and debris.<BR/>During an interview on 3/24/25 at 11:36 AM, Resident #2 said facility staff did change his bed linens and clean his room, but not daily.<BR/>During an interview on 3/24/25 at 11:45 AM Housekeeper C said all resident rooms were cleaned every day. She said the daily cleaning consisted of cleaning the restroom, wiping down all surfaces, sweeping and mopping the floors, and taking out the trash. She said she doesn't always clean behind resident beds or underneath them because she would need help to move the beds away from the wall. She said Resident #2 never exhibited any violent behaviors that interfered with housekeeping staff's ability to clean his room, and his room had already been cleaned today.<BR/>An observation on 3/25/25 at 9:00 AM Resident #2's room revealed what appeared to be the same soiled bed linens and pillowcase on his bed. The floor, window, and window blinds appeared to have not been cleaned from previous observation. <BR/>During an interview on 3/25/25 at 9:45 AM Housekeeper D said every resident room was cleaned daily and a daily cleaning included wiping down all surfaces, sweeping and mopping floors, and taking out the trash. Housekeeper C said she had enough time to complete all assigned duties and no resident behaviors had ever affected her ability to clean their rooms. <BR/>During an interview on 3/25/25 at 10:05 AM, CNA E said the facility had been having problems running out of clean linens in the morning. She said sometimes she had to delay changing bed linens until laundry staff washed more linens. <BR/>During an interview on 3/25/25 at 10:30 AM, EVS Manager said housekeepers were expected to clean each resident's room daily, which consisted of taking out the trash, wiping down all surfaces, and sweeping and mopping floors. She said, additionally, each housekeeper was assigned one room daily to be deep cleaned. She said a deep clean was cleaning everything in the room and it was also done for new resident admissions. She said CNAs were bringing soiled linens to the laundry room too late in the day to be washed and ready for the next morning, because laundry staff left at 2:00 PM. She said linens were provided late some days, but there was always clean linen available to accommodate resident needs.<BR/>During an interview on 3/25/25 at 11:00 AM, the ADON said the facility had identified an issue with their laundry processing. The ADON said CNAs recently changed to a 12-hour shift, and left at 6:00 PM instead of 2:00 PM. She said CNAs were waiting until the end of their shift to bring linens to the laundry room and laundry staff left at 2:00 PM. The ADON said she wasn't satisfied with the quality of housekeeping services, and administration was in discussion with the company they were contracted with.<BR/>An observation on 3/25/25 at 3:00 PM of Resident #2's room revealed what appeared to be the same soiled bed linens and pillowcase on his bed. The floor, window, and window blinds appeared to have not been cleaned from the initial observation. <BR/>During an interview on 3/25/25 at 3:00 PM, Resident #2 said staff had helped him change his clothing that day, but his linens had not been changed in a few days.<BR/>During an interview on 3/25/25 at 4:30 PM, the ADM said the facility had identified there was an issue with their laundry processing. She said CNAs were not emptying linen barrels early enough in the day to provide laundry staff time to wash them. The ADM said CNAs had been instructed to empty linen barrels earlier in the day. She said the facility always had clean linens available to accommodate resident needs.<BR/>Review of a policy dated May 2003 titled Housekeeping Standards indicated the following:<BR/> .The facility will provide a clean and sanitary living environment for the physical and emotional wellbeing of the resident .<BR/>And<BR/> .Daily cleaning schedules will be followed to provide a clean, safe, sanitary environment for residents, staff and visitors .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 20 residents (Resident #20) reviewed for care plans.<BR/>The facility failed to revise Resident #20's care plan to reflect his choice to be a DNR. <BR/>This failure could place residents at risk for not receiving appropriate care and interventions to meet their current choices and needs.<BR/>Findings include: <BR/>Record review of Resident #20's, undated, face sheet indicated an [AGE] year-old male who was admitted to the facility on [DATE]. <BR/>Record review of Resident #20's physician's orders, dated [DATE] , indicated Resident #20 had diagnoses which included: Parkinson's Disease (a disorder of the nervous system that affects movement, often including tremors), Cerebrovascular Disease (affects blood flow to the brain) and dementia (persistent loss of intellectual functioning). <BR/>Record review of Resident #20's physician's order, dated [DATE], indicated Resident #20 was a DNR. <BR/>Record review of Resident #20's OOH-DNR indicated it was signed on [DATE] by Resident #20's family member. <BR/>Record review of the care plan, dated [DATE], indicated Resident #20 had impaired cognition with a risk for further decline and indicated he was a full code. Resident has physician's orders that include a status of full code. The goal indicated staff would administer CPR if resident had an arrest. The interventions were to ensure the full code order was on the chart and begin CPR after absence of vital signs, call 911, notify physician, and notify family/responsible party. <BR/>Record review of the admission MDS, dated [DATE], indicated Resident #20 had clear speech, was sometimes understood by others, and sometimes understood others. Resident #20 had a BIMS score of 6, which indicated severe cognitive impairment. He had inattention that was continuously present. <BR/>Record review of the care plan on [DATE] at 11:05 AM indicated Resident #20 was full code. <BR/>Record review of the physician's orders, dated [DATE], indicated Resident #20 was a DNR. The DNR was ordered by the physician on [DATE].<BR/>Record review of an OOH-DNR for Resident #20 was dated [DATE] . <BR/>During an interview on [DATE] at 11:39 AM, MDS Q said the care plan was an IDT approach. She said different staff were responsible for the care plan in the different disciplines put different things in the care plan. She said the person responsible for the code status of a resident was the SW . <BR/>During an interview and record review on [DATE] at 11:41 AM, the DON and the State Surveyor looked at Resident #20's care plan. The DON agreed the care plan indicated the resident was full code. She and she looked at his DNR, dated [DATE], and she stated she knew he was a DNR. She said his care plan should have been changed and updated to indicate he was a DNR, and it was not. She said his most recent care plan meeting was Wednesday [DATE] and the next day, [DATE] his family member came in and signed a DNR with the SW. She said the SW should have updated the care plan when she got the DNR paperwork. The SW and the DON reviewed the resident's physician's orders for a DNR, dated [DATE] and an OOH-DNR also dated [DATE]. She said the process was, whoever received the DNR paperwork should change the care plan. She said the SW did not change the care plan and it was her responsibility. She said ultimately, she was responsible for the care plan being updated to reflect the current status of Resident #20 because she was the DON. <BR/>During an interview on [DATE] at 12:34 PM, the DON said the advance directive policy indicated the SW should document all DNR's. She said the SW knew it was her responsibility, and it was she who met with the family to discuss and complete the DNR. <BR/>During an interview on [DATE] at 2:39 PM, the SW said she met with Resident #20's family to do the DNR on [DATE]. She said she was supposed to update the care plan but got busy and did not do it. She said it was her responsibility to update the care plan and she should have done it .<BR/>During an interview on [DATE] at 12:07 PM, LVN R said the importance of code status on the care plan was for nurses to know whether or not to perform CPR on a resident. She said she would not want to do CPR if a resident was a DNR because it could cause a poor quality of life. She said you would certainly want to do CPR on a resident who had chosen a full code status. She said nurses had to know whether a resident was a full code or a DNR and their information had to be documented correctly. She said if staff did CPR on a resident who chose a DNR, that resident could end up on a tracheostomy (surgically created hole in the neck to allow air into the lungs) or life support. She said a DNR or a full code was the resident/family's choice to make. She said resident choices were very important. She said the SW was responsible for making sure the code status was documented correctly on the care plan.<BR/>During an interview on [DATE] at 12:14 PM, LVN S said code status was important. She said if a resident was a DNR and they gave that resident CPR and revived them, they could be in a lot of trouble. She said if a resident was a full code and they thought the resident was a DNR, and did not try to revive them the resident could die. She said they had to be sure all information was in the care plan correctly. She said the residents choice was very important. She said the SW was responsible for making sure a resident's code status was correct in the care plan. <BR/>During an interview on [DATE] at 12:23 PM, ADON P said the resident's code status on the care plan was how they determined whether or not to initiate CPR for a resident. She said it was very important for the information to be correct regarding the resident's choices. She said if a resident was a DNR and they did CPR, it could cause harm to the resident because they could have broken bones during CPR, caused a poor quality of life, caused the resident's family to be upset, not acknowledged the resident's wishes or their right to choose. ADON P said if it was the other way around, and a resident was a full code and did not get CPR, they could die. She said the family would be very upset if the facility did not try to save them. <BR/>During an interview on [DATE] at 1:11 PM, the DON said she expected the SW or the licensed staff who received DNR paperwork to update the care plan. She said she thought Resident #20's care plan not being updated with the new DNR order was an oversite on the part of the SW. She said she expected the care plan to be updated with the resident's wishes regarding a full code or a DNR. The DON said it would be a big problem if a resident who was a DNR was given CPR because that was a dignity issue and not the resident's wishes. She said that could cause the resident depression and a poor quality of life. She said giving a DNR resident CPR would be the worst scenario ever. She said if you did not give CPR to a resident who was a full code it could cause a resident to die before they should and not attempting to save their life. She said that was playing with someone's life. She said if the wishes of the resident were not followed it could also cause the family to be grievous. <BR/>During an interview on [DATE] at 1:41 PM, the ADM said she expected the care plan to be correct regarding a resident's code status. She said the SW was responsible for making sure the care plan was updated to reflect the correct code status. She said the SW's responsibility for the care plan was the code status. She said regarding Resident #20's incorrect care plan (which indicated he was a full code when he was a DNR) that could have caused him to get CPR when that was against his wishes and it could be a dignity issue. She said they had a code book that ADON P updated with new information and staff could look in the book to see who was a DNR and who was a full code. She said she did not know if Resident #20's code status was updated in the Code Book . She said if a resident was a full code and incorrectly marked as a DNR the resident could die when they should not have, and that could cause legal issues. She said resident choices were important. <BR/>During an interview and record review on [DATE] at 1:46 PM, ADON P showed the State Surveyor the Code Book which included a DNR for Resident #20 and a copy of his OOH-DNR dated [DATE]. She said she put the information for Resident #20's code status in the Code Book but did not remember when. <BR/>Record review of an Advance Directives/Advance Care Planning Policy, dated 4/2007, revised 1/2023, and 4/2015, indicated: <BR/>Policy<BR/>It is the policy of this facility to recognize two fundamental rights of a person; the right to live and to continue treatment and the right to refuse or terminate unwanted treatment. This facility will honor a resident's wished and advanced directives pertaining to his/her own medical treatment, including wishes to withhold treatment . <BR/>In the absence of the Social Worker the Administrator appoints a staff member to assume the responsibility for advance directives and advanced care planning. <BR/> .8.Social Service communicates to a nursing a residents advanced directive/code status implementation or changes. <BR/>Record review of the Comprehensive Care Plans Policy, dated [DATE], indicated: <BR/>Policy<BR/>It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. <BR/> .3.The comprehensive care plan will describe, at a minimum, the following:<BR/>a. <BR/>The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.<BR/>b. <BR/>Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an environment that was free of accident hazards for 1 of 6 residents reviewed for accidents hazards. (Resident #130)<BR/>The facility failed to implement a fall intervention when Resident #130 said he fell on [DATE] to prevent Resident #130 from falling on 02/27/2023.<BR/>These failures could place residents at risk for falls and falls with serious injury. <BR/>Findings included:<BR/>Record review of a face sheet dated 03/02/2023 indicated Resident #130 was an [AGE] year-old male who admitted on [DATE] with the diagnoses of stroke, heart attack, heart failure, and diabetes. <BR/>Record review of a baseline care plan dated 02/23/2023 documented by the ADON indicated Resident #130 had self-care performance with personal hygiene, toileting, dressing and bathing. The base line care plan indicated Resident #130 was alert but cognitively impaired. The base line care plan indicated Resident #130 was at risk to fall with the goal will not sustain a fall related injury by utilizing fall precautions through next review date. The Fall care plan indicated an intervention would be to provide assistance to transfer and ambulate as needed.<BR/>Record review of a comprehensive care plan dated 02/23/2023 and revised on 03/01/2023 indicated Resident #130 had a potential to falls related to high blood pressure medications, gait problems, and incontinence. The goal was he would not sustain a fall related injury by utilizing the fall precautions. The interventions included anticipate his needs, educate resident/family/caregivers on safety reminders, encourage socialization, encourage activities, anticipate needs by placing items close to him, and attempt to determine cause of past falls. The comprehensive care plan did not address a bed alarm.<BR/>Record review of the most recent MDS dated [DATE] indicated Resident #130 usually understands and was usually understood. Resident #130 BIMS score was 12 but he required cueing to recall. The MDs indicated Resident #130 had difficulty focusing his attention and was easily distracted. The MDS indicated Resident #130 required limited assistance of one staff with bed mobility, transfers, walking, locomotion, dressing, toileting, personal hygiene, and extensive assistance of one staff for bathing. The MDS indicated Resident #130 was incontinent occasionally of bladder and frequently of bowel. The MDS indicated Resident #130 had one fall with an injury.<BR/>Record review of a fall risk dated 02/23/2023 indicated Resident #130 scored a 14 indicating he was at moderate risk to fall. The fall risk indicated Resident #130 had a history of multiple falls in the last six months. The fall risk assessment indicated Resident #130 could not recall the season, where he was, the location of his room or the names of the staff. The assessment failed to assess his gait.<BR/>Record review of a nurse's note dated 02/26/2023 at 11:30 a.m., RN G wrote Resident #130's family was visiting today and informed the RN supervisor and staff nurse of Resident #130 reporting he had a fall last night and got himself back to bed and did not report to anyone. RN G documented there was new discoloration around the right eye of Resident #130.<BR/>Record review of an incident report dated 02/26/2023 indicated Resident #130 reported a fall last night. The daughter's statement indicated she reported Resident #130 said he fell against his wheelchair. The immediate action taken on the incident report indicated a head-to-toe assessment was completed with noted old bruises to trunk with yellow discoloration. Slight bruising noted to the right peri-orbital area (surrounding the eye).<BR/>Record review of a progress note documented by LVN V dated 02/27/2023 at 9:59 p.m., indicated Resident #130 was found on his buttocks on the floor between the bed and wheelchair. LVN V documented Resident #130 said he was trying to get in his chair. LVN V documented there were no injuries. LVN V indicated the bed was in low position and he had his call light in his hand. LVN V indicated she provided re-education. <BR/>Record review of the consolidated physician's orders indicated Resident #130 had a bed alarm ordered on 02/28/2023 two days after he reported to his family, he fell and sustained bruising to his right eye. <BR/>Record review of the electronic medical record dated February 2023 indicated Resident #130 had a physician's order for a bed alarm when in bed, monitor every shift for falls beginning on 02/28/2023 at 6:00 p.m. The medical record did not indicate a nurse completed this task; the space was blank.<BR/>During an observation and interview on 03/01/2023 at 4:10 p.m., Resident #130 was lying in bed. Resident #130 had deep purple peri-orbital (around the eye) bruising. Resident #130 said he did not know he had bruising to his right eye. Resident #130 denied falling.<BR/>During an interview on 03/03/2023 at 11:00 a.m., the DON said the care plan should be updated with fall interventions as they occur to prevent another fall or risk for injuries. The DON said the nursing team was responsible for putting interventions in place.<BR/>During an interview on 03/03/2023 at 11:30 a.m., the Interim Administrator said interventions should be put in place with each fall to prevent the next fall. The Interim Administrator said not putting an intervention in place could result in a serious injury.<BR/>Record review of an Investigation of Incidents and Accidents policy dated 12/03/2020 indicated the resident environment will remain s free of accident hazards as possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This included: identifying hazards and risks, evaluating, and analyzing hazards and risk, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Implementation of Interventions-using specific interventions to try to reduce a resident's risk from hazards in the environment. This process included: Ensuring interventions were put into action.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to secure all drugs and biologicals in locked compartments, including the storage of schedule II-V medications in separately locked, permanently affixed compartments, permitting only authorized personnel to have access for 4 of 6 medication carts. (Stations #1, #2, #3, and #4)<BR/>The facility failed to ensure only authorized personnel had access to the facility's medication carts containing narcotics. <BR/>The facility failed to ensure medication carts with narcotics, were kept double locked.<BR/>These failures could place residents at risk of drug diversion and misuse of medication.<BR/>Findings included: <BR/>During an observation on 01/31/23 at 05:02 AM, two medication carts located near Nurse's station 1 were unattended and the outer lock was open.<BR/>During an interview on 01/31/23 at 5:02 AM, LVN A said both carts should be locked because they contained narcotics and should be under double lock.<BR/>During an observation on 01/31/23 at 5:13 AM, a medication cart located near Nurse's station 3 was unattended and unlocked.<BR/>During an interview on 01/31/23 at 5:15 AM, LVN B said the cart should be always locked because there were narcotics in the cart. LVN B said during the night shift LVN B and LVN A share the keys to the medication cart because not all the medications were in each cart. <BR/>During an observation and interview on 01/31/23 at 5:20 AM, the cart 3 was locked. When asked to open the cart, LVN B said she did not have the key and used her hand to pat the top of the notebook on top of the cart looking for the keys. LVN B said she must have left them in her jacket and walked toward Station 3. LVN A walked toward the cart and said she had the keys. LVN A handed the keys to LVN B. LVN B unlocked the cart showing narcotics inside the cart. <BR/>During an interview on 01/31/23 at 5:21 AM, LVN A said she normally left the keys inside the narcotic count book on top of the medication cart. LVN B said she sometimes left the keys in the book. <BR/>During an interview on 01/31/23 at 6:20 AM, the ADON said all narcotics should be stored under double lock according to facility policy. The ADON said carts should be secured any time they were unattended, and keys should never be left on top of the cart. The ADON said the facility had some recent drug diversions.<BR/>During an observation 02/02/23 at 5:11 AM, Station 4 medication cart was locked. Two sets of keys were on top of the cart in plain view. Surveyor approached the cart, NA A, looked at Surveyor, reached for the keys and pulled her hand back rapidly. Surveyor walked to station 3, the cart was locked. Surveyor turned around and went back to the cart on station 4 the keys were no longer on the cart. <BR/>During an interview on 02/02/23 at 5:14 AM, NA A said LVN C motioned for her to get the keys when she saw the surveyor coming. When asked how she knew LVN wanted her to get the keys, NA said, Because she was standing down the hall in front of room [ROOM NUMBER] and pointed to the cart and felt of her pockets. NA A said she should not have keys to the medication cart. <BR/>During an interview on 02/02/23 at 5:15 AM, LVN C said it was a mistake to leave the keys on top of the cart. LVN C said normally she does not leave the keys. LVN C said the keys on top of the cart were for the medication cart and the nursing cart for Hall 1. LVN C said she motioned for NA to move her cart.<BR/>During an observation and interview on 02/02/23 at 5:15 AM, Surveyor asked LVN C to unlock the nursing cart on Station 1. LVN C felt her pockets and said, I don't have the keys. NA A must have them. LVN C asked NA A for the keys. LVN C got the keys from NA A, opened the Nurse's cart on Station 1 revealing 20 containers of narcotics in the cart. <BR/>During an observation on 02/02/23 at 5:25 AM, station 2 medication cart was unlocked inside a room next to the nurses' station. LVN D walked into the unlocked room.<BR/>During an interview on 02/02/23 at 5:26 AM, LVN D said she was just around the corner restocking the other cart. LVN D said she left the cart unlocked when she took supplies to the other cart that was in the hallway, just around the corner. <BR/>During an observation on 02/02/23 at 5:26 AM, LVN D opened the Narcotic lock box for station 2 and seven cards of narcotics were inside the box. <BR/>Record review of a policy titled medication storage dated 01/20/21 showed .1. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication room) under proper temperature controls. B. Only authorized personnel will have access to the keys to locked compartments . 2. Narcotics and Controlled Substances: a. Scheduled II drugs and back-up stock of Schedule III, IV and V medications are stored under double-lock and key. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections were maintained for 4 of 6 residents reviewed for communicable disease (Resident #'s 41, 45, 54, and 74) and 1 of 12 months reviewed for infection control tracking and trending (January 2023).<BR/>The facility failed to initiate transmission-based precautions with the onset of the diagnosis of shingles F(painful rash with blisters) for Resident #45. <BR/>The facility failed to initiate transmission-based precautions with the onset of and ongoing of diarrhea for Resident #74. <BR/>CNA C failed to change gloves and washing her hands during incontinent care and prior to exiting Resident #74's room. <BR/>The facility failed to separate the linen from the rooms with communicable infections from the general linen for Resident #'s 45 and 74. <BR/>The facility failed to test Resident #41 for Clostridium Difficile (Inflammation of the colon caused by bacteria) when he had chronic diarrhea. <BR/>The facility failed to document tracking and trending of infection and antibiotic use for January of 2023. <BR/>LVN F failed to remove soiled gloves after obtaining Resident #50's blood sugar and he failed to perform hand hygiene before donning clean gloves.<BR/>The facility failed to ensure LVN D did not use a dirty cloth to clean Resident #54's catheter during catheter care. <BR/>The Infection Preventionist allowed RN G to work with a temperature of 102.2. <BR/>An Immediate Jeopardy (IJ) situation was identified on 02/28/2023 at 4:47 p.m. While the IJ was removed on the 03/03/2023 at 1:21 p.m., the facility remained out of compliance at an actual harm with a scope of widespread with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. <BR/>This failure could place residents at risk for being exposed to shingles, and diarrhea related to clostridium difficile (bacteria causing diarrhea to life-threatening damage to the colon. <BR/>Findings included:<BR/>1) Record review of a face sheet dated 03/02/2023 indicated Resident #45 was an [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of heart failure, depression, malnutrition, and high blood pressure. <BR/>Record review of the consolidated physician's orders dated 02/01/2023 indicated Resident #45 was did not indicated contact isolation was ordered.<BR/>Record review of the consolidated physician's orders dated 03/01/2023 indicated Resident #45 had Acyclovir 800 milligrams 5 times daily for 5 days for possible shingles started on 03/01/2023. Resident #45 had Clindamycin 300 milligrams three times a day for cellulitis x 7 days started on 02/28/2023 and Doxycycline Monohydrate 100 mg twice a day for cellulitis until 03/07/2023. Resident #45 was also ordered Gentamicin Sulfate Ophthalmic ointment 0.3% 1 application in right eye two times a day for infection x 7 days to start on 02/28/2023.<BR/>Record review of the comprehensive care plan dated 11/09/2022 failed to indicate Resident #45 had shingles involving his face, and right eye. The comprehensive care plan did not address isolation precautions. <BR/>Record review of the most recent Significant change MDS dated [DATE] indicated Resident #45 was usually understood and usually understands. Resident #45 required large print to read. The MDS indicated Resident #45's BIMS score was 11 indicating he had moderately impaired cognition. The MDS indicated during the assessment period Resident #45 did not reject care. The MDS indicated Resident #45 required extensive assistance of one staff with bed mobility, dressing, toilet use, personal hygiene, and with bathing Resident #45 required total assistance of one staff member. Resident #45 was incontinent of bowel and bladder. <BR/>Record review of Resident #45's February 2023 electronic medication record indicated he received Acyclovir 800 milligrams one tablet three times a day for shingles for 7 days started on 02/20/2023 and completed on 02/27/2023. Resident #45 was ordered Ofloxacin Ophthalmic Solution 0.3% one drop to the right eye 4 times daily for 5 days starting on 02/20/2023. Acyclovir 800 milligrams was restarted on 02/28/2023, Ofloxacin Ophthalmic Solution 0.3% instill one drop in right eye at bedtime for 7 days started on 2/27/2022, and Doxycycline 100 milligram give one tablet twice daily for 7 days started on 02/28/2023 after surveyor intervention. <BR/>Record review of a nursing note dated 02/20/2023 at 10:12 a.m., LVN G wrote the physician was notified regarding Resident #45's redness, swelling, and matter to his right eye.<BR/>Record review of a nursing note dated 02/20/2023 at 10:54 a.m., LVN G wrote he received new orders for Acyclovir 800 milligrams three times a day for 7 days, ofloxacin 0.3% one drop in right eye four times a day for 5 days, appointment with an ophthalmologist and check a HSV ig M level.<BR/>Record review of a nursing note dated 02/20/2023 at 8:34 p.m., LVN M wrote monitoring for edema every day and night shift, with the right side of Resident #45's face/eye with edema with the MD aware with labs ordered.<BR/>Record review of a nursing note dated 02/21/2023 at 1:03 a.m., LVN M wrote right side of Resident #45's face/eye continues with edema and redness, and Resident #45 denied pain. LVN M noted Resident #45's son would like to see if the facility ophthalmologist could see resident #45 instead of having to be transferred out of the facility. <BR/>Record review of a nursing note dated 02/22/2023 at 9:08 a.m., LVN O indicated Resident #45 continued the Acyclovir eye drops to his eye every night, continued to assess for pain, discomfort, and changes.<BR/>During an observation on 02/27/2023 at 12:17 p.m., Resident #45 was lying in his bed. He had scabbing appearing areas to his right eye and forehead. Resident #45's right eye is scabbed closed he could not open it on command. There were no isolation precautions posted on Resident #45's room.<BR/>During an interview on 02/27/2023 at 12:26 p.m., CNA N said Resident #45 had not been on any isolation precautions. CNA N said she regularly cares for Resident #45 and has floated to other halls to help. CNA N said she had questioned the DON as to why Resident #45 was not on any type of isolation because CNA N said shingles were contagious. CNA N said she floated to work on other halls. CNA N said Resident #45 did not eat any of his noon meal because he was hurting from the shingles.<BR/>During an interview on 02/27/2023 at 8:55 a.m., the DON said the nurses had not realized Resident #45 required isolation. The DON said the nurses did not make her aware of a case of shingles. The DON said Resident #45 should have been placed on contact isolation. The DON said the risk for unvaccinated and residents who had not had chicken pox as a child were at risk of having shingles. The DON said she was unaware Resident #45 had an order to see an ophthalmologist related to his right eye. The DON said they facility eye physician had already made rounds around February 9th or the 10th. The DON said she had not contacted the mobile eye physician or the son with a plan to have Resident #45's right eye examined. The DON said shingles in the eye could result in vision loss for Resident #45. The DON said she was the infection preventionist for the building. The DON said she was unsure how Resident #45's infection of the shingles as missed because she said the nurse managers log the infections and review the orders in morning meeting. <BR/>Record review of a nurse note dated 02/28/2023 at 1:06 p.m., indicated Resident #45 was administered a tramadol 50 milligram tablet for pain.<BR/>During an interview on 02/28/2023 at 3:11 p.m., LVN P said CNA N asked why Resident #45 was not on isolation if he had shingles. LVN P said she asked the DON to explain why Resident #45 was being treated for shingles why was he not on isolation. LVN P said the DON said Resident #45 should have been on isolation. LVN P said she had worked February 19, 2023, through February 23, 2023. LVN P said Resident #45's eye was much worse. LVN P said no one had contacted the physician for Resident #45's worsening shingles. LVN P said Resident #45 had not been on isolation for the shingles, but he should have been to prevent the spread to other residents. <BR/>During an interview on 02/28/2023 at 3:26 p.m., the medical director said she was unaware of Resident #45's right eye condition with shingles covering the entire eye lid and the right eye would not open. The medical director said she was unaware Resident #45 had not seen an eye specialist related to the shingles to the right side of the face and eye. The medical director said she expected the facility to obtain an appointment promptly due to the risk of blindness with ocular shingles. <BR/>During an observation and interview on 02/28/2023 at 3:45 p.m., LVN P applied a warm compress to Resident #45's right eye. LVN P asked Resident #45 to open his right eye, and he could not open the eye at all. Resident #45 said his right eye was hurting and LVN P immediately stopped and said she would administer a pain medication. LVN P said she would notify the physician. Resident #45 now had isolation signs and PPE outside of the room.<BR/>Record review of a nurses note dated 02/28/2023 at 12:57 p.m., Resident #45 had an appointment scheduled for March 2, 2023, at 3:15 p.m. The note indicated Resident #45's son was notified of the appointment related to shingles to the right eye. <BR/>Record review of a nurse note dated 02/28/2023 at 8:03 p.m., the ADON wrote Resident #45's family was notified of the lab results of the Herpes Simplex IgM result of 0.66 and the new order received from the physician for Clindamycin 300 mg one three times and day and discontinue the acyclovir. <BR/>Record review of a nurse note dated 02/28/2022 at 8:21 p.m., the DON wrote Resident #45's isolation was discontinued for shingle precautions and indicated Resident #45 had a new diagnosis of cellulitis and with a new medication ordered. The new order was Clindamycin 300 mg one capsule three times a day for 7 days. <BR/>Record review of a nurse note dated 02/28/2023 at 11:08 p.m., LVN B wrote Resident #45 was administered gentamycin eye drops. LVN B wrote Resident #45 face was red and swollen with blisters and scabs.<BR/>During an interview on 02/28/2023 at 8:55 a.m., the DON said the nurses did not realize Resident #45 required isolation for the shingles. The DON said Resident #45 should have been placed on contact isolation. <BR/>During an interview on 02/28/2023 at 10:07 a.m., the Interim Administrator said she was unaware of Resident #45 having shingles. The Interim Administrator said shingles should be isolated in so not to spread to other residents.<BR/>Record review of Resident #45's March 2023 electronic medical record indicated he had Gentamicin Sulfate Ophthalmic Ointment 0.3% instill one application in the right eye two times a day for 7 days starting on 03/01/2023, Ofloxacin Ophthalmic Solution 0.3% instill one drop in right eye at bedtime for 7 days starting on 02/27/2023; Doxycycline monohydrate 100 milligrams one capsule twice daily for cellulitis until 03/07/2023; and Clindamycin 300 mg one capsule by moth three times a day for cellulitis for 7 days; and Acyclovir 800 milligrams one tablet by mouth 5 times a day for 5 days for possible shingles starting on 03/01/2023. <BR/>Record review of a nurse note dated 03/01/2023 at 1:24 a.m., LVN B documented Resident #45 had a diagnosis of cellulitis, day 2 of isolation, acyclovir was discontinued, day 2 of 7 on ofloxacin and gentamicin eye drops, day 3 of 7 on doxycycline with no adverse reactions. The note indicated Resident #45 had redness, swelling, and scabs to his face with warm compresses used.<BR/>During an interview on 03/01/2023 at 8:34 a.m., the Regional Corporate Nurse said after digging deeper the lab result for an IgM level was 0.66 which was negative. The Regional Corporate Nurse said Resident #45 was negative for shingles but was being treated for cellulitis. <BR/>During an observation and interview on 03/01/2023 at 9:18 a.m., Resident #45 said his right eye was hurting. Resident #45 had a very minimal opening between his eye lids and there was yellow stingy material in the opening. Resident #45's isolation precautions remained removed. <BR/>During an interview on 03/01/2023 at 2:57 p.m., the medical director indicated initially Resident #45's rash appeared to be shingles. The medical director indicated the IgM test (antibody test for an infection) was negative. The medical director said she would complete a PCR HSV and VSV, and place Resident #45 back on isolation. The medical director said she would order a PCR HSV and VSV (testing for Herpes simplex virus and varicella simplex virus) because the test would be the most accurate test according to CDC recommendation.<BR/>Record review of a nurses note dated 03/01/2023 at 6:10 p.m., LVN G placed Resident #45 back on isolation precautions further pending laboratory results. <BR/>Record review of a nurses note dated 03/01/2023 at 6:24 p.m., ADON wrote she notified the Resident #45's son of the new orders to restart Acyclovir 800 milligrams five times daily x 5 days, PCR HSV and VZV lab (laboratory test for herpes simplex and varicella zoster), and reinstate the isolation precautions. <BR/>Record review of an incident report dated 03/02/2023 at 3:30 p.m., indicated Resident #45 slid from his wheelchair to the floor. The ADON wrote there were no injuries noted but Resident #45 was sent to the emergency room.<BR/>Record review of an After Visit Summary dated 03/02/2023 indicated Resident #45 was provided instructions related to shingles and minor head injury. The summary indicated his diagnoses included an unspecified fall, facial contusion, and herpes zoster (shingles). The educational material included in the Visit Summary report indicated:<BR/>*If the shingles affects your eye the doctor may cover your eye with a bandage<BR/>*Infections of the eye and the skin around the eye were other health problems to treat<BR/>*To prevent the shingles do not share towels, go swimming, or play contact sports with people who have shingles if you never had chicken pox.<BR/>*Do not touch or scratch your rashes, if you do wash your hand afterwards.<BR/>2) Record review of a face sheet dated 03/02/2023 indicated Resident #74 was an [AGE] year-old female who admitted on [DATE] with the diagnoses of spondylolisthesis (disorder of which a bone vertebra slips forward onto the bone below), eating disorder, and high blood pressure. <BR/>Record review of a Baseline care plan dated 01/24/2023 at 8:39 a.m., the ADON did not document Resident #74 had a recent history of Clostridium Difficile (infection of the colon from bacteria), diarrhea, or isolation precautions needed for on-going symptoms. <BR/>Record review of the comprehensive care plan dated 02/07/2023 indicated Resident #74 was at risk for Covid 19 infection but did not mention Clostridium Difficile or the need for isolation precautions. <BR/>Record review of an admission MDS dated [DATE] indicated Resident #74 was usually understood and usually understands. The MDS indicated Resident #74 BIMS score was a 13 indicating cognitively intact. The MDS indicated Resident #74 required extensive assistance of one staff with bed mobility, transfers, locomotion, toilet use, personal hygiene, and bathing. The MDS indicated Resident #74 was frequently incontinent of bowel and was not on a toileting plan. <BR/>Record review of the February 2023 electronic medical record indicated Resident #74 received Colestipol 1 gram twice daily for treating diarrhea since 01/24/2023, lactobacillus capsule one capsule by mouth twice daily, and Lomotil 2.5-0.025 milligrams one tablet every 6 hours as needed for diarrhea since 01/24/2023. The electronic medical record indicated Resident #74 had 8 doses in the month of February and two doses were unknown if effective. <BR/>Record review of a nursing progress note dated 01/24/2023 documented by LVN T indicated Resident #74 was post Clostridium Difficile .<BR/>Record review of a nursing progress note dated 01/31/2023 at 1:22 a.m., indicated LVN V administered Lomotil for diarrhea, but the medication was ineffective. The note did not indicate the physician was notified.<BR/>Record review of a nursing progress note dated 01/31/2023 at 12:24 p.m., LVN F documented Resident #74 was administered Lomotil for diarrhea.<BR/>Record review of a skilled nurses note dated 02/01/2023 at 12:48 a.m., indicated Resident #74 was post Clostridium Difficile.<BR/>Record review of a progress note dated 02/01/2023 at 1:30 a.m., indicated Resident #74 was administered Lomotil for diarrhea by LVN M. <BR/>Record review of a nursing note dated 02/03/2023 at 5:40 a.m., LVN T documented an administration of Lomotil for diarrhea was provided to Resident #74. <BR/>Record review of a nurses note dated 02/04/2023 at 3:32 a.m., LVN R documented Resident #74 was post clostridium difficile. <BR/>Record review of a nurses note dated 02/04/2023 at 3:32 a.m., LVN R documented Resident #74 was post clostridium difficile.<BR/>Record review of a nurses note dated 02/06/2023 at 8:37 a.m., indicated LVN S documented Resident #74 was post clostridium difficile. <BR/>Record review of a nurses note dated 02/06/2023 at 11:18 p.m., LVN T documented Resident #74 required the administration of Lomotil for diarrhea. <BR/>Record review of a nurses note dated 02/07/2023 at 11:40 p.m., LVN T documented Resident #74 required Lomotil administration related to diarrhea. <BR/>Record review of a nurses note dated 02/15/2023 at 9:42 p.m., LVN T documented Resident #74 required administration of Lomotil for diarrhea.<BR/>Record review of a nurses note dated 02/24/2023 at 12:54 a.m., indicated Resident #74 continued to have been monitored for diarrhea none noted on this shift. <BR/>Record review of a nurses note dated 02/25/2023 at 6:41 a.m., LVN T indicated Resident #74 had 3 diarrhea bowel movements with Lomotil given and effective at present. The note indicated Resident #74's peri area was very red.<BR/>Record review of a nurses note dated 02/25/2023 at 6:43 p.m., LVN B documented Resident #74 required Lomotil for diarrhea and the medication was effective. <BR/> During an observation on 02/27/2023 at 10:08 a.m., Resident #74 said her brief needed changing due to having a very large diarrhea bowel movement. Resident #74 was assisted to activate her call light for assistance. CNA C answered the call light and left the room. CNA C returned with bed linen and incontinent care supplies. CNA C washed her hands then initiated care to Resident #74. CNA C opened Resident #74's brief, then wiped down the left side of her groin, and then across Resident #74's abdomen. CNA C removed her gloves and applied new gloves. Then CNA C took a roll of trash bags and unrolled a bag for use with the same gloves on. CNA C removed gloves and washed her hands. She returned to Resident #74 applied new gloves then removed the soiled brief. CNA C touched the wipe bag and obtained more wipes to cleanse Resident #74's buttocks. CNA C dropped the new brief on the floor. CNA C removed her soiled gloves, opened Resident #74's door and exited the room without washing her hands. CNA C returned to the room with a new brief. CNA C then washed her hands and laid the new brief on top of soiled linen she had rolled up underneath Resident #74. CNA C touched the foot of the bed and moved the bed out to walk around the bed to provide care. CNA C then walked to end of the bed, moved the bed back against the wall and continued with the care. CNA C removed her gloves and donned more gloves applying a barrier cream to Resident #74's buttocks. Resident #74's room had no isolation signs posted or PPE (personal protective equipment).<BR/>Record review of a nurses note dated 02/27/2023 at 5:55 p.m., LVN F documented Resident #74 made the statement she thought she needed to return to the hospital due to the ongoing diarrhea. LVN F documented he informed Resident #74 he had a stool sample waiting for pickup. <BR/>During an interview on 02/28/2023 at 7:47 a.m., CNA C said she made a lot of mistakes with incontinent care. CNA C said she should have closed Resident #74's blind, should have washed hands with glove changes. CNA C said Resident #74 has had diarrhea since she admitted . <BR/>During an interview on 02/28/2023 at 7:51 a.m., the Housekeeping Supervisor said she was unaware there were residents with possible Clostridium Difficile. The housekeeping supervisor said for Clostridium Difficile there was a special tablet to add to the water for cleaning of these rooms. The housekeeping supervisor said she was also unaware of Resident #74 or Resident #45 having communicable disease processes requiring special laundry procedures. The housekeeping supervisor said when the laundry receives linen in the yellow bags the laundry personnel would be alerted to wash this linen separate from the general linen. <BR/>During an interview on 02/28/2023 at 3:26 p.m., the Medical Director said Resident #74 had Clostridium Difficile in the recent past. The Medical Director said she was not notified Resident #74 had on-going diarrhea since admission. The Medical Director said Resident #74 could be a carrier of Clostridium Difficile. The medical director said Resident #74 could still be infectious up to 6 weeks and should have been isolated to prevent the spread of a potential reinfection. The Medical Director said she was unaware Resident #74 was the neighbor to a resident who had non-Hodgkin's lymphoma (cancer of lymphatic system) and recently had a stem cell transplant.<BR/>Record review of a nurses note dated 02/28/2023 at 4:00 p.m., the Marketer QQ documented the medical director was notified of ongoing loose stool and ongoing since admission. The note indicated Marketer QQ notified the medical director of the negative C-diff lab test prior to admission on [DATE] and Resident #74 having Lomotil as needed. The note indicated a new order was received for Imodium 2 mg three times daily until C-diff test returns negative. <BR/>During an interview on 03/01/2023 at 10:58 a.m., LVN S said Resident #74's stool sample result was not back.<BR/>During an observation on 03/01/2023 at 9:18 a.m., Resident #74 was in the therapy gym with other residents present. Resident #74's room had isolation precautions signs and PPE available. <BR/>During an interview on 03/01/2023 at 11:17 a.m., LVN S said if Resident #74 does have clostridium difficile she was told the germ would be contained in her brief. LVN S agreed Resident #74 was incontinent of stool.<BR/>During an interview on 03/01/2023 at 11:30 a.m., the occupational therapist assistant said she checked with LVN S and was advised Resident #74 although on isolation precautions could come to the gym for therapy.<BR/>During an interview on 03/01/2023 at 11:36 a.m., the DON said Resident #74 should have not been allowed in the therapy gym increasing the risk to spread the communicable disease. <BR/>During an observation on 03/02/2023 at 9:48 a.m., Resident #74's neighbor next door had a sign placed beside her entrance indicating she was now in enhanced barrier precautions. The sign indicated everyone must:<BR/>*Clean hands before entering room<BR/>*All personnel must wear gloves, gown, with high care activities such as dressing, bathing, showers, and transfers<BR/>*Changing linen<BR/>*Providing hygiene<BR/>*Changing brief/toileting<BR/>*Device care<BR/>*Wound care.<BR/>This was determined to be an Immediate Jeopardy (IJ) situation on 02/28/2023 at 4:47 p.m. The Interim Administrator and the Regional Corporate Nurse was notified. The Administrator was provided with the IJ template on 02/28/2023 at 4:58 p.m.<BR/>The following Plan of Removal submitted by the facility was accepted on 03/03/23 at 1:21 p.m. and included the following:<BR/>Immediate Action:<BR/>*On 02/27/2023 Resident #45 was placed in contact isolation<BR/>*On 02/28/2023 Resident #74 was placed in contact isolation<BR/>*On 02/28/2023 Resident #45 was removed from contact isolation per physician's order, related to a negative Herpes Simplex IGM test on 02/21/2023, Medical Director ordered Acyclovir treatment which was administer per physician's order<BR/>*On 03/01/2023 after Medical Director spoke to the survey team, the Medical Director ordered Resident #45 to be placed back in isolation, restart Acyclovir, and PCR (Polymerase chain reaction) testing for HSV (herpes simplex virus) and VZV (varicella-zoster virus).<BR/>*On 03/01/2023 Resident #45 was placed back on contact isolation<BR/>*On 02/28/2023 Regional Nurse Consultant completed an assessment of resident #74 to validate Resident had no negative outcome from alleged improper peri-care.<BR/>Facility's plan to ensure compliance quickly:<BR/>*On 02/28/2023 DON/designee began training on Transmission Based Precautions to guide the center on when and what precautions to take to prevent transmission of pathogens base on mode of transmission including linen handling, storage, and sanitation for residents with presumed or confirmed infections, with all staff on duty. This education was completed on 02/28/2023with 20 of 89 staff trained. On 03/01/2023 at 2:00 p.m., no staff will be allowed to work until his education was completed.<BR/>*The DON/Designee was responsible for ensuring residents were placed on appropriate isolation precautions.<BR/>*On 03/01/2023 the DON was provided 1:1 education on Transmission Based Precautions to guide the center on when and what precautions to take to prevent transmission of pathogens based on mode of transmission, on monitoring, tracking, trending of infections by Regional Nurse Consultant. <BR/>*On 03/01/2023 an additional 8 staff were trained prior to working<BR/>*Again, no staff would be allowed to work until the education had been completed<BR/>*On 03/01/1023 DON/designee began performing Hand Hygiene Skills Validation with Nurse Assistants. The skill competencies were completed on 02/28/2023 at 10:00 p.m., with 19 of 89 staff trained. NO staff would be allowed to work until the skills competency was completed.<BR/>*On 03/01/2023 DON/designee began performing Hand Hygiene Skills Validation with all staff with an additional 39 of 89 staff trained.<BR/>*On 02/28/2023 DON/designee began performing Peri-Skills Validation with Nurse Assistants. The skills competencies were completed on 02/28/2023 at 10:00 p.m. with 11 of 29 Nurse Assistants trained. No Nurse Assistants would be allowed to work until the education was completed. <BR/>*On 03/01/2023 DON/designee began performing Peri-Skills Validation with Nurse assistants with an additional 10 of 29 staff trained.<BR/>*On 03/01/2023 housekeeping staff completed deep thorough cleaning/disinfection of resident #'s 45, 74, and 1 other identified resident's room. The cleaning included halls and common areas. <BR/>Quality Assurance:<BR/>*Medical Director was notified on 02/28/2023 at 8:00 p.m. of the Immediate Jeopardies.<BR/>*On 03/01/2023 an Ad Hoc QAPI meeting was conducted to discuss identified issues and to develop plan for sustaining compliance. <BR/>In-services Conducted:<BR/>Transmission Based (Isolation) Precautions dated 10/24/2022 indicated it was the policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' mode of transmission. For training and quick referencing purposes a summary of precautions was contained at the end of the policy.<BR/>Airborne Precautions refer to actions taken to prevent or minimize the transmission of infectious agents/organisms that remain infections over long distances when suspended in air.<BR/>Contact precautions refer to measures that were intended to prevent transmission of infectious agents which were spread by direct or indirect contact with the resident or the resident's environment.<BR/>Droplet precautions refer to actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions.<BR/>Transmission-based precautions (aka Isolation Precautions) refer to actions implemented in addition to standard precautions that were based upon the means of transmission (airborne, contact, and droplet) in order to prevent or control infections. <BR/>Policy Explanation and Compliance Guidelines:<BR/>1.Facility staff will apply Transmission-Based Precautions, in addition to standard precautions, to residents who were known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission.<BR/>2.The facility would use standard approaches, as defined by the CDC, for transmission-based precautions: airborne, contact, and droplet precautions. The category of transmission-based precautions will determine the type of personal protective equipment to be used.<BR/>3.When implementing transmission-based precautions, the facility will consider the following: <BR/>a. The identification of resident risk factors <BR/>b. The provision of a private room .<BR/>c. Cohorting .<BR/>d. sharing a room with a roommate with limited risk factors.<BR/>4. Residents on transmission-based precautions should remain in their rooms except for medically necessary care.<BR/>5. High touch objects and environmental surfaces should be cleaned and disinfected with an EPA-registered disinfectant .<BR/>6. Prompt recognition of need<BR/>Type and Duration of transmission-based precautions recommend for selected infections and conditions:<BR/>Clostridioides difficile formerly Clostridium difficile requires contact precautions, for the duration of the illness and hand hygiene with soap and water.<BR/>Herpes zoster (shingles) requires airborne (if disseminated), contact I if resident was immunocompromised, standard (if localized).<BR/>Validation Checklist Hand Hygiene:<BR/>*Necessary supplies present<BR/>*Water turned on with clean, dry towel; temperature adjusted for comfort<BR/>*Soap applied to hands<BR/>*Hands rubbed together vigorously with antimicrobial soap<BR/>*Friction applied to all surfaces of the hands and fingers<BR/>*Hand hygiene activity continued for 20-30 seconds<BR/>*Hands rinsed thoroughly under running water<BR/>*Hands kept lower than level of wrist during procedure<BR/>*No contact with the inside of the sink<BR/>*Stood away from sink to prevent splashing of uniform/clothing<BR/>*Hands dried thoroughly with paper towels<BR/>*Clean, dry paper towels used to turn off faucet<BR/>*Towels discarded into trash receptacles<BR/>*Alcohol gel used as adjunct<BR/>*Understands the use of gloves and when they were to be used<BR/>*Appropriate use of alcohol-based products.<BR/>Validation Checklist Perineal Care:<BR/>*Reviewed plan of care<BR/>*Gathered needed supplies<BR/>*Summoned for assistance if needed<BR/>*Knock and gained permission to enter resident's room<BR/>*Identified self, explained the procedure, provided privacy and asked permission to proceed<BR/>*Set up needed supplies on the bedside stand in easy reach<BR/>*Positioned the bed at a comfortable working position<BR/>*Washed hands correctly<BR/>*Avoided over exposure of resident while placing linens in proper place<BR/>*Filled wash basin half full of water<BR/>*Donned appropriate personal protective equipment<BR/>*Placed waterproof pad under resident if necessary<BR/>*Followed correct procedure for removing fecal material<BR/>*Performed correct procedure for female<BR/>*Performed correct procedure for male<BR/>*Followed infection control protocol<BR/>*Placed call-light device within easy reach of the resident<BR/>*Cleaned wash basin and returned to storage area<BR/>*Cleaned bedside stand<BR/>*Returned the door and blinds open if resident desired<BR/>*Recorded/reported appropriate data<BR/>*Maintained clean technique and observed any isolation precautions.<BR/>Monitoring included:<BR/>During Interviews on 03/03/2023 from 3:08 p.m. until 3:54 p.m., the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the IJ by:<BR/>Interview with the DON indicated she was [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported no later than 24 hours as required for two of 10 reviewed for abuse, neglect, and exploitation (Resident #1 and Resident #2). <BR/>The facility did not report an incident of drug diversion and of misappropriation of drug medication to state agency.<BR/>This failure could place residents at risk of drug diversion and misuse of medication<BR/>Findings included:<BR/>Record Review of the facility investigation report indicated the incident was reported on 12/12/2023 at 10:27 PM. The report indicated on 12/9/22, the medication aide discovered potassium pills in the hydrocodone card for Resident #1. The report indicated the card was almost empty and only had a few pills remaining. The card had no obvious signs of tampering, and the pharmacy was notified. The report indicated the next day 4 more cards were found to be affected. The report indicated on 12/12/22, evidence of an empty potassium card was found, and it was concluded to have been the card of pills that were switched with the narcotic card. The report indicated audits revealed no further evidence. The pharmacy audit had no evidence of foul play. The report indicated staff who had access to the medications were drug tested and none tested positive. Staff were questioned and none reported knowledge of foul play amongst staff members. The report indicated the investigation indicated no evidence of who was responsible nor where the tampering took place.<BR/>During an interview on 02/01/2023 at 1:09 PM, LVN E said he worked 6:00 PM to 6:00 AM shift on 12/09/22. LVN E said around 6:30 PM, just after he started his shift, LVN C told him that Resident 1's Norco was really Potassium. LVN E said he assumed that LVN C had already reported it to the ADON. LVN E said he thought LVN C was just sharing information with him, and he did not think to report it at that time. LVN E said later that evening when he was passing medication around midnight, became curious, and looked at Resident #2's Norco. He said there were 4 cards. LVN E said the first 2 cards were Norco. LVN E said the first card had about 20 pills in the blister pack and the second card was full and there were 30 pills. LVN E said cards 3 and 4, were both full. LVN E said there were a total of 60 pills (30 in each pack) but the pills inside the pack were Potassium and not Norco. LVN E said the pills look a lot alike. LVN E said he called the ADON to report the Norco were Potassium and not Norco as it showed on the card. LVN E said he did an audit of other medications and did not find any other Norco that had been replaced.<BR/>During an interview on 02/01/2023 at 12:58 PM, the ADON said she first learned of Norco being replaced with Potassium around midnight on 12/09/22. The ADON said LVN E, called her and said two full cards of Norco had been replaced with potassium tablets.<BR/>During an interview on 02/02/2023 at 10:10 AM, The ADON said the drug diversion was reported to the previous Administrator of the facility on 12/10/22.<BR/>During Record Review of a written statement signed and dated 12/12/2022 by LVN E indicated, On 12/09/22, I was told that the [Resident #1's], Norco 10 mg were Potassium. Later that shift, I was just curious and looked at [Resident #2's] Norco 10 mg. That is when I noticed they were Potassium pills instead of Norco like the package says. I could tell it was Potassium due to how the pill looked. It was grainy/spotted looking, plus it has KCM10 which is Potassium 10 mg. That's when I decided to look at the new card sent that was delivered on 12/07/22. The first two partial cards were Norco 10 mg, the last 2 cards were Potassium. 60 in total. I checked to see if the package was tampered with, not marks were found. The foil was intact, the clear bubble and card was intact. The cards looked just like a new card from the Pharmacy. I then notified the Nurse Practitioner and ADON.<BR/>During Record Review of a letter dated 12/15/22 from Pharmacy Tech, and Customer Success Representative for the pharmacy company indicated, On Monday, December 13th, 2022, I performed a full audit of all medications stored in the medication carts throughout the facility. I verified the contents of each blister card to confirm the medication on the label matched the entire contents of each blister card. During my audit, there were no discrepancies in the medications located.<BR/>During Record Review of a witness statement dated 12/12/22 at 4:25 PM, signed by LVN F indicated, I found out about the narcotics being potassium on 12/09 from LVN E <BR/>During an interview on 02/02/2023 at 10:20 AM, with LVN F. LVN F said he worked on 12/09/22. LVN F said on 12/09/22 he heard LVN C telling LVN E, that a resident's Norco was really Potassium.<BR/>During an interview on 02/02/2023 at 10:33 AM, LVN E said the first time he heard of medication being switched from Norco to Potassium was from LVN C when he started his shift at 6:00 PM on 12/09/22. <BR/>During an interview on 02/02/2023 at 12:26 PM, the ADM said the incident of the missing medication was not reported within 24-hours because they thought it was a pharmacy error and did not know the packets had been tampered with at the time. The ADM said they discussed it and did not feel it was a reportable incident when they first heard about the wrong medications. The ADM said the incident should have been reported before 12/12/22 according to facility policy. <BR/>During Record Review of a Face Sheet, Resident #2 was a [AGE] year-old male admitted [DATE] with diagnoses of Chronic Pain. Consolidated Orders for January 2023 showed Resident #1 was prescribed Hydrocodone-Acetaminophen Tablet 10-325 MG give 1 tablet by mouth every 8 hours related to Chronic Pain Syndrome. Resident is given Tylenol #3 and Mobic to help manage pain. Order dated 01/28/2023 include Tylenol with Codeine#3 oral tablet 300-30MG, give 1 tablet by mouth every 6 hours as needed for moderate pain 4-6 for 14 days. Laboratory report dated 12/10/23 showed Resident #1's Potassium leve1 as 4.0, which was in the normal limits of 3.5 and 5.1. Review of Medication Administration Records (MAR) for January 2023, showed Medications were given as prescribed.<BR/>Record review of the Abuse Policy dated 01/01/2021 revealed . a.Shall report to the state agency and one or more law enforcement entities . any responsible suspicion of a crime against any individual who is a resident of or receiving care from the facility B.Shall report immediately, but no later than 2 hours after forming the suspicion .result in serious bodily injury, or not later than 24 hours if the events causing the suspicion do not result in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to secure all drugs and biologicals in locked compartments, including the storage of schedule II-V medications in separately locked, permanently affixed compartments, permitting only authorized personnel to have access for 4 of 6 medication carts. (Stations #1, #2, #3, and #4)<BR/>The facility failed to ensure only authorized personnel had access to the facility's medication carts containing narcotics. <BR/>The facility failed to ensure medication carts with narcotics, were kept double locked.<BR/>These failures could place residents at risk of drug diversion and misuse of medication.<BR/>Findings included: <BR/>During an observation on 01/31/23 at 05:02 AM, two medication carts located near Nurse's station 1 were unattended and the outer lock was open.<BR/>During an interview on 01/31/23 at 5:02 AM, LVN A said both carts should be locked because they contained narcotics and should be under double lock.<BR/>During an observation on 01/31/23 at 5:13 AM, a medication cart located near Nurse's station 3 was unattended and unlocked.<BR/>During an interview on 01/31/23 at 5:15 AM, LVN B said the cart should be always locked because there were narcotics in the cart. LVN B said during the night shift LVN B and LVN A share the keys to the medication cart because not all the medications were in each cart. <BR/>During an observation and interview on 01/31/23 at 5:20 AM, the cart 3 was locked. When asked to open the cart, LVN B said she did not have the key and used her hand to pat the top of the notebook on top of the cart looking for the keys. LVN B said she must have left them in her jacket and walked toward Station 3. LVN A walked toward the cart and said she had the keys. LVN A handed the keys to LVN B. LVN B unlocked the cart showing narcotics inside the cart. <BR/>During an interview on 01/31/23 at 5:21 AM, LVN A said she normally left the keys inside the narcotic count book on top of the medication cart. LVN B said she sometimes left the keys in the book. <BR/>During an interview on 01/31/23 at 6:20 AM, the ADON said all narcotics should be stored under double lock according to facility policy. The ADON said carts should be secured any time they were unattended, and keys should never be left on top of the cart. The ADON said the facility had some recent drug diversions.<BR/>During an observation 02/02/23 at 5:11 AM, Station 4 medication cart was locked. Two sets of keys were on top of the cart in plain view. Surveyor approached the cart, NA A, looked at Surveyor, reached for the keys and pulled her hand back rapidly. Surveyor walked to station 3, the cart was locked. Surveyor turned around and went back to the cart on station 4 the keys were no longer on the cart. <BR/>During an interview on 02/02/23 at 5:14 AM, NA A said LVN C motioned for her to get the keys when she saw the surveyor coming. When asked how she knew LVN wanted her to get the keys, NA said, Because she was standing down the hall in front of room [ROOM NUMBER] and pointed to the cart and felt of her pockets. NA A said she should not have keys to the medication cart. <BR/>During an interview on 02/02/23 at 5:15 AM, LVN C said it was a mistake to leave the keys on top of the cart. LVN C said normally she does not leave the keys. LVN C said the keys on top of the cart were for the medication cart and the nursing cart for Hall 1. LVN C said she motioned for NA to move her cart.<BR/>During an observation and interview on 02/02/23 at 5:15 AM, Surveyor asked LVN C to unlock the nursing cart on Station 1. LVN C felt her pockets and said, I don't have the keys. NA A must have them. LVN C asked NA A for the keys. LVN C got the keys from NA A, opened the Nurse's cart on Station 1 revealing 20 containers of narcotics in the cart. <BR/>During an observation on 02/02/23 at 5:25 AM, station 2 medication cart was unlocked inside a room next to the nurses' station. LVN D walked into the unlocked room.<BR/>During an interview on 02/02/23 at 5:26 AM, LVN D said she was just around the corner restocking the other cart. LVN D said she left the cart unlocked when she took supplies to the other cart that was in the hallway, just around the corner. <BR/>During an observation on 02/02/23 at 5:26 AM, LVN D opened the Narcotic lock box for station 2 and seven cards of narcotics were inside the box. <BR/>Record review of a policy titled medication storage dated 01/20/21 showed .1. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication room) under proper temperature controls. B. Only authorized personnel will have access to the keys to locked compartments . 2. Narcotics and Controlled Substances: a. Scheduled II drugs and back-up stock of Schedule III, IV and V medications are stored under double-lock and key. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to immediately consult with the resident's physician when there was significant change in the resident's physical, mental, or psychosocial status for 2 of 6 residents reviewed for notification of changes. (Resident #'s 45 and 74)<BR/>The facility failed to notify the resident's physician when Resident #45 had worsening symptomatic shingles (painful rash with blisters) covering his right eye lid. <BR/>The facility failed to notify the resident's physician when Resident #74 had diarrhea since admission on [DATE].<BR/>An Immediate Jeopardy (IJ) situation was identified on 02/28/2023 at 4:47 p.m. While the IJ was removed on the 03/03/2023 at 1:21 p.m., the facility remained out of compliance at an actual harm with a scope of pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. <BR/>These failures could place residents at risk of their physicians not being aware of the resident conditions and delay treatments for the residents' conditions of loss of vision and/or loss of life.<BR/>Findings included:<BR/>1)Record review of a face sheet dated 03/02/2023 indicated Resident #45 was an [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of heart failure, depression, malnutrition, and high blood pressure. <BR/>Record review of the most recent Significant change MDS dated [DATE] indicated Resident #45 was usually understood and usually understood others. The MDS indicated Resident #45's BIMS score was 11 indicating he had moderately impaired cognition. The MDS indicated during the assessment period Resident #45 did not reject care. The MDS indicated Resident #45 required extensive assistance of one staff with bed mobility, dressing, toilet use, personal hygiene, and with bathing Resident #45 required total assistance of one staff member. <BR/>Record review of the consolidated physician's orders dated 03/01/2023 indicated Resident #45 had Acyclovir 800 milligrams 5 times daily for 5 days for possible shingles(painful rash with blisters) started on 03/01/2023. Resident #45 had Clindamycin 300 milligrams three times a day for cellulitis (potentially serious bacterial skin infection) x 7 days started on 02/28/2023 and Doxycycline Monohydrate 100 mg twice a day for cellulitis until 03/07/2023. Resident #45 was also ordered Gentamicin Sulfate Ophthalmic ointment 0.3% 1 application in right eye two times a day for infection x 7 days to start on 02/28/2023.<BR/>Record review of the comprehensive care plan dated 11/09/2022 revealed it did not address that Resident #45 had shingles involving his face and right eye. The comprehensive care plan did not address isolation precautions. <BR/>Record review of Resident #45's February 2023 electronic medication administration record indicated these medications were ordered and administered medications: Acyclovir 800 milligrams one tablet three times a day for shingles for 7 days started on 02/20/2023 and completed on 02/27/2023. Resident #45 was ordered Ofloxacin Ophthalmic Solution 0.3% one drop to the right eye 4 times daily for 5 days starting on 02/20/2023. Acyclovir 800 milligrams was restarted on 02/28/2023, Ofloxacin Ophthalmic Solution 0.3% instill one drop in right eye at bedtime for 7 days started on 2/27/2023, and Doxycycline 100 milligram give one tablet twice daily for 7 days started on 02/28/2023.<BR/>Record review of Resident #45's March 2023 electronic medication record indicated these medications were ordered and administered: Gentamicin Sulfate Ophthalmic Ointment 0.3% instill one application in the right eye two times a day for 7 days starting on 03/01/2023, Ofloxacin Ophthalmic Solution 0.3% instill one drop in right eye at bedtime for 7 days starting on 02/27/2023; Doxycycline monohydrate 100 milligrams one capsule twice daily for cellulitis until 03/07/2023; and Clindamycin 300 mg one capsule by moth three times a day for cellulitis for 7 days; and Acyclovir 800 milligrams one tablet by mouth 5 times a day for 5 days for possible shingles starting on 03/01/2023. <BR/>Record review of a nursing note dated 02/20/2023 at 10:12 a.m., indicated LVN G wrote the physician was notified regarding Resident #45's redness, swelling, and matter to his right eye.<BR/>Record review of a nursing note dated 02/20/2023 at 10:54 a.m., indicated LVN G wrote he received new orders for Acyclovir 800 milligrams three times a day for 7 days, ofloxacin 0.3% one drop in right eye four times a day for 5 days, appointment with an ophthalmologist and to check a HSV ig M level (anti-body test to indicate a current or recent infection). <BR/>Record review of a nursing note dated 02/20/2023 at 8:34 p.m., indicated LVN M wrote monitoring for edema (swelling) every day and night shift, with the right side of Resident #45's face/eye with edema with the MD aware with laboratory test ordered.<BR/>Record review of a nursing note dated 02/21/2023 at 1:03 a.m., indicated LVN M wrote that the right side of Resident #45's face/eye continued with edema and redness, and Resident #45 denied pain. LVN M noted Resident #45's family member would like to see if the facility ophthalmologist could see Resident #45 instead of having to be transferred out of the facility. <BR/>Record review of a nursing note dated 02/22/2023 at 9:08 a.m., indicated LVN O wrote that Resident #45 continued the Acyclovir eye drops to his eye every night, continued to assess for pain, discomfort, and changes.<BR/>During an observation on 02/27/2023 at 12:17 p.m. revealed, Resident #45 was lying in his bed. He had scabbing appearing areas to his right eye and forehead. Resident #45's right eye was scabbed closed, and he could not open it when requested Resident #45 said he did not know what was on his face and eye.<BR/>During an interview on 02/27/2023 at 12:26 p.m., CNA N said she was told Resident #45 had shingles (painful rash with blisters) and not been on any isolation precautions. CNA N said she regularly careds for Resident #45 and had floated to other halls to help. CNA N said she had questioned the DON today as to why Resident #45 was not on any type of isolation because she said shingles were contagious. CNA N said Resident #45 did not eat his noon meal because he was hurting from the shingles.<BR/>During an interview on 02/27/2023 at 8:55 a.m., the DON said the nurses had not realized Resident #45 required isolation due to shingles being a contagious communicable disease. The DON said the nurses did not make her aware of Resident #45 having shingles when the symptoms started. The DON said Resident #45 should have been placed on contact isolation. The DON said the risk for unvaccinated and residents who had not had chicken pox as a child were at risk of having shingles. The DON said she was unaware Resident #45 had an order to see an ophthalmologist related to his right eye. The DON said they facility's eye physician had already made rounds around February 9th or the 10th 2023. The DON said she had not contacted the mobile eye physician or the family member with a plan to have Resident #45's right eye examined. The DON said shingles in the eye could result in vision loss for Resident #45. The DON said she was the infection preventionist for the building. The DON said she was unsure how Resident #45's infection of the shingles was missed because she said the nurse managers log the infections and review the orders in morning meeting. The DON said the physician should be notified immediately when symptoms occur or worsen.<BR/>Record review of a nurses note written by LVN P dated 02/28/2023 at 12:57 p.m., revealed Resident #45 had an appointment scheduled for March 2, 2023, at 3:15 p.m. The note indicated Resident #45's family member was notified of the appointment related to shingles to the right eye. <BR/>Record review of a nurse note dated 02/28/2023 at 1:06 p.m., indicated Resident #45 was administered a Tramadol 50 milligram tablet for pain to his right eye.<BR/>During an interview on 02/28/2023 at 3:11 p.m., LVN P said she had worked February 19, 2023, through February 23, 2023 and had observed Resident #45 during that time period. LVN P said Resident #45's eye was much worse than when she last saw the eye on February 23, 2023. LVN P said the medical record did not indicate any one had contacted the physician for Resident #45's worsening shingles. <BR/>During an interview on 02/28/2023 at 3:26 p.m., the Medical Director said she was #45's physician and she said she was unaware of Resident #45's right eye condition with shingles covering the entire eye lid and the right eye would not open. The Medical Director said she was unaware Resident #45 had not seen an eye specialist related to the shingles to the right side of the face and eye. The Medical Director said she expected the facility to obtain an appointment promptly due to the risk of blindness with ocular shingles. <BR/>During an observation and interview on 02/28/2023 at 3:45 p.m., revealed LVN P applied a warm compress to Resident #45's right eye. LVN P asked Resident #45 to open his right eye, and he could not open the eye at all. Resident #45 said his right eye was hurting and LVN P immediately stopped and said she would administer a pain medication. LVN P said she would notify the physician. <BR/>Record review of a nurse note dated 02/28/2023 at 8:03 p.m., indicated the ADON wrote Resident #45's family was notified of the lab results of the Herpes Simplex IgM (antibody test of recent or current infection) result of 0.66 and a new order was received from the physician for Clindamycin 300 mg one three times and day and discontinue the Acyclovir.<BR/>Record review of a medication administration record dated February 2023 indicated Clindamycin 300 mg was administered on 02/28/2023. <BR/>During an interview on 02/28/2023 9:57 a.m., the responsible party for Resident #45 said he was never told officially Resident #45 had shingles (painful rash with blisters). Resident #45's responsible party said he asked if the mobile eye doctor could see Resident #45 but he definitely would have had him sent to another local eye physician if Resident #45 needed to go.<BR/>Record review of a nurse note dated 02/28/2022 at 8:21 p.m., indicated the DON wrote Resident #45's isolation was discontinued for shingle precautions and indicated Resident #45 had a new diagnosis of cellulitis and with a new medication ordered. The new order was Clindamycin 300 mg one capsule three times a day for 7 days. <BR/>Record review of a nurse note dated 02/28/2023 at 11:08 p.m., indicated LVN B wrote Resident #45 was administered gentamycin eye drops. LVN B wrote Resident #45 face was red and swollen with blisters and scabs.<BR/>During an interview on 02/28/2023 at 10:07 a.m., the Interim Administrator said she was unaware of Resident #45 having shingles. <BR/>Record review of a nurse note dated 03/01/2023 at 1:24 a.m., indicated LVN B documented Resident #45 had a diagnosis of cellulitis, day 2 of isolation, acyclovir was discontinued, day 2 of 7 on Ofloxacin and G entamicin eye drops, day 3 of 7 on doxycycline with no adverse reactions. The note indicated Resident #45 had redness, swelling, and scabs to his face and a warm compress was used.<BR/>During an interview on 03/01/2023 at 8:34 a.m., the Regional Corporate Nurse said after digging deeper the lab result for an IgM level (antibody level detecting recent or new infection) was 0.66 which was negative. The Regional Corporate Nurse said Resident #45 was negative for shingles but was being treated for cellulitis. <BR/>During an observation and interview on 03/01/2023 at 9:18 a.m., Resident #45 said his right eye was hurting. Resident #45 had a very minimal opening between his eye lids and there was yellow stingy material in the opening. <BR/>During an interview on 03/01/2023 at 2:57 p.m., the Medical Director indicated initially Resident #45's rash appeared to be shingles. The medical director indicated the IgM test was negative for antibodies.<BR/> On 02/20/2023. The medical director said she would complete a PCR HSV and VSV (recommended testing for diagnosing of shingles), and place Resident #45 back on isolation. The medical director said she would order a PCR HSV and VSV because the test would be the most accurate test for diagnosing shingles according to CDC recommendation.<BR/>Record review of a nurses note dated 03/01/2023 at 6:24 p.m., indicated the ADON wrote she notified the Resident #45's family member on of the new orders to restart Acyclovir 800 milligrams five times daily x 5 days, PCR HSV and VZV lab, and reinstate the isolation precautions. <BR/>Record review of an incident report dated 03/02/2023 at 3:30 p.m., indicated Resident #45 slid from his wheelchair to the floor. The ADON wrote there were no injuries noted but Resident #45 was sent to the emergency room.<BR/>Record review of an After Visit Summary dated 03/02/2023 indicated Resident #45 was provided instructions related to shingles and minor head injury. The summary indicated his diagnoses included an unspecified fall, facial contusion, and herpes zoster (shingles). The educational material included in the Visit Summary report indicated:<BR/>*If the shingles affects your eye the doctor may cover your eye with a bandage<BR/>*Infections of the eye and the skin around the eye were other health problems to treat<BR/>*To prevent the shingles do not share towels, go swimming, or play contact sports with people who have shingles if you never had chicken pox.<BR/>*Do not touch or scratch your rashes, if you do wash your hand afterwards.<BR/>2) Record review of a face sheet dated 03/02/2023 indicated Resident #74 was an [AGE] year-old female who admitted on [DATE] with the diagnoses of spondylolisthesis (disorder of which a bone vertebra slips forward onto the bone below), eating disorder, and high blood pressure. <BR/>Record review of an admission MDS dated [DATE] indicated Resident #74 was usually understood and usually understood others. The MDS indicated Resident #74 BIMS score was a 13 indicating she was cognitively intact. The MDS indicated Resident #74 required extensive assistance of one staff with bed mobility, transfers, locomotion, toilet use, personal hygiene, and bathing. The MDS indicated Resident #74 was frequently incontinent of bowel and was not on a toileting plan. <BR/>Record review of a Baseline care plan dated 01/24/2023 at 8:39 a.m., indicated the ADON did not document Resident #74 had a recent history of Clostridium Difficile from the physicians history and physical (inflammation of the colon cause by bacteria), diarrhea, or isolation precautions needed for on-going symptoms. <BR/>Record review of the comprehensive care plan dated 02/07/2023 indicated Resident #74 was at risk for Covid 19 infection but the care plan did not mention Clostridium Difficile or the need for isolation precautions. <BR/>Record review of the February 2023 electronic medication record indicated Resident #74 received Colestipol 1 gram twice daily for treating diarrhea since 01/24/2023, lactobacillus capsule one capsule by mouth twice daily, and Lomotil 2.5-0.025 milligrams one tablet every 6 hours as needed for diarrhea since 01/24/2023. The electronic medication record indicated Resident #74 had 8 doses in the month of February and two doses were unknown if effective. <BR/>Record review of a nursing progress note dated 01/24/2023 documented by LVN T indicated Resident #74 was post C-diff.<BR/>Record review of a nursing progress note dated 01/31/2023 at 1:22 a.m., indicated LVN V administered Lomotil for diarrhea, but the medication was ineffective. The note did not indicate the physician was notified.<BR/>Record review of a nursing progress note dated 01/31/2023 at 12:24 p.m., indicated LVN F documented Resident #74 was administered Lomotil for diarrhea.<BR/>Record review of a skilled nurses note dated 02/01/2023 at 12:48 a.m., indicated LVN T documented Resident #74 was post C-diff.<BR/>Record review of a progress note dated 02/01/2023 at 1:30 a.m., indicated Resident #74 was administered Lomotil for diarrhea by LVN M. <BR/>Record review of a nursing note dated 02/03/2023 at 5:40 a.m., LVN T documented an administration of Lomotil for diarrhea was provided to Resident #74. <BR/>Record review of a nurses note dated 02/04/2023 at 3:32 a.m., indicated LVN R documented Resident #74 was post C-diff. <BR/>Record review of a nurses note dated 02/04/2023 at 3:32 a.m., indicated LVN R documented Resident #74 was post C-diff.<BR/>Record review of a nurses note dated 02/06/2023 at 8:37 a.m., indicated LVN S documented Resident #74 was post C-diff. <BR/>Record review of a nurses note dated 02/06/2023 at 11:18 p.m., LVN T documented Resident #74 required the administration of Lomotil for diarrhea. <BR/>Record review of a nurses note dated 02/07/2023 at 11:40 p.m., LVN T documented Resident #74 required Lomotil administration related to diarrhea. <BR/>Record review of a nurses note dated 02/15/2023 at 9:42 p.m., LVN T documented Resident #74 required administration of Lomotil for diarrhea.<BR/>Record review of a nurses note dated 02/24/2023 at 12:54 a.m., indicated LVN PP documented Resident #74 continued to have been monitored for diarrhea none on this shift. The note failed to indicate the physician was notified. <BR/>Record review of a nurses note dated 02/25/2023 at 6:41 a.m., indicated LVN T documented that Resident #74 had 3 diarrhea bowel movements with Lomotil given and effective at present. The note indicated Resident #74's peri area was very red. LVN T indicated she notified the physician and was waiting on orders.<BR/>Record review of a nurses note dated 02/25/2023 at 8:59 a.m., indicated LVN D apply Nystatin ointment to Resident #74's inner thighs and buttocks for redness. <BR/>Record review of a nurses note dated 02/25/2023 at 6:41 a.m., indicated LVN D received a new order for Nystatin ointment and zinc oxide twice daily for 30 days.<BR/>Record review of a nurses note dated 02/25/2023 at 6:43 p.m., indicated LVN B documented Resident #74 required Lomotil for diarrhea and the medication was effective. The note did not reflect LVN B notified the physician. <BR/>During an interview an observation on 02/27/2023 at 10:08 a.m., Resident #74 said her brief needed changing due to having a very large diarrhea bowel movement. Resident #74 said she thought she should return to the hospital due to her continuous diarrhea since she left the hospital. Resident #74 was assisted to activate her call light for assistance. CNA C answered the call light and left the room. CNA C returned with bed linen and incontinent care supplies. CNA C washed her hands then initiated care to Resident #74. LVN F said Resident #74 has had diarrhea since admission. LVN F said he had been trying to obtain a stool sample but the stool was so loose the bowel movement absorbed in the brief.<BR/>Record review of the physician's orders dated February 2023 did not reveal a stool specimen was ordered by the physician. <BR/>Record review of a nurses note dated 02/27/2023 at 5:55 p.m., indicated LVN F documented Resident #74 made the statement she thought she needed to return to the hospital due to the ongoing diarrhea. LVN F documented he informed Resident #74 he had a stool sample waiting for pickup. <BR/>During an interview on 02/28/2023 at 7:51 a.m., the Housekeeping Supervisor said she was unaware there were residents with possible Clostridium Difficile. The Housekeeping Supervisor said for Clostridium Difficile there was a special tablet to add to the water for cleaning of these rooms. The housekeeping supervisor said she was also unaware of Resident #74 or Resident #45 having communicable disease processes requiring special laundry procedures. The housekeeping supervisor said when the laundry receives linen in the yellow bags the laundry personnel would be alerted to wash this linen separate from the general linen. <BR/>During an interview on 02/28/2023 at 3:26 p.m., the physician for Resident #74 said Resident #74 had Clostridium Difficile in the recent past. The physician said she was not notified Resident #74 had on-going diarrhea since admission. The physician said Resident #74 could be a carrier of Clostridium Difficile. <BR/>Record review of a hydration assessment completed by the DON dated 02/28/2023 indicated Resident #74 had poor skin turgor, had more than a 3-pound weight loss in a month, and was at risk due to diarrhea/vomiting occurred in the last 7 days.<BR/>Record review of a Notification Policy dated 07/13/2015 and revised on 02/12/2023 indicated the policy was to provide guidance on when to communicate acute changes in status to MD, NP, and responsible party. The facility will immediately inform the resident; consult with the resident's physician; and if known, the resident's legal representative or appropriate family members of the following: <BR/>1. <BR/>An accident resulting in injury to the resident that potentially requires physician's intervention<BR/>2. <BR/>An emergency response situation that requires EMS involvement<BR/>3. <BR/>A significant change in the physical, mental, or psychosocial status of the resident.<BR/>4. <BR/>The need to significantly alter the resident's treatment.<BR/>5. <BR/>A decision to transfer or discharge the resident to another facility.<BR/>6. <BR/>A change in room or roommate assignment.<BR/>7. <BR/>A change in resident rights under Federal or State law, including changes to items and services included under State plans.<BR/>8. <BR/>The facility's Medical Director will be contacted if the attending or admitting physician can not be contacted and/or does not respond timely. <BR/>This was determined to be an Immediate Jeopardy (IJ) situation on 02/28/2023 at 4:47 p.m. The Interim Administrator and the Regional Corporate Nurse was notified. The Administrator was provided with the IJ template on 02/28/2023 at 4:58 p.m. and requested a Plan of Removal (POR).<BR/>The Plan of Removal (POR) was accepted on 03/02/2023 at 4:22 p.m. and indicated the following: <BR/>Immediate action:<BR/>*On 02/28/2023 the physician was notified of Resident #74's on-going diarrhea<BR/>*On 02/28/2023 the physician was notified of Resident #45's worsening symptoms of shingles.<BR/>Facilities plan to ensure compliance quickly:<BR/>*On 02/28/2023 DON/designee began training on notification of change in condition policy which provides guidance on when to communicate acute changes in status to physician and the need to significantly alter the resident's treatment with all licensed nurses on duty to include post-tests. This education was completed on 02/28/2023 at 10:00 p.m. with 11 of 34 licensed nurses trained. No licensed nurse will be allowed to work until this education is completed.<BR/>*On 03/01/2023 an additional 6 of 34 (total 17) licensed nurses were trained prior to working.<BR/>*Again, no licensed nurse will be allowed to work until this education has been completed<BR/>*On 03/01/2023 DON/designee began training on Clinical Documentation Guidelines which provides direction to the healthcare team on documentation and communication with the resident's progress and current treatment with all licensed nurse on duty. This education was completed on 03/01/2023 at 2:00 p.m. with 7 of 34 licensed nurses trained. No licensed nurse will be allowed to work until this education is completed.<BR/>*On 03/01/2023 an additional 6 of 34 (13 total) licensed nurses were trained prior to working<BR/>*Again, no licensed nurse will be allowed to work until this education has been completed. <BR/>Quality Assurance<BR/>*The Medical Director was notified on 02/28/2023 at 08:00 p.m., of the Immediate Jeopardies.<BR/>On 03/01/2023 An Ad Hoc QAPI meeting was conducted to discuss identified issues, and to develop plan for sustaining compliance<BR/>Monitoring included:<BR/>During Interviews on 03/03/2023 from 3:08 p.m. until 1:21 p.m., the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the IJ by:<BR/>Interview with the DON stated she was in-serviced on her role as Director of Nurses and Infection Preventionist. She was in-serviced on documentation of changes of condition requirements, notification of the responsible party and physicians, and following up on changes of condition to ensure all care needs were met. <BR/>Interviews with 2 RNs: DON and RN KK (6am-6pm); 4 nurses LVN L (6a-6p), LVN A (6a-6p), LVN F (6a-6p), LVN B (6p-6a), ADON (all shifts), Tx nurse (all shifts) in-serviced on transmission-based precautions, notification of the physician and family of acute changes such as accidents, illness, transfers, emergencies, and injuries.<BR/>Record review of Resident #74's laboratory PCR HSV and VSV pending taking 5-7 days for return.<BR/>Record review of Resident #74's stool culture dated 2/27/2023 indicated a negative result for C-diff.<BR/>Record review of Resident #45's ophthalmologist appointment dated 03/02/2023 at 3:15 p.m. but he slid from his wheelchair preparing to leave the facility. The facility working with a local EMS ambulance to take Resident #45 to the ophthalmologist on a stretcher. <BR/>In-services:<BR/>Record review of an in-service dated 03/03/3023 used the Notification of Changes policy with a revision date of 02/12/2021 indicated the policy was to provide guidance on when to communicate acute changes in status to MD, NP and /responsible party. The facility will immediately inform the resident: consult with the resident's physician; and if known, notify the resident's legal representative or appropriate family member(s) of the following:<BR/>3. A significant change in the physical, mental, or psychosocial status of the resident. <BR/>5. The facility documents resident assessment (s), interventions, physician and family notification (s) on SBAR, Nurse Progress Notes or Telephone Order Form (physician /family notice) as appropriate.<BR/>During an interview on 03/03/2023 at 11:15 a.m., the Interim Administrator said she expected the physician to be notified off all changes of condition.<BR/>On 03/03/2023 at 5:22 p.m. the Interim Administrator was informed the IJ was removed: however, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record reviews, the facility failed to review and revise by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessment for 1 of 1 (Resident #45) reviewed for comprehensive person-centered care plans.<BR/>The facility failed to revise Resident #45's care plan when he was receiving treatment for shingles (painful rash with blisters).<BR/>This failure could place residents at risk of not having their individualized needs met in a timely manner and communicated to providers and could result in a decline in physical well-being and care needs not being addressed.<BR/>Findings included:<BR/>1)Record review of a face sheet dated 03/02/2023 indicated Resident #45 was an [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of heart failure, depression, malnutrition, and high blood pressure. <BR/>Record review of the most recent Significant change MDS dated [DATE] indicated Resident #45 was usually understood and usually understands. Resident #45 required large print to read. The MDS indicated Resident #45's BIMS score was 11 indicating he had moderately impaired cognition. The MDS indicated during the assessment period Resident #45 did not reject care. The MDS indicated Resident #45 required extensive assistance of one staff with bed mobility, dressing, toilet use, personal hygiene, and with bathing Resident #45 required total assistance of one staff member. Resident #45 was incontinent of bowel and bladder. <BR/>Record review of the consolidated physician's orders dated 03/01/2023 indicated Resident #45 had Acyclovir 800 milligrams 5 times daily for 5 days for possible shingles started on 03/01/2023. Resident #45 had Clindamycin 300 milligrams three times a day for cellulitis x 7 days started on 02/28/2023 and Doxycycline Monohydrate 100 mg twice a day for cellulitis until 03/07/2023. Resident #45 was also ordered Gentamicin Sulfate Ophthalmic ointment 0.3% 1 application in right eye two times a day for infection x 7 days to start on 02/28/2023.<BR/>Record review of the February 2023 and March 2023 medication administration record indicated Resident #45 was receiving Acyclovir, Clindamycin, Doxycycline, and Gentamicin eye drops.<BR/>Record review of the comprehensive care plan dated 11/09/2022 revealed it did not address that Resident #45 had shingles involving his face, and right eye. The comprehensive care plan did not address isolation precautions. <BR/>During an interview on 03/01/2023 at 11:01 a.m., the MDS nurse NN said the residents''s comprehensive care plans were updated during the interdisciplinary team meetings in the mornings. The MDS nurse indicated the nurse managers were responsible for updating the care plans with acute infections.<BR/>During an interview on 03/03/2023 at 11:00 a.m., the DON said the nurse management team, and the MDS nurses should update the care plan. The DON said she was unsure how the charge nurses got away from documenting on the care plan. The DON said the care planning needs were reviewed in the morning meeting. The DON said Resident #45's care plan should have been updated by the nurse managers and herself included.<BR/>During an interview on 03/03/2023 at 11:15 a.m., the Interim Administrator said she was not sure who updated the care plans and she said that was a problem. The Interim Administrator said not updating the care plan could cause a resident to have missed care needs and services. <BR/>Record review of a Care Plans and Care Area Assessment Policy dated 01/21/2015 indicated the intent was to meet and abide by all State and Federal regulations that pertain to resident care plans and subsequent Care Area Assessments completion. The purpose of this guide was to ensure that an interdisciplinary approach was utilized in addressing the Care Area Triggers that were generated by the completion of the MDS to effectively address the Care Area Assessments and ultimately achieve the completion of an effective comprehensive plan of care for each resident. Acute Care Plans: As acute problems or changes to intervention or goals were identified, an appropriate care plan would be developed or modified by a nursing staff member.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of a face sheet dated 03/02/2023 indicated Resident #131 was an [AGE] year-old female who admitted on [DATE] with the diagnoses of respiratory failure, pneumonia, related to Covid 19, Covid 19 virus, and major depressive disorder.<BR/>Record review of Resident #131's electronic medical record on 02/28/2023 revealed the MDS assessment, the comprehensive care plan, and the baseline care plan were not completed.<BR/>During an interview and observation on 03/02/2023 at 8:51 a.m., the ADON was the nurse for Resident #131. The ADON was informed by Resident #131 that she had not been bathed since she admitted on [DATE]. The ADON said Resident #131 would have a bath/shower today. The ADON said the nurses were responsible for ensuring the baths were completed. The ADON said the bath sheets were removed from use when the facility went to all electronic. The ADON said they no longer used the paper bath sheets and the computer documentation did not indicate a resident had a bath only the assistance required for bathing. <BR/>During an interview on 03/02/23 at 10:14 a.m., CNA H said the bath schedule was done by room numbers. CNA H said if a resident was in the room by themselves then they were considered being in the A bed. CNA H said Resident #131 had refused her shower today but was given a bed bath. CNA H said Resident #131 received her bath on the 2:00 p.m. - 10:00 p.m. shift.<BR/>Record review of an undated bath sheet provided by the ADON on 03/02/2023 indicated Resident #131 would receive her showers on Monday-Wednesday-Friday on the 2:00 p.m. to 10:00 p.m. shift.<BR/>Record review of Resident #131's ADL flow sheets did not reveal any refused bathing or showering.<BR/>3)Record review of a face sheet dated 03/02/2023 indicated Resident #74 was an [AGE] year-old female who admitted on [DATE] with the diagnoses of spondylolisthesis (disorder of which a bone vertebra slips forward onto the bone below), eating disorder, and high blood pressure. <BR/>Record review of an admission MDS dated [DATE] indicated Resident #74 was usually understood and usually understood others. The MDS indicated Resident #74 BIMS score was a 13 indicating she was cognitively intact. The MDS indicated Resident #74 required extensive assistance of one staff with bed mobility, transfers, locomotion, toilet use, personal hygiene, and bathing. The MDS indicated Resident #74 was frequently incontinent of bowel and was not on a toileting plan. <BR/>During an observation and interview on 02/27/2023 at 10:08 a.m., revealed Resident #74 was lying in her bed leaning to the left side. Resident #74's room smelled of foul-smelling bowel movement at the doorway. Resident #74 said she had been incontinent of bowel since right before breakfast. Resident #74 said she was still lying-in bed with an incontinent episode at this time. Resident #74 said she refused therapy because she was waiting to be changed. Resident #74 said she had to eat with bowel movement in her brief and bed.<BR/>During an observation on 02/27/2023 at 10:16 a.m., revealed CNA C entered Resident #74's room and answered the call light. Resident #74 made CNA C aware she needed her brief changed. CNA C left the room and obtained the needed supplies. During the incontinent care Resident #74's brief had overflowed with liquid bowel movement. Resident #74 had liquid stool was up her abdomen past her umbilicus (belly button) and up her low back. Resident #74's back of her shirt was saturated with liquid stool as well. <BR/>During an interview on 03/03/2023 at 2:30 p.m., CNA OO said on 02/27/2023 Resident #74 activated her call light during breakfast. CNA OO said she did not change Resident #74 because the regulation (state regulation) said changing of briefs during breakfast was cross contamination. CNA OO said she was aware Resident #74 had a bowel movement.<BR/>During an interview on 03/03/2023 at 11:00 a.m., the DON said no one should eat their meal with an incontinent episode. The DON said it was a dignity issue. The DON said Resident #74 should have been changed prior to her having her breakfast.<BR/>During an interview on 03/03/2023 at 11:15 a.m., the Interim Administrator said she did not expect anyone to eat their meals with soiling in their briefs. The Interim Administrator said leaving someone with a soiled brief on could cause skin problems, loss of dignity, and make a resident not want to eat. <BR/>During an interview on 03/03/2023 at 11:00 a.m., the DON said the CNAs were responsible for the bathing and the nurses for ensuring the baths were completed. <BR/>During an interview on 03/03/2023 at 11:15 a.m., the Interim Administrator said the baths/showers should be monitored using the electronic computer system. The Interim Administrator said again this was monitored in the morning meetings with the corporate tools (morning meeting tool used to audit). The Interim Administrator said the previous administrator failed to implement the tools the corporate tools. The Interim Administrator said not bathing could make a resident feel good because they may not smell good. <BR/>Record review of the facility's policy, Resident Showers, dated 02/11/2022, indicated .the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation, and help prevent skin issues as per current standards of practice . 1. Residents will be provided showers as per request or as per shower schedule .<BR/>Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene were provided for 3 of 4 residents (Residents #280, #74 and #131) reviewed for ADL care.<BR/>The facility failed to ensure Resident #280 was routinely showered/bathed.<BR/>The facility failed to ensure Resident #131 was routinely showered/bathed.<BR/>The facility failed to ensure Resident #74's brief with bowel incontience was changed prior to her morning meal.<BR/>These failures could place residents at risk of not receiving care/services, decreased quality of life impacting their loss of dignity.<BR/>Findings included:<BR/>1. Record review of Resident #280's face sheet, dated 03/02/23, indicated an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included fracture of right femur, history of falling, asthma, anxiety, and osteoporosis (condition in which bones become weak and brittle). <BR/>Record review of Resident #280's comprehensive care plan, dated 02/28/23, indicated she had an ADL self-care performance deficit and was at risk for not having her needs met in a timely manner. The care plan interventions included to provide shower, shave, oral care, hair care, and nail care per schedule and when needed. <BR/>Record review of the admission MDS, dated [DATE], indicated Resident #280 was usually understood and usually understood others. The MDS revealed Resident #280 had a BIMS score of 10, which indicated she had moderately impaired cognition. Resident #280 required limited assistance with transfers, dressing, toileting, and personal hygiene. Resident #280 required extensive assistance with bed mobility and locomotion. She was totally dependent on staff for bathing.<BR/>During an interview on 02/27/23 at 10:12 a.m., Resident #280 was in her room with family member present at bedside. Resident #280 said she had only received one shower since she admitted on [DATE]. Resident #280's family member agreed with Resident #280's statement and indicated that was correct. <BR/>During an interview on 03/01/23 at 08:11 a.m., Resident #280 said had not received another shower since the one she received Sunday (02/26/23).<BR/>Record review of Resident #280's ADL flow sheets did not reveal any refused bathing or showering.<BR/>During an interview on 03/01/23 at 10:32 a.m., CNA U said the showers were completed as per the shower sheet that was posted at the nurse's station. CNA U said shower schedule was as follows:<BR/>Monday, Wednesday, Friday- Morning shift women on A beds.<BR/>Monday, Wednesday, Friday- Evening shift women on B beds.<BR/>Tuesday, Thursday, Saturday- Morning shift men on A beds.<BR/>Tuesday, Thursday, Saturday- Evening shift men on B beds.<BR/>CNA U said they do not have shower sheets that they complete. CNA U said they document on the POC where they indicate if the resident received a shower. CNA U said there was not a place in the POC to indicate if a resident did not receive a shower or bath. CNA U said she would notify the charge nurse for any resident refusals. CNA U said she did not care for Resident #280.<BR/>During an interview on 03/01/23 at 10:40 a.m., RN G said the showers were done as per the schedule that was posted at the nurse's station. RN G said Resident #280 had indicated to him that she had been having problems receiving a bath. RN G said he instructed the nurse aide to give Resident #280 a shower on Sunday (02/26/23). RN G said he had notified the ADON regarding the issues Resident #280 was having receiving her showers or baths. RN G said there was usually only one aide on that hall and that there needed to be at least two aides for residents to receive the care they needed. <BR/>During an interview on 03/01/23 at 10:57 a.m., the ADON said they were in the middle of implementing the shower sheets again. The ADON said she was not aware of Resident #280 issues receiving a shower.<BR/>During an interview on 03/02/23 at 10:14 a.m., CNA H said the bath schedule was done by room numbers. CNA H said if a resident was in the room by themselves then they were considered being in the A bed. CNA H said she had given Resident #280 a bed bath one time. CNA H said the reason Resident #280 did not receive a shower was because when Resident #280 admitted to the facility, she had a wound thing on her hip and Resident #280 did not want to get the wound wet. CNA H said if a resident did not receive a bath or shower, N/A was checked on the POC. <BR/>During an interview on 03/02/23 at 10:28 a.m., the ADON said she expected showers or baths to be done according to the shower schedule unless the resident refuses. The ADON said if a resident refuses their shower, the aide was responsible for notifying the charge nurse. The ADON said the charge nurse was responsible of charting the refusal, notifying the family and physician if necessary. The ADON said the charge nurses were responsible of ensuring the baths were being completed as scheduled. The ADON said by not providing the showers as scheduled the resident was at risk for skin breakdown, dignity issue, or infection. <BR/>During an interview on 03/02/23 at 11:34 a.m., Resident #280 said she had not received a bed bath. Resident #280 said when she had the wound vac to her right hip the aides said they could give her a bed bath, but one was never provided. Resident #280 said the only shower she had received was the one that was provided to her on Sunday (02/26/23).<BR/>During an interview on 03/03/23 at 10:50 a.m., the DON said she expected the aides to follow the shower schedule and expected all the residents to be provided with a shower or bath depending on their preference. The DON said if a resident was to refuse their shower or bath, the aide was to notify the charge nurse so they could go talk to the resident as to why they refused. The DON said by not receiving a bath as scheduled the resident was at risk for skin problems, increased infection, and poor hygiene. The DON said she was responsible, as well as the charge nurse, to ensure the showers or baths were being completed as scheduled.<BR/>During an interview on 03/03/23 at 11:05 a.m., the Interim Administrator said she expected the showers or baths to be completed as scheduled. The Interim Administrator said by not receiving showers or baths the resident was at risk for not feeling well and a risk for infection. The Interim Administrator said the DON was responsible for ensuring the baths or showers were completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 3 of 6 residents reviewed changes of condition. (Resident #'s 41, 45 and 74)<BR/>The facility failed to obtain a PCR HSV and VZV lab when Resident #45 had worsening symptomatic shingles (painful rash with blisters) covering his right eye lid. <BR/>The facility failed to obtain a stool culture when Resident #74 had on-going diarrhea since admission on [DATE].<BR/>An Immediate Jeopardy (IJ) situation was identified on 02/28/2023 at 4:47 p.m. While the IJ was removed on the 03/03/2023 at 1:21 p.m., the facility remained out of compliance at an actual harm with a scope pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. <BR/>These failures could place residents at risk of their physicians not being aware of the resident conditions and delay treatments for the residents' conditions of loss of vision, dehydration, and/or loss of life.<BR/>Findings included:<BR/>1)Record review of a face sheet dated 03/02/2023 indicated Resident #45 was an [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of heart failure, depression, malnutrition, and high blood pressure. <BR/>Record review of the most recent Significant change MDS dated [DATE] indicated Resident #45 was usually understood and usually understood others. The MDS indicated Resident #45's BIMS score was 11 indicating he had moderately impaired cognition. The MDS indicated during the assessment period Resident #45 did not reject care. The MDS indicated Resident #45 required extensive assistance of one staff with bed mobility, dressing, toilet use, personal hygiene, and with bathing Resident #45 required total assistance of one staff member. <BR/>Record review of the consolidated physician's orders dated 03/01/2023 indicated Resident #45 had Acyclovir 800 milligrams 5 times daily for 5 days for possible shingles(painful rash with blisters) started on 03/01/2023. Resident #45 had Clindamycin 300 milligrams three times a day for cellulitis (potentially serious bacterial skin infection) x 7 days started on 02/28/2023 and Doxycycline Monohydrate 100 mg twice a day for cellulitis until 03/07/2023. Resident #45 was also ordered Gentamicin Sulfate Ophthalmic ointment 0.3% 1 application in right eye two times a day for infection x 7 days to start on 02/28/2023.<BR/>Record review of the comprehensive care plan dated 11/09/2022 revealed it did not address that Resident #45 had shingles involving his face and right eye. The comprehensive care plan did not address isolation precautions. <BR/>Record review of Resident #45's February 2023 electronic medication administration record indicated these medications were ordered and administered medications: Acyclovir 800 milligrams one tablet three times a day for shingles for 7 days started on 02/20/2023 and completed on 02/27/2023. Resident #45 was ordered Ofloxacin Ophthalmic Solution 0.3% one drop to the right eye 4 times daily for 5 days starting on 02/20/2023. Acyclovir 800 milligrams was restarted on 02/28/2023, Ofloxacin Ophthalmic Solution 0.3% instill one drop in right eye at bedtime for 7 days started on 2/27/2022, and Doxycycline 100 milligram give one tablet twice daily for 7 days started on 02/28/2023.<BR/>Record review of Resident #45's March 2023 electronic medication record indicated these medications were ordered and administered: Gentamicin Sulfate Ophthalmic Ointment 0.3% instill one application in the right eye two times a day for 7 days starting on 03/01/2023, Ofloxacin Ophthalmic Solution 0.3% instill one drop in right eye at bedtime for 7 days starting on 02/27/2023; Doxycycline monohydrate 100 milligrams one capsule twice daily for cellulitis until 03/07/2023; and Clindamycin 300 mg one capsule by moth three times a day for cellulitis for 7 days; and Acyclovir 800 milligrams one tablet by mouth 5 times a day for 5 days for possible shingles starting on 03/01/2023. <BR/>Record review of a nursing note dated 02/20/2023 at 10:12 a.m., indicated LVN G wrote the physician was notified regarding Resident #45's redness, swelling, and matter to his right eye.<BR/>Record review of a nursing note dated 02/20/2023 at 10:54 a.m., indicated LVN G wrote he received new orders for Acyclovir 800 milligrams three times a day for 7 days, ofloxacin 0.3% one drop in right eye four times a day for 5 days, appointment with an ophthalmologist and to check a HSV ig M level (anti-body test to indicate a current or recent infection). <BR/>Record review of a nursing note dated 02/20/2023 at 8:34 p.m., indicated LVN M wrote monitoring for edema (swelling) every day and night shift, with the right side of Resident #45's face/eye with edema with the MD aware with laboratory test ordered.<BR/>Record review of a nursing note dated 02/21/2023 at 1:03 a.m., indicated LVN M wrote that the right side of Resident #45's face/eye continued with edema and redness, and Resident #45 denied pain. LVN M noted Resident #45's family member would like to see if the facility ophthalmologist could see Resident #45 instead of having to be transferred out of the facility. <BR/>Record review of a nursing note dated 02/22/2023 at 9:08 a.m., indicated LVN O wrote that Resident #45 continued the Acyclovir eye drops to his eye every night, continued to assess for pain, discomfort, and changes.<BR/>During an observation on 02/27/2023 at 12:17 p.m. revealed, Resident #45 was lying in his bed. He had scabbing appearing areas to his right eye and forehead. Resident #45's right eye was scabbed closed, and he could not open it when requested Resident #45 said he did not know what was on his face and eye.<BR/>During an interview on 02/27/2023 at 12:26 p.m., CNA N said she was told Resident #45 had shingles (painful rash with blisters) and not been on any isolation precautions. CNA N said she regularly careds for Resident #45 and had floated to other halls to help. CNA N said she had questioned the DON today as to why Resident #45 was not on any type of isolation because she said shingles were contagious. CNA N said Resident #45 did not eat his noon meal because he was hurting from the shingles.<BR/>During an interview on 02/27/2023 at 8:55 a.m., the DON said the nurses had not realized Resident #45 required isolation due to shingles being a contagious communicable disease. The DON said the nurses did not make her aware of Resident #45 having shingles when the symptoms started. The DON said Resident #45 should have been placed on contact isolation. The DON said the risk for unvaccinated and residents who had not had chicken pox as a child were at risk of having shingles. The DON said she was unaware Resident #45 had an order to see an ophthalmologist related to his right eye. The DON said they facility's eye physician had already made rounds around February 9th or the 10th 2023. The DON said she had not contacted the mobile eye physician or the family member with a plan to have Resident #45's right eye examined. The DON said shingles in the eye could result in vision loss for Resident #45. The DON said she was the infection preventionist for the building. The DON said she was unsure how Resident #45's infection of the shingles was missed because she said the nurse managers log the infections and review the orders in morning meeting. The DON said the physician should be notified immediately when symptoms occur or worsen.<BR/>Record review of a nurses note written by LVN P dated 02/28/2023 at 12:57 p.m., revealed Resident #45 had an appointment scheduled for March 2, 2023, at 3:15 p.m. The note indicated Resident #45's family member was notified of the appointment related to shingles to the right eye. <BR/>Record review of a nurse note dated 02/28/2023 at 1:06 p.m., indicated Resident #45 was administered a Tramadol 50 milligram tablet for pain to his right eye.<BR/>During an interview on 02/28/2023 at 3:11 p.m., LVN P said she had worked February 19, 2023, through February 23, 2023 and had observed Resident #45 during that time period. LVN P said Resident #45's eye was much worse than when she last saw the eye on February 23, 2023. LVN P said the medical record did not indicate any one had contacted the physician for Resident #45's worsening shingles. <BR/>During an interview on 02/28/2023 at 3:26 p.m., the Medical Director said she was #45's physician and she said she was unaware of Resident #45's right eye condition with shingles covering the entire eye lid and the right eye would not open. The Medical Director said she was unaware Resident #45 had not seen an eye specialist related to the shingles to the right side of the face and eye. The Medical Director said she expected the facility to obtain an appointment promptly due to the risk of blindness with ocular shingles. <BR/>During an observation and interview on 02/28/2023 at 3:45 p.m., revealed LVN P applied a warm compress to Resident #45's right eye. LVN P asked Resident #45 to open his right eye, and he could not open the eye at all. Resident #45 said his right eye was hurting and LVN P immediately stopped and said she would administer a pain medication. LVN P said she would notify the physician. <BR/>Record review of a nurse note dated 02/28/2023 at 8:03 p.m., indicated the ADON wrote Resident #45's family was notified of the lab results of the Herpes Simplex IgM (antibody test of recent or current infection) result of 0.66 and a new order was received from the physician for Clindamycin 300 mg one three times and day and discontinue the Acyclovir.<BR/>Record review of a medication administration record dated February 2023 indicated Clindamycin 300 mg was administered on 02/28/2023. <BR/>During an interview on 02/28/2023 9:57 a.m., the responsible party for Resident #45 said he was never told officially Resident #45 had shingles (painful rash with blisters). Resident #45's responsible party said he asked if the mobile eye doctor could see Resident #45 but he definitely would have had him sent to another local eye physician if Resident #45 needed to go.<BR/>Record review of a nurse note dated 02/28/2022 at 8:21 p.m., indicated the DON wrote Resident #45's isolation was discontinued for shingle precautions and indicated Resident #45 had a new diagnosis of cellulitis and with a new medication ordered. The new order was Clindamycin 300 mg one capsule three times a day for 7 days. <BR/>Record review of a nurse note dated 02/28/2023 at 11:08 p.m., indicated LVN B wrote Resident #45 was administered gentamycin eye drops. LVN B wrote Resident #45 face was red and swollen with blisters and scabs.<BR/>During an interview on 02/28/2023 at 10:07 a.m., the Interim Administrator said she was unaware of Resident #45 having shingles. <BR/>Record review of a nurse note dated 03/01/2023 at 1:24 a.m., indicated LVN B documented Resident #45 had a diagnosis of cellulitis, day 2 of isolation, acyclovir was discontinued, day 2 of 7 on Ofloxacin and G entamicin eye drops, day 3 of 7 on doxycycline with no adverse reactions. The note indicated Resident #45 had redness, swelling, and scabs to his face and a warm compress was used.<BR/>During an interview on 03/01/2023 at 8:34 a.m., the Regional Corporate Nurse said after digging deeper the lab result for an IgM level (antibody level detecting recent or new infection) was 0.66 which was negative. The Regional Corporate Nurse said Resident #45 was negative for shingles but was being treated for cellulitis. <BR/>During an observation and interview on 03/01/2023 at 9:18 a.m., Resident #45 said his right eye was hurting. Resident #45 had a very minimal opening between his eye lids and there was yellow stingy material in the opening. <BR/>During an interview on 03/01/2023 at 2:57 p.m., the Medical Director indicated initially Resident #45's rash appeared to be shingles. The medical director indicated the IgM test was negative for antibodies.<BR/> On 02/20/2023. The medical director said she would complete a PCR HSV and VSV (recommended testing for diagnosing of shingles), and place Resident #45 back on isolation. The medical director said she would order a PCR HSV and VSV because the test would be the most accurate test for diagnosing shingles according to CDC recommendation.<BR/>Record review of a nurses note dated 03/01/2023 at 6:24 p.m., indicated the ADON wrote she notified the Resident #45's family member on of the new orders to restart Acyclovir 800 milligrams five times daily x 5 days, PCR HSV and VZV lab, and reinstate the isolation precautions. <BR/>Record review of an incident report dated 03/02/2023 at 3:30 p.m., indicated Resident #45 slid from his wheelchair to the floor. The ADON wrote there were no injuries noted but Resident #45 was sent to the emergency room.<BR/>Record review of an After Visit Summary dated 03/02/2023 indicated Resident #45 was provided instructions related to shingles and minor head injury. The summary indicated his diagnoses included an unspecified fall, facial contusion, and herpes zoster (shingles). The educational material included in the Visit Summary report indicated:<BR/>*If the shingles affects your eye the doctor may cover your eye with a bandage<BR/>*Infections of the eye and the skin around the eye were other health problems to treat<BR/>*To prevent the shingles do not share towels, go swimming, or play contact sports with people who have shingles if you never had chicken pox.<BR/>*Do not touch or scratch your rashes, if you do wash your hand afterwards.<BR/>2) Record review of a face sheet dated 03/02/2023 indicated Resident #74 was an [AGE] year-old female who admitted on [DATE] with the diagnoses of spondylolisthesis (disorder of which a bone vertebra slips forward onto the bone below), eating disorder, and high blood pressure. <BR/>Record review of an admission MDS dated [DATE] indicated Resident #74 was usually understood and usually understood others. The MDS indicated Resident #74 BIMS score was a 13 indicating she was cognitively intact. The MDS indicated Resident #74 required extensive assistance of one staff with bed mobility, transfers, locomotion, toilet use, personal hygiene, and bathing. The MDS indicated Resident #74 was frequently incontinent of bowel and was not on a toileting plan. <BR/>Record review of a Baseline care plan dated 01/24/2023 at 8:39 a.m., indicated the ADON did not document Resident #74 had a recent history of Clostridium Difficile from the physicians history and physical (inflammation of the colon cause by bacteria), diarrhea, or isolation precautions needed for on-going symptoms. <BR/>Record review of the comprehensive care plan dated 02/07/2023 indicated Resident #74 was at risk for Covid 19 infection but the care plan did not mention Clostridium Difficile or the need for isolation precautions. <BR/>Record review of the February 2023 electronic medication record indicated Resident #74 received Colestipol 1 gram twice daily for treating diarrhea since 01/24/2023, lactobacillus capsule one capsule by mouth twice daily, and Lomotil 2.5-0.025 milligrams one tablet every 6 hours as needed for diarrhea since 01/24/2023. The electronic medication record indicated Resident #74 had 8 doses in the month of February and two doses were unknown if effective. <BR/>Record review of a nursing progress note dated 01/24/2023 documented by LVN T indicated Resident #74 was post C-diff.<BR/>Record review of a nursing progress note dated 01/31/2023 at 1:22 a.m., indicated LVN V administered Lomotil for diarrhea, but the medication was ineffective. The note did not indicate the physician was notified.<BR/>Record review of a nursing progress note dated 01/31/2023 at 12:24 p.m., indicated LVN F documented Resident #74 was administered Lomotil for diarrhea.<BR/>Record review of a skilled nurses note dated 02/01/2023 at 12:48 a.m., indicated LVN T documented Resident #74 was post C-diff.<BR/>Record review of a progress note dated 02/01/2023 at 1:30 a.m., indicated Resident #74 was administered Lomotil for diarrhea by LVN M. <BR/>Record review of a nursing note dated 02/03/2023 at 5:40 a.m., LVN T documented an administration of Lomotil for diarrhea was provided to Resident #74. <BR/>Record review of a nurses note dated 02/04/2023 at 3:32 a.m., indicated LVN R documented Resident #74 was post C-diff. <BR/>Record review of a nurses note dated 02/04/2023 at 3:32 a.m., indicated LVN R documented Resident #74 was post C-diff.<BR/>Record review of a nurses note dated 02/06/2023 at 8:37 a.m., indicated LVN S documented Resident #74 was post C-diff. <BR/>Record review of a nurses note dated 02/06/2023 at 11:18 p.m., LVN T documented Resident #74 required the administration of Lomotil for diarrhea. <BR/>Record review of a nurses note dated 02/07/2023 at 11:40 p.m., LVN T documented Resident #74 required Lomotil administration related to diarrhea. <BR/>Record review of a nurses note dated 02/15/2023 at 9:42 p.m., LVN T documented Resident #74 required administration of Lomotil for diarrhea.<BR/>Record review of a nurses note dated 02/24/2023 at 12:54 a.m., indicated LVN PP documented Resident #74 continued to have been monitored for diarrhea none on this shift. The note failed to indicate the physician was notified. <BR/>Record review of a nurses note dated 02/25/2023 at 6:41 a.m., indicated LVN T documented that Resident #74 had 3 diarrhea bowel movements with Lomotil given and effective at present. The note indicated Resident #74's peri area was very red. LVN T indicated she notified the physician and was waiting on orders.<BR/>Record review of a nurses note dated 02/25/2023 at 8:59 a.m., indicated LVN D apply Nystatin ointment to Resident #74's inner thighs and buttocks for redness. <BR/>Record review of a nurses note dated 02/25/2023 at 6:41 a.m., indicated LVN D received a new order for Nystatin ointment and zinc oxide twice daily for 30 days.<BR/>Record review of a nurses note dated 02/25/2023 at 6:43 p.m., indicated LVN B documented Resident #74 required Lomotil for diarrhea and the medication was effective. The note did not reflect LVN B notified the physician. <BR/>During an interview an observation on 02/27/2023 at 10:08 a.m., Resident #74 said her brief needed changing due to having a very large diarrhea bowel movement. Resident #74 said she thought she should return to the hospital due to her continuous diarrhea since she left the hospital. Resident #74 was assisted to activate her call light for assistance. CNA C answered the call light and left the room. CNA C returned with bed linen and incontinent care supplies. CNA C washed her hands then initiated care to Resident #74. LVN F said Resident #74 has had diarrhea since admission. LVN F said he had been trying to obtain a stool sample but the stool was so loose the bowel movement absorbed in the brief.<BR/>Record review of the physician's orders dated February 2023 did not reveal a stool specimen was ordered by the physician. <BR/>Record review of a nurses note dated 02/27/2023 at 5:55 p.m., indicated LVN F documented Resident #74 made the statement she thought she needed to return to the hospital due to the ongoing diarrhea. LVN F documented he informed Resident #74 he had a stool sample waiting for pickup. <BR/>During an interview on 02/28/2023 at 7:51 a.m., the Housekeeping Supervisor said she was unaware there were residents with possible Clostridium Difficile. The Housekeeping Supervisor said for Clostridium Difficile there was a special tablet to add to the water for cleaning of these rooms. The housekeeping supervisor said she was also unaware of Resident #74 or Resident #45 having communicable disease processes requiring special laundry procedures. The housekeeping supervisor said when the laundry receives linen in the yellow bags the laundry personnel would be alerted to wash this linen separate from the general linen. <BR/>During an interview on 02/28/2023 at 3:26 p.m., the physician for Resident #74 said Resident #74 had Clostridium Difficile in the recent past. The physician said she was not notified Resident #74 had on-going diarrhea since admission. The physician said Resident #74 could be a carrier of Clostridium Difficile. <BR/>Record review of a hydration assessment completed by the DON dated 02/28/2023 indicated Resident #74 had poor skin turgor, had more than a 3-pound weight loss in a month, and was at risk due to diarrhea/vomiting occurred in the last 7 days.<BR/>Record review of a Notification Policy dated 07/13/2015 and revised on 02/12/2023 indicated the policy was to provide guidance on when to communicate acute changes in status to MD, NP, and responsible party. The facility will immediately inform the resident; consult with the resident's physician; and if known, the resident's legal representative or appropriate family members of the following: <BR/>9. <BR/>An accident resulting in injury to the resident that potentially requires physician's intervention<BR/>10. <BR/>An emergency response situation that requires EMS involvement<BR/>11. <BR/>A significant change in the physical, mental, or psychosocial status of the resident.<BR/>12. <BR/>The need to significantly alter the resident's treatment.<BR/>13. <BR/>A decision to transfer or discharge the resident to another facility.<BR/>14. <BR/>A change in room or roommate assignment.<BR/>15. <BR/>A change in resident rights under Federal or State law, including changes to items and services included under State plans.<BR/>16. <BR/>The facility's Medical Director will be contacted if the attending or admitting physician cannot be contacted and/or does not respond timely. <BR/>Record review of a Provision of Quality-of-Care policy dated 01/24/2023 indicated based on comprehensive assessments, the facility will ensure that residents receive treatments and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the residents' choices. 1. Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. 4. Qualified persons will provide the care and treatment in accordance with professional standards of practice, the resident's care plan and the resident's choices. 6. Policies and procedures will reflect current professional standards of practice. a. All employees are responsible for following established policies and procedures. B. Violations of policies and procedures will result in disciplinary action up to and including termination.<BR/>This was determined to be an Immediate Jeopardy (IJ) situation on 02/28/2023 at 4:47 p.m. The Interim Administrator and the Regional Corporate Nurse was notified. The Administrator was provided with the IJ template on 02/28/2023 at 4:58 p.m. and requested a Plan of Removal (POR).<BR/>The Plan of Removal (POR) was accepted on 03/03/2023 at 1:21 p.m. and indicated the following: <BR/>Immediate action:<BR/>On 02/27/2023 Stool culture was obtained and sent to lab for Resident #74.<BR/>On 02/28/2023 DON RN completed a Hydration assessment on Resident #74.<BR/>On 03/01/2023 Regional Registered Dietician completed a Nutritional assessment on Resident #74 with no new recommendations.<BR/>On 02/28/2023 Social Services/Designee obtained an Ophthalmology consult for Resident #45 for 03/03/23 related to worsening symptomatic Shingles.<BR/>On 02/28/2023 ADON LVN completed rounds and identified 1 other resident with diarrhea who is in a private room and was placed on isolation precautions on 02/28/2023. DON RN completed a hydration assessment on this resident and notified the Physician 02/28/2023 regarding on-going diarrhea and hydration assessment.<BR/>On 02/28/2023 stool culture was obtained and sent to lab for the one other identified resident.<BR/>On 03/01/2023 Regional Registered Dietician completed a review on the 1 other resident in the center who was experiencing diarrhea, an identified as having the potential to be affected by this alleged practice with no recommendations.<BR/>Facilities plan to ensure compliance quickly<BR/>On 03/03/2023 DON Designee began training on Provision of Quality of Care to ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice. This education will be completed on 03/03/2023. No staff will be allowed to work until this education is completed. <BR/>Quality Assurance<BR/>Medical Director was notified on 02/28/2023 at 08:00 p.m., of the Immediate Jeopardies.<BR/>On 03/01/2023 An Ad Hoc QAPI meeting was conducted to discuss identified issues, and to develop plan for sustaining compliance<BR/>In-services:<BR/>*Provision of Quality Care:<BR/>The facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the resident's choice.<BR/>During an interview on 03/03/2023 at 11:15 a.m., the Interim Administrator said she expected the physician to be notified off all changes of condition.<BR/>Interviews with 2 RNs: DON and RN KK (6am-6pm); 4 nurses LVN L (6a-6p), LVN A (6a-6p), LVN F (6a-6p), LVN B (6p-6a), ADON (all shifts), Tx nurse (all shifts) in-serviced on transmission-based precautions, notification of the physician and family of acute changes such as accidents, illness, transfers, emergencies, and injuries.<BR/>Record review of Resident #74's laboratory PCR HSV and VSV pending taking 5-7 days for return.<BR/>Record review of Resident #74's stool culture dated 2/27/2023 indicated a negative result for C-diff.<BR/>Record review of Resident #45's ophthalmologist appointment dated 03/02/2023 at 3:15 p.m. but he slid from his wheelchair preparing to leave the facility. The facility working with a local EMS ambulance to take Resident #45 to the ophthalmologist on a stretcher. <BR/>During an interview on 03/03/2023 at 11:00 a.m., the DON said she expected nurses to monitor for changes of condition and then act on the physician's orders. The DON said a resident could have their needs not met. <BR/>On 03/03/2023 at 5:22 p.m. the Interim Administrator was informed the IJ was removed: however, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate threat with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an environment that was free of accident hazards for 1 of 6 residents reviewed for accidents hazards. (Resident #130)<BR/>The facility failed to implement a fall intervention when Resident #130 said he fell on [DATE] to prevent Resident #130 from falling on 02/27/2023.<BR/>These failures could place residents at risk for falls and falls with serious injury. <BR/>Findings included:<BR/>Record review of a face sheet dated 03/02/2023 indicated Resident #130 was an [AGE] year-old male who admitted on [DATE] with the diagnoses of stroke, heart attack, heart failure, and diabetes. <BR/>Record review of a baseline care plan dated 02/23/2023 documented by the ADON indicated Resident #130 had self-care performance with personal hygiene, toileting, dressing and bathing. The base line care plan indicated Resident #130 was alert but cognitively impaired. The base line care plan indicated Resident #130 was at risk to fall with the goal will not sustain a fall related injury by utilizing fall precautions through next review date. The Fall care plan indicated an intervention would be to provide assistance to transfer and ambulate as needed.<BR/>Record review of a comprehensive care plan dated 02/23/2023 and revised on 03/01/2023 indicated Resident #130 had a potential to falls related to high blood pressure medications, gait problems, and incontinence. The goal was he would not sustain a fall related injury by utilizing the fall precautions. The interventions included anticipate his needs, educate resident/family/caregivers on safety reminders, encourage socialization, encourage activities, anticipate needs by placing items close to him, and attempt to determine cause of past falls. The comprehensive care plan did not address a bed alarm.<BR/>Record review of the most recent MDS dated [DATE] indicated Resident #130 usually understands and was usually understood. Resident #130 BIMS score was 12 but he required cueing to recall. The MDs indicated Resident #130 had difficulty focusing his attention and was easily distracted. The MDS indicated Resident #130 required limited assistance of one staff with bed mobility, transfers, walking, locomotion, dressing, toileting, personal hygiene, and extensive assistance of one staff for bathing. The MDS indicated Resident #130 was incontinent occasionally of bladder and frequently of bowel. The MDS indicated Resident #130 had one fall with an injury.<BR/>Record review of a fall risk dated 02/23/2023 indicated Resident #130 scored a 14 indicating he was at moderate risk to fall. The fall risk indicated Resident #130 had a history of multiple falls in the last six months. The fall risk assessment indicated Resident #130 could not recall the season, where he was, the location of his room or the names of the staff. The assessment failed to assess his gait.<BR/>Record review of a nurse's note dated 02/26/2023 at 11:30 a.m., RN G wrote Resident #130's family was visiting today and informed the RN supervisor and staff nurse of Resident #130 reporting he had a fall last night and got himself back to bed and did not report to anyone. RN G documented there was new discoloration around the right eye of Resident #130.<BR/>Record review of an incident report dated 02/26/2023 indicated Resident #130 reported a fall last night. The daughter's statement indicated she reported Resident #130 said he fell against his wheelchair. The immediate action taken on the incident report indicated a head-to-toe assessment was completed with noted old bruises to trunk with yellow discoloration. Slight bruising noted to the right peri-orbital area (surrounding the eye).<BR/>Record review of a progress note documented by LVN V dated 02/27/2023 at 9:59 p.m., indicated Resident #130 was found on his buttocks on the floor between the bed and wheelchair. LVN V documented Resident #130 said he was trying to get in his chair. LVN V documented there were no injuries. LVN V indicated the bed was in low position and he had his call light in his hand. LVN V indicated she provided re-education. <BR/>Record review of the consolidated physician's orders indicated Resident #130 had a bed alarm ordered on 02/28/2023 two days after he reported to his family, he fell and sustained bruising to his right eye. <BR/>Record review of the electronic medical record dated February 2023 indicated Resident #130 had a physician's order for a bed alarm when in bed, monitor every shift for falls beginning on 02/28/2023 at 6:00 p.m. The medical record did not indicate a nurse completed this task; the space was blank.<BR/>During an observation and interview on 03/01/2023 at 4:10 p.m., Resident #130 was lying in bed. Resident #130 had deep purple peri-orbital (around the eye) bruising. Resident #130 said he did not know he had bruising to his right eye. Resident #130 denied falling.<BR/>During an interview on 03/03/2023 at 11:00 a.m., the DON said the care plan should be updated with fall interventions as they occur to prevent another fall or risk for injuries. The DON said the nursing team was responsible for putting interventions in place.<BR/>During an interview on 03/03/2023 at 11:30 a.m., the Interim Administrator said interventions should be put in place with each fall to prevent the next fall. The Interim Administrator said not putting an intervention in place could result in a serious injury.<BR/>Record review of an Investigation of Incidents and Accidents policy dated 12/03/2020 indicated the resident environment will remain s free of accident hazards as possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This included: identifying hazards and risks, evaluating, and analyzing hazards and risk, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Implementation of Interventions-using specific interventions to try to reduce a resident's risk from hazards in the environment. This process included: Ensuring interventions were put into action.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and records review the facility failed to ensure residents were free from abuse for 1 of 5 residents (Resident #1) reviewed for abuse, neglect, and exploitation. The facility failed to ensure Resident #1 was free from physical abuse on 8/17/25 at approximately 4:00 p.m. when Resident #2 pushed her down and kicked her causing two skin tears and pain rated as a 10/10 on a numeric pain scale following the incident. This failure could place residents at risk of pain, injury, hospitalization, and diminished quality of life.Findings included:1.Review of an admission Record for Resident #1 dated 9/16/2025 indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of dementia (altered cognition), peripheral vascular disease (poor circulation in legs), and bilateral (both left and right sides) osteoarthritis of hip.Review of a quarterly MDS for Resident #1 dated 9/6/2025 indicated she had severely impaired thinking with a BIMS of 3. She had exhibited difficulty focusing attention and being easily distracted. She had exhibited no verbal or aggressive physical behaviors directed toward others.Review of the care plan for Resident #1 dated 2/1/24 indicated she resided in a secured unit related to cognitive impairment and elopement risk secondary to dementia. Review of the care plan for Resident #1 dated 4/15/24 indicated she had behavioral problem of rummaging in other residents' rooms and/or belongings. Appropriate interventions were in place including anticipating the resident's needs, intervening early, and providing as many daily care activity choices as possible for resident.Review of an admission Record for Resident #2 dated 9/16/25 indicated she was a [AGE] year-old female readmitted to the facility on [DATE] with diagnoses of dementia, cognitive communication deficit, and aphasia (communication disorder).Review of a quarterly MDS for Resident #2 dated 9/2/25 indicated a BIMS was not conducted due to the resident being rarely or never understood. She had exhibited difficulty focusing attention and being easily distracted. She had exhibited no verbal or aggressive physical behaviors directed toward others.Review of the care plan for Resident #2 dated 8/28/25 indicated she had a behavior problem as evidenced by potential for physical aggression if bathroom is used by another resident. Appropriate interventions were in place including intervening early when resident shows agitation by guiding away from source of distress, engaging calmy in conversation, or attempting over interventions, and if response is aggressive approach at a later time after ensuring resident's safety. Resident #2 had no aggressive behaviors identified in the care plan prior to 8/28/25.Review of an incident report titled Physical Aggression Initiated dated 8/17/25 by RN A indicated .staff stopped and removed [Resident #2] from another pt that was in her room. Staff witnessed pt pushing her. The same incident report indicated immediate action was taken in placing Resident #2 on 1-to-1 supervision and completing assessments and notifications to the family and providers for Resident #1.Review of an incident report titled Physical Aggression Received dated 8/17/25 by RN A indicated .Staff stopped other resident after she starting kicking this [Resident #1] after pushing her to the floor. the same incident report indicated Resident #1 was assessed for injuries and two new skin tears to her right arm were identified. Her level of pain on a PAINAD (observational pain scale) was assessed as 7/10 which indicated severe pain. Predisposing factors were identified as Resident #1 went into Resident #2's room.Review of a nurse's progress note dated 8/17/25 at 4:43 p.m. by RN A indicated .[Resident #1] received physical aggression from other patient.pt was assessed and Stat x-rays were ordered for R hip, pelvis, R femur (thigh bone), pain 10/10 after incident. Was witnessed by staff member, pt did not hit head, but hit right arm and caused two skin tears.Review of a provider progress note dated 8/18/25 indicated [Resident #1] has two skin tears on her RUE.X-rays were negative for fractures or dislocations. Neuro is intact.During an observation and interview on 9/16/25 at 10:30 a.m., Resident #2 was observed in a common sitting area, sitting on a couch. She appeared clean and well-groomed and she had no visible marks, bruises, or skin tears. Resident #2 was not able to recall the altercation with Resident #1 due to her diagnosis of dementia.During an interview on 9/16/25 at 10:33 a.m., LVN B said she did not witness the altercation between Residents #1 and #2 and only knew of the incident through report. LVN B said Resident #2 had a history of getting into verbal altercations with any resident who went into her room. LVN B said the CNA was responsible for monitoring the residents and redirecting them from entering other residents' rooms.During an interview on 9/16/25 at 10:43 a.m., CNA C said Resident #2 was known to be verbally aggressive toward residents who tried to enter her room. CNA C said she had not witnessed any physical aggression from Resident #2. CNA C said CNAs were responsible for monitoring the residents and redirecting them from entering other residents' rooms.During an observation and interview on 9/16/25 at 3:00 p.m., Resident #1 was observed in self-propelling herself in a wheelchair in the hallway on the secured memory care unit. She appeared clean and well-groomed and she had no visible marks, bruises, or skin tears. Resident #1 was not able to recall the altercation with Resident #2 due to her diagnosis of dementia.During a telephone interview on 9/16/25 at 3:45 p.m., CNA D said she was working on the memory care unit the day of the altercation between Residents #1 and #2. CNA D said she was in the hallway talking to CNA E when Resident #1 walked by her stating she was going to the restroom. CNA D said Resident #1 and Resident #2 had a shared bathroom. CNA D said Resident #2 went into her own room approximately 1 to 2 minutes later. CNA D said they heard Resident #1 yell out. CNA D said CNA E ran down to Resident #2's room and opened the door. CNA D said she saw Resident #2 stepping toward the door to leave the room as CNA E was going in. CNA D said she heard CNA E tell the residents to stop fighting so she went and alerted RN A for assistance.During an interview on 9/17/25 at 9:00 a.m., LVN F said Resident #2 had exhibited verbal aggression towards residents who wandered into her room in the past. LVN F said Resident #2 had not exhibited any physical aggression towards residents. LVN F said CNAs were responsible for monitoring the residents and redirecting them from entering other residents' rooms.During an interview on 9/17/25 at 10:45 a.m., the DON said Resident #2 had no previous aggressive behavior noted. The DON said she believed the incident occurred because Resident #2 valued her personal space and considered the shared bathroom to be her personal space. The DON said Resident #2 was put on 1-to-1 observation immediately and referrals were sent to two inpatient behavioral health facilities. The DON said Resident #2 was also moved to a room with a private bathroom. The DON said staff were expected to intervene and redirect any resident wandering into other resident rooms.During an interview on 9/17/25 at 11:00 a.m., CNA E said she was assigned to work on the hall next to the secured unit on 8/17/25 and witnessed the resident-to-resident altercation between Residents #1 and #2. CNA E said she was on the secured unit talking to CNA D when Resident #1 passed by them and went into her room. CNA E said approximately 1 to 2 minutes later Resident #2 went into her own room, which shared a bathroom with Resident #1's room. CNA E said she heard Resident #1 hollering and ran down to Resident #2's room. CNA E said she saw Resident #2 push Resident #1 down on the floor by the bed, with both hands and kick her in the side. CNA E said Resident #2 was jumping back as she was coming into the room. CNA E said she told the residents to stop fighting and told Resident #2 to leave the room. CNA E said CNA D ran and alerted the charge nurse, RN A, who conducted the post incident assessments.During an interview on 9/17/25 at 11:10 a.m., the ADM said Resident #2 had displayed verbal aggression with other residents, but there had been no previous physically aggressive behavior. The ADM said following the altercation between Residents #1 and #2 the residents were immediately separated; Resident #2 was placed on 1-to-1 supervision and referred to behavioral health inpatient facility. The ADM said Resident #2's medications were adjusted, and she was moved to a room with a private bathroom and there had been no more incidents of physical aggression. Attempted interviews with RN A by telephone and text message on 9/17/25 at 11:34 a.m. Review of progress note dated 8/17/25 at 4:30 p.m. by the DON indicated Resident #2 was placed on 1-to-1 supervision immediately following altercation with Resident #1.Review of a progress note dated 8/17/25 at 5:24 p.m. by RN A indicated Resident #2 was tolerating 1-to-1 supervision well.Review of a nursing follow-up dated 8/18/25 at 5:46 a.m. by FNP indicated Resident #2's Olanzapine dose was increased from 2.5mg to 5mg nightly and she was put on one-to-one observation.Review of a psychiatric hospital Discharge summary dated [DATE] at 2:40 p.m. indicated Resident #2 was admitted to the facility on [DATE] at 4:32 p.m. and discharged on 8/27/25 with medication changes including discontinuing Olanzapine and starting Uzedy.Review of an admission record dated 9/16/25 indicated Resident #2 was admitted to the facility from a psychiatric hospital and assigned to room [ROOM NUMBER]-B.During an observation on 9/17/2025 at 11:30 am, Resident #2's room [ROOM NUMBER]-B revealed the room to have a private bathroom. Review of facility policy titled Policy and Procedures: Abuse, Neglect, and Exploitation revised on 9/6/24 indicated .Identifying, correcting, and intervening in situations in which abuse.is suspected or identified.by taking immediate action to correct any issues that can reduce the risk of further harm continuing or occurring.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 8 (Resident #1) reviewed for dignity in that:<BR/>CNA A spoke to Resident #1 in a loud and harsh tone while attempting to assist the resident out of bed.<BR/>This failure placed residents in the facility at risk of diminished quality of life, and loss of dignity and self-worth. <BR/>Findings Include:<BR/>Review of Resident #1's undated face sheet revealed he was a [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of heart failure and secondary diagnoses of shoulder pain, low back pain, and muscle wasting (loss of muscle mass due to disuse or nerve problems). <BR/>Review of a quarterly MDS assessment dated [DATE] indicated Resident #1 had a BIMS score of 12 which indicated moderate cognitive impairment, and he required total assistance with toileting, putting on/taking off footwear; he required maximum assistance with showering/bathing and lower body dressing; he required moderate assistance with upper body dressing; he required setup assistance with personal and oral hygiene; he required no assistance eating. He was occasionally incontinent of bladder and frequently incontinent of bowel.<BR/>A comprehensive care plan revised on 9/26/24 indicated Resident #1 had an ADL self-care performance deficit and Resident #1 did not always like to change his clothing daily or shower when scheduled. Interventions were in place to provide ADL care as needed, encouraging resident to participate to the fullest extent possible, and praising resident when attempts were made. <BR/>A comprehensive care plan revised on 9/30/24 indicated Resident #1 had impaired cognition and was at risk for further decline related to encephalopathy (group of conditions that cause brain dysfunction) and dementia (altered cognition). Interventions were in place including explaining all procedures to resident and stopping and returning later if resident becomes agitated during care.<BR/>During an interview on 3/24/25 at 12:21 PM, Resident #1 said CNA A came into his room and told him he needed to get up and out of bed. Resident #1 said he told CNA A he did not want to get up right then, and CNA A replied that he had to get up and then pulled his blanket off him. Resident #1 said the CNA attempted to assist him to his feet by pulling his legs over to the side of the bed and he told her again that he did not want to get up yet. Resident #1 said CNA A said, We don't play around here in loud and harsh voice and left the room.<BR/>During an interview on 3/24/25 at 12:30 PM, Resident #3, who was Resident #1's roommate, said he remembered CNA A coming into their room on the morning of the incident. He said CNA A yelled at Resident #1 and told him he had to get out of bed. He said he did not remember CNA A pulling Resident #1 out of bed or jerking his leg. <BR/>During an interview on 3/24/25 at 12:40 PM, Resident Representative said the facility notified him of the incident, and he accompanied Resident #1 to a meeting with the ADM. He said Resident #1 told the ADM he didn't think CNA A should be fired, but he did not want CNA A to be allowed in his room anymore.<BR/>Attempted a telephone interview on 3/24/25 at 1:00 PM with CNA A. An automated voice recording indicated the correct number was reached and there was no voicemail box setup.<BR/>During an interview on 3/24/25 at 3:10 PM, MA B said she went into Resident #1's room to check Resident #3's vital signs in preparation of a medication pass. MA B said she heard Resident #1 tell CNA A he did not want to get up and CNA A responded you need to get up or I'll get in trouble in a loud and harsh-sounding tone of voice. MA B said she left the room to get Resident #3's medication, and when she returned, Resident #1 was seated in his wheelchair dressing himself; CNA A was not in the room.<BR/>During an interview on 3/25/25 at 11:00 AM, the DON said there was nothing in CNA A's background checks or job performance that indicated a risk to residents in the facility. She said CNA A was a large woman with a loud voice and she could have been intimidating to some residents, but there had been no previous allegations of mistreatment from any resident in the facility against CNA A.<BR/>Second attempted telephone interview on 3/25/25 at 3:45 PM with CNA A. An automated voice recording indicated the correct number was reached and there was no voicemail box setup.<BR/>During an interview on 3/25/25 at 4:00 PM, the ADM said CNA A had nothing in her background or job history that indicated a concern for resident safety. She said there had been no allegations of abuse or neglect against CNA A from any resident before this incident. She said CNA A was suspended while the facility investigated the allegation, and the decision was made to terminate CNA A based off MA B's witness statement. The ADM said CNA A was too direct and did not respect Resident #1's personal choice and that would not be tolerated at the facility. She said all CNAs were trained and expected to fully explain all care being provided and encourage residents to participate in care. <BR/>Review of facility policy titled Promoting/Maintaining Resident Dignity last reviewed on 2/16/20 indicated all staff involved in providing resident care will promote and maintain resident dignity by .personal choices will be considered when providing care and services to meet the resident's needs and preferences . and .speak respectfully to residents .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based interview, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status when there was a nutrition a problem for 2 of 6 residents reviewed for unplanned weight loss. (Resident #'s 74 and 130)<BR/>The facility failed to ensure a weight variance was addressed and documented to ensure management of weight loss for Resident #'s 74 and 130. <BR/>These failures could place residents at risk for undetectable weight loss, malnutrition, and poor quality of life.<BR/>Findings included:<BR/>1. Record review of a face sheet dated 03/02/2023 indicated Resident #74 was an [AGE] year-old female who admitted on [DATE] with the diagnoses of spondylolisthesis (disorder of which a bone vertebra slips forward onto the bone below), eating disorder, and high blood pressure. <BR/>Record review of a Baseline care plan dated 01/24/2023 at 8:39 a.m., the ADON did not document Resident #74 had a recent history of Clostridium Difficile, and current diarrhea having an increased risk of weight loss. <BR/>Record review of an admission MDS dated [DATE] indicated Resident #74 was usually understood and usually understands. The MDS indicated Resident #74 BIMS score was a 13 indicating cognitively intact. The MDS indicated Resident #74 required extensive assistance of one staff with bed mobility, transfers, locomotion, toilet use, personal hygiene, and bathing. The MDS indicated Resident #74 was frequently incontinent of bowel and was not on a toileting plan. <BR/>Record review of the electronic weight summary dated 01/24/2023 indicated Resident #74's weight was 96.0 pounds. The electronic medical record did not reveal a weight for the month of February.<BR/>Record review of the comprehensive care plan dated 02/07/2023 indicated Resident #74 was at risk for Covid 19 infection but did not mention Clostridium Difficile (inflammation of the colon caused by bacteria causing diarrhea) or the need for isolation precautions. <BR/>During an interview on 02/28/2023 at 5:00 p.m., the DON said Resident #74's current weight was 87.4 pounds. The DON said she was unaware of this weight indicated Resident #74 had weight loss.<BR/>Record review dietician note dated 03/01/2023 indicated Resident #74's weight was 87.5 pounds. The dietician note indicated Resident #74's consumed of meals but still had unintended weight loss. The Dietician recommended to reweigh to confirm actual weight loss, weekly weights for 4 weeks, try super cereal at breakfast, start Prostat 30 milliliters twice daily (protein supplement), and offer beverage of choice and house snacks between meals.<BR/>2). Record review of a face sheet dated 03/02/2023 indicated Resident #130 was an [AGE] year-old male who admitted on [DATE] with the diagnoses of stroke, heart attack, heart failure, and diabetes. <BR/>Record review of a baseline care plan dated 02/23/2023 documented by the ADON indicated Resident #130 had self-care performance with personal hygiene, toileting, dressing and bathing. The base line care plan indicated Resident #130 was alert but cognitively impaired. <BR/>Record review of a comprehensive care plan dated 03/01/2023 indicated Resident #130 had a self-care deficit and was at risk of not having his needs met. The goal was to participate to be best of their ability and maintain current level of function with ADLs. The intervention included to provide supervision and set up help with eating. The comprehensive care plan indicated Resident #130 had a nutritional status deficit, and he would receive a mechanical soft diet with thin liquids due to complaints of difficulty swallowing. The goal was to maintain adequate nutritional and hydration status as evidenced by weight stable with no signs or symptoms of malnutrition or dehydration with the interventions to provide and serve diet as ordered and speech therapy to evaluate. The care plan interventions failed to indicate monitoring Resident #130's weight. <BR/>Record review of the most recent MDS dated [DATE] indicated Resident #130 usually understands and was usually understood. Resident #130 BIMS score was 12 but he required cueing to recall. The MDs indicated Resident #130 had difficulty focusing his attention and was easily distracted. The MDS indicated Resident #130 required limited assistance of one staff with bed mobility, transfers, walking, locomotion, dressing, toileting, personal hygiene, and extensive assistance of one staff for bathing. The MDS indicated Resident #130 was incontinent occasionally of bladder and frequently of bowel. The MDS indicated Resident #130 had one fall with an injury.<BR/>Record review of the hospital records indicated Resident #130 weight on 02/19/2023 was 206 pounds. <BR/>Record review of the electronic medical record on 02/28/2023 indicated Resident #130 failed to have an admission with for February 2023.<BR/>During an interview on 03/02/2023 at 4:10 p.m., the DON said Resident #130's current weight was 194.6. The DON said Resident #130 should have had a weight on his admission, but she could not provide one.<BR/>During an interview on 03/02/2023 at 11:00 a.m., the DON said she expected the admitting nurse to input a completed assessment including the weight. The DON said she expected the Resident #74 and #130 to have weekly weights for 4 weeks to ensure no weight loss was occurring. The DON said she was unaware Resident #74 had an eating disorder. The DON said she would have reviewed Resident #74 differently with the knowledge of the eating disorder. The DON said she would have provided psychological therapy, smaller meals, and more protein. <BR/>During an interview on 03/02/2023 at 11:30 a.m., the Interim Administrator said she the DON was responsible for weight management. The Interim Administrator said Resident #'s 74 and #130 should have had weekly weights.<BR/>Record review of the facility's policy, Weight Management, dated 01/2005 and revised on 04/23/2014, indicated .The facility management/clinical team will know the weight status of their residents, including the number of residents who have had a significant and insidious weight loss. Resident weights will be recorded in each resident's medical record monthly, using the Monthly Weight Report. Residents will maintain an acceptable weight unless clinically unavoidable, it is a planned weight change, or it is against the resident wishes. The parameters for significance of unplanned and undesired weight loss are: 1 month -Significant Loss- 5%, Severe loss- greater than 5% It is also important that all residents weights are accurately recorded in the individual resident's clinical record in a timely manner 1. All weights (admission, weekly and monthly) are to be entered into the Point Click Care weight system .All residents should be weighed on admission, readmission and monthly, unless more frequent weights are deemed necessary by the clinical team

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 2 of 22 residents reviewed for laboratory services (Residents #20 and 77). <BR/>The facility failed to obtain ordered CBC (Complete Blood Count), CMP (Complete Metabolic Panel, and Mg (Magnesium) levels for Resident #20.<BR/>The facility failed to obtain ordered CBC, CMP and Mg levels for Resident #77. <BR/>These failures could place residents at risk of not receiving timely diagnoses, treatment, and services to meet their needs.<BR/>This failure could place residents at risk of not receiving the care required to meet their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome. <BR/>Findings included: <BR/>1. A record review of the physician's orders dated March 2023 indicated Resident #20 admitted t the facility on 4/13/22, was [AGE] years old, with diagnoses that included: recurrent depressive disorders (lowering of mood), hypertension (high blood pressure), Alzheimer's Disease (progressive mental deterioration), pain, generalized anxiety disorder (a mental condition characterized by unrealistic anxiety about two or more aspects of life), unspecified mood affective disorder (a disorder affecting a person's emotional state, most commonly sadness), and seizures (uncontrolled burst of electrical activity in the brain). The physician's orders indicated: 12/20/22, CBC, CMP, Mg every 3 months. <BR/>A record review of the MDS dated [DATE] indicated Resident #20 had severe cognitive impairment, clear speech, usually understood others and was usually understood by others. The MDS indicated she had inattention that was continuously present. The MDS indicated she required supervision with no set up or physical help from staff for bed mobility and transfer. <BR/>A record review of the Care Plan dated 6/23/22 indicated Resident #20 required supervision for bed mobility and transfer and was able to effectively communicate when she had pain. <BR/>During an interview on 3/01/23 at 9:10 AM, LVN J said she could not find the labs (CBC, CMP, Mg) ordered for Resident #20 in December 2022. She said she looked yesterday and could not find them then either. She said it appeared they had not been done. <BR/>During an interview on 3/01/23 at 9:15 AM, the ADON said she could not find the labs were done for Resident #20 that were ordered in December of 2022. She said she called the lab provider and they could not find them either. She said the procedure for orders for labs was the nurse took the order, wrote the order, filled out the pharmacy recommendation and then would put the pharmacy recommendation in the lab book. She said the lab provider came in Monday through Friday, got the recommendations from the book, then took the labs per the orders. She said when the results were back the lab would fax the results. She said if the results were critical the lab would also call them. She said she did not know who missed the labs for Resident #20 but not getting her labs could cause serious harm, injury, or death. She said it was important to get all the labs. <BR/>During an interview on 3/01/23 at 9:46 AM, the DON said the risks of Resident #20 not getting her ordered labs on 12/20/22 was that they or the MD would not know her baseline. She said not having the labs would mean they could miss an infection, or a heart problem. She said they would not know if there was a shift in one of her labs. She said there was a danger of serious harm, injury, or death. She said the process for ordering labs was the nurse would take the order, then put the order in the computer. She said then the nurse would fill out a lab requisition, fax it to the lab and then put it into the lab book. She said the lab provider would then collect it and fax the results. She said the lab would stay on the 24-hour report until it was completed. She said she was not here at the time that lab was ordered. <BR/>A record review on 3/01/23 of the progress notes for Resident #20 from 12/19/22 - 12/21/22 did not address the labs ordered on 12/20/22. <BR/>During an interview and record review on 3/01/23 at 11:04 AM, RN K said she took the order for Resident #20 on 12/20/22 for a CBC, CMP, and MG. She said she probably did not put it on the 24-hour report because that was up to the charge nurse. She said her responsibility was to tell the charge nurse and the charge nurse would put that information on the 24-hour report. She showed this surveyor her work schedule for 12/20/22 and 12/21/22. The schedule indicated she had worked 12/20/22 and 12/21/22. RN K agreed she had worked 12/20/22 and 12/21/22. RN K said she did not follow up on the order for Resident #20's labs. She said it was not her responsibility to follow up on the orders. She said it was the charge nurse's responsibility to follow up on the new orders. She said she did not remember who the charge nurse was at that time. She said at that time (12/20/22) she took the order for the labs and made out the lab requisition. She said she did not fax it to the lab because it was not a STAT lab. She said she put the lab requisition for Resident #20 in the lab book. She said there was no written procedure for the particular way to go about getting labs for residents. She said the lab did an audit of the labs for the facility in November of 2022. She said she reviewed the lab audit that showed many labs were missed so she had done her own audit. She said she missed Resident #20's labs in the audit she did. She said she just realized the labs were missed. She said Resident #20 did not get the labs that were ordered 12/20/22.<BR/>During a interview and record review on 3/01/23 at 11:36 AM, the DON showed this surveyor the 24-hour reports dated 12/19/22 - 12/22/22. She said the 24-hour reports did not indicate any new orders for Resident #20. <BR/>During an interview on 3/01/23 at 3:02 PM, the Medical Director for Resident #20 said there should not be any problems with Resident #20 not getting her CBC, CMP or Mg labs. She said the CBC, CMP, and Mg labs were something they were required to do every so often and that was why they were ordered. She said she had taken care of Resident #20 since 2021 and she had not had a seizure. She said the labs were something that they did every so often and not related to seizures. <BR/>During an interview on 3/02/23 at 8:11 AM, the ADON said following MD orders was important regarding labs. She said Resident #20 could have had an infection that they missed. She said labs were important to see if anything had changed from her last labs. The ADON said they would want to catch anything abnormal. She said not having her labs could cause serious injury, or illness. She said depending on what labs, if she had elevated bloodwork of some type, it could potentially be very bad to not know what the labs were. <BR/>During an interview on 3/02/23 at 8:22 AM, the DON said physician's orders should have been followed for Resident #20 for patient safety, positive outcomes, and maintenance of health status. She said she was not at the facility in December 2022, but with the current process the nurse would take the order, put it in the computer, complete the lab requisition and put it in the doctor's lab book. She said the lab provider would come around Monday through Friday and get the order. She said on weekends if it was a timed lab (a lab that had to be done in a certain time frame), they had to call the lab, the same as with a STAT (as soon as possible) lab. She said the charge nurse for that unit would put it on the 24-hour report until they got the results. She said the charge nurse was the actual nurse so she should have known to put it on the 24-hour report. She said RN K was working PRN (as needed) at the time and was not the charge nurse at the time. She said RN K was at the facility helping but the charge nurse at the station should have put the new orders on the 24-hour report. She said she would look and see who that was. <BR/>During an interview on 3/02/23 at 8:29 AM, the Interim Administrator said labs were important no matter what they were. She said if they did not know what the labs were, there were all kinds of things that could go wrong with the resident. She said Resident #20 not getting her labs could have caused them to miss an infection or an illness. She said missing the labs could cause serious injury to the resident. The Interim Administrator said she was not a nurse or a MD so she did not know if it could cause death. <BR/>During a phone interview on 3/02/23 at 10:54 AM, LVN L said she was the charge nurse on 12/20/22 (at the time when Resident #20 got the lab orders). She said if RN K took the order, it was up to her to get that order on the 24-hour report so that the order could be followed through. She said that was so long ago she did not remember if RN K told her about the new lab orders for Resident #20. She said if RN K did not put the new orders on the 24-hour report she should have told her about the new orders so she could have put them on the 24-hour report. She said the information on the 24-hour report was how the nurses followed up and made sure the labs were completed. <BR/>2. Record review of Resident # 77's face sheet, dated 03/02/23, indicated a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included right femur (thigh bone) fracture, muscle weakness, high blood pressure, and depression (persistent feeling of sadness).<BR/>Record review of Resident #77's admission MDS, dated [DATE], indicated she was understood and understood others. The MDS revealed Resident #77 had a BIMS score of 15 which indicated her cognition was intact. Resident #77 required limited assistance with dressing and extensive assistance with bathing. She was independent with transfers, locomotion, eating and toileting.<BR/>Record review of Resident #77's comprehensive care plan did not address lab orders.<BR/>Record review of Resident #77's order summary report, dated 03/02/23, indicated she had the following order: CBC, CMP, and Mg every 3 months with an order date of 01/30/23 and a start date of 02/28/23.<BR/>During an interview on 03/02/23 at 02:34 p.m., the ADON said she had looked in Resident #77's records and her labs for CBC, CMP, and Mg could not be found. The ADON also reviewed the laboratory book, and she indicated the labs were not completed. The ADON said the labs for CBC, CMP, and MG were done on admission as standard orders for labs. The ADON said the charge nurse was responsible for ensuring the lab requisitions were completed and she was unsure as to why Resident #77 labs were not completed. The ADON said it was her responsibility to check the orders the next day and to ensure the lab requisition were completed for all lab orders. The ADON said by no completing the labs as order placed the resident at risk for harm. <BR/>During an interview on 03/03/23 at 10:23 a.m., the DON said she expected the labs to be completed as ordered. The DON said the nurse that obtained the lab order was responsible for ensuring the lab requisition was completed and placed in the lab book. The DON said she was ultimately responsible for ensuring the labs were completed and was unsure as to of why Resident #77 had missed labs. The DON said the clinical team reviews orders the next day during the morning meeting or the following Monday. The DON said they ensure the orders are correct and the lab requisitions were completed. The DON said by the obtaining the labs as ordered the resident was at risk for not receiving the care they need.<BR/>During an interview on 03/03/23 at 11:05 a.m., the Interim Administrator said she expected labs to be completed as ordered. The Interim Administrator said the DON was responsible for ensuring the labs were completed as ordered. The Interim Administrator said by not obtaining the labs as ordered the resident was at risk for being sick or having nontherapeutic medication levels. <BR/>A record review of the Lab Tracking Documentation Clinical Practice Guidelines dated 8/2015 indicated:<BR/>Anticipated Outcome<BR/>Lab documentation provides a record of the ordered lab test, including a system to monitor timely completion of ordered lab test and serves as a primary document describing lab services provided to the patient. <BR/>Fundamental Information<BR/>Lab tracking tools are used by healthcare team to track and record timely completion of ordered lab tests. <BR/>Procedure<BR/>Only physician ordered laboratory tests are completed .<BR/>Lab requisition form will be completed and placed under appropriate date in the lab notebook. <BR/>Individual tests are recorded on separate lines in the lab notebook and on the appropriate (Lab Tracking Tool or PT/INR Lab tracking tool) in the facility lab tracking notebook.<BR/>The new order is then recorded in facility's lab tracking notebook on appropriate tracking form (Lab Tracking Tool or PT/INR Lab tracking tool) <BR/>A Following Physician's Orders policy dated 9/28/21 provided by the Regional Nurse did not address orders for labs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections were maintained for 4 of 6 residents reviewed for communicable disease (Resident #'s 41, 45, 54, and 74) and 1 of 12 months reviewed for infection control tracking and trending (January 2023).<BR/>The facility failed to initiate transmission-based precautions with the onset of the diagnosis of shingles F(painful rash with blisters) for Resident #45. <BR/>The facility failed to initiate transmission-based precautions with the onset of and ongoing of diarrhea for Resident #74. <BR/>CNA C failed to change gloves and washing her hands during incontinent care and prior to exiting Resident #74's room. <BR/>The facility failed to separate the linen from the rooms with communicable infections from the general linen for Resident #'s 45 and 74. <BR/>The facility failed to test Resident #41 for Clostridium Difficile (Inflammation of the colon caused by bacteria) when he had chronic diarrhea. <BR/>The facility failed to document tracking and trending of infection and antibiotic use for January of 2023. <BR/>LVN F failed to remove soiled gloves after obtaining Resident #50's blood sugar and he failed to perform hand hygiene before donning clean gloves.<BR/>The facility failed to ensure LVN D did not use a dirty cloth to clean Resident #54's catheter during catheter care. <BR/>The Infection Preventionist allowed RN G to work with a temperature of 102.2. <BR/>An Immediate Jeopardy (IJ) situation was identified on 02/28/2023 at 4:47 p.m. While the IJ was removed on the 03/03/2023 at 1:21 p.m., the facility remained out of compliance at an actual harm with a scope of widespread with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. <BR/>This failure could place residents at risk for being exposed to shingles, and diarrhea related to clostridium difficile (bacteria causing diarrhea to life-threatening damage to the colon. <BR/>Findings included:<BR/>1) Record review of a face sheet dated 03/02/2023 indicated Resident #45 was an [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of heart failure, depression, malnutrition, and high blood pressure. <BR/>Record review of the consolidated physician's orders dated 02/01/2023 indicated Resident #45 was did not indicated contact isolation was ordered.<BR/>Record review of the consolidated physician's orders dated 03/01/2023 indicated Resident #45 had Acyclovir 800 milligrams 5 times daily for 5 days for possible shingles started on 03/01/2023. Resident #45 had Clindamycin 300 milligrams three times a day for cellulitis x 7 days started on 02/28/2023 and Doxycycline Monohydrate 100 mg twice a day for cellulitis until 03/07/2023. Resident #45 was also ordered Gentamicin Sulfate Ophthalmic ointment 0.3% 1 application in right eye two times a day for infection x 7 days to start on 02/28/2023.<BR/>Record review of the comprehensive care plan dated 11/09/2022 failed to indicate Resident #45 had shingles involving his face, and right eye. The comprehensive care plan did not address isolation precautions. <BR/>Record review of the most recent Significant change MDS dated [DATE] indicated Resident #45 was usually understood and usually understands. Resident #45 required large print to read. The MDS indicated Resident #45's BIMS score was 11 indicating he had moderately impaired cognition. The MDS indicated during the assessment period Resident #45 did not reject care. The MDS indicated Resident #45 required extensive assistance of one staff with bed mobility, dressing, toilet use, personal hygiene, and with bathing Resident #45 required total assistance of one staff member. Resident #45 was incontinent of bowel and bladder. <BR/>Record review of Resident #45's February 2023 electronic medication record indicated he received Acyclovir 800 milligrams one tablet three times a day for shingles for 7 days started on 02/20/2023 and completed on 02/27/2023. Resident #45 was ordered Ofloxacin Ophthalmic Solution 0.3% one drop to the right eye 4 times daily for 5 days starting on 02/20/2023. Acyclovir 800 milligrams was restarted on 02/28/2023, Ofloxacin Ophthalmic Solution 0.3% instill one drop in right eye at bedtime for 7 days started on 2/27/2022, and Doxycycline 100 milligram give one tablet twice daily for 7 days started on 02/28/2023 after surveyor intervention. <BR/>Record review of a nursing note dated 02/20/2023 at 10:12 a.m., LVN G wrote the physician was notified regarding Resident #45's redness, swelling, and matter to his right eye.<BR/>Record review of a nursing note dated 02/20/2023 at 10:54 a.m., LVN G wrote he received new orders for Acyclovir 800 milligrams three times a day for 7 days, ofloxacin 0.3% one drop in right eye four times a day for 5 days, appointment with an ophthalmologist and check a HSV ig M level.<BR/>Record review of a nursing note dated 02/20/2023 at 8:34 p.m., LVN M wrote monitoring for edema every day and night shift, with the right side of Resident #45's face/eye with edema with the MD aware with labs ordered.<BR/>Record review of a nursing note dated 02/21/2023 at 1:03 a.m., LVN M wrote right side of Resident #45's face/eye continues with edema and redness, and Resident #45 denied pain. LVN M noted Resident #45's son would like to see if the facility ophthalmologist could see resident #45 instead of having to be transferred out of the facility. <BR/>Record review of a nursing note dated 02/22/2023 at 9:08 a.m., LVN O indicated Resident #45 continued the Acyclovir eye drops to his eye every night, continued to assess for pain, discomfort, and changes.<BR/>During an observation on 02/27/2023 at 12:17 p.m., Resident #45 was lying in his bed. He had scabbing appearing areas to his right eye and forehead. Resident #45's right eye is scabbed closed he could not open it on command. There were no isolation precautions posted on Resident #45's room.<BR/>During an interview on 02/27/2023 at 12:26 p.m., CNA N said Resident #45 had not been on any isolation precautions. CNA N said she regularly cares for Resident #45 and has floated to other halls to help. CNA N said she had questioned the DON as to why Resident #45 was not on any type of isolation because CNA N said shingles were contagious. CNA N said she floated to work on other halls. CNA N said Resident #45 did not eat any of his noon meal because he was hurting from the shingles.<BR/>During an interview on 02/27/2023 at 8:55 a.m., the DON said the nurses had not realized Resident #45 required isolation. The DON said the nurses did not make her aware of a case of shingles. The DON said Resident #45 should have been placed on contact isolation. The DON said the risk for unvaccinated and residents who had not had chicken pox as a child were at risk of having shingles. The DON said she was unaware Resident #45 had an order to see an ophthalmologist related to his right eye. The DON said they facility eye physician had already made rounds around February 9th or the 10th. The DON said she had not contacted the mobile eye physician or the son with a plan to have Resident #45's right eye examined. The DON said shingles in the eye could result in vision loss for Resident #45. The DON said she was the infection preventionist for the building. The DON said she was unsure how Resident #45's infection of the shingles as missed because she said the nurse managers log the infections and review the orders in morning meeting. <BR/>Record review of a nurse note dated 02/28/2023 at 1:06 p.m., indicated Resident #45 was administered a tramadol 50 milligram tablet for pain.<BR/>During an interview on 02/28/2023 at 3:11 p.m., LVN P said CNA N asked why Resident #45 was not on isolation if he had shingles. LVN P said she asked the DON to explain why Resident #45 was being treated for shingles why was he not on isolation. LVN P said the DON said Resident #45 should have been on isolation. LVN P said she had worked February 19, 2023, through February 23, 2023. LVN P said Resident #45's eye was much worse. LVN P said no one had contacted the physician for Resident #45's worsening shingles. LVN P said Resident #45 had not been on isolation for the shingles, but he should have been to prevent the spread to other residents. <BR/>During an interview on 02/28/2023 at 3:26 p.m., the medical director said she was unaware of Resident #45's right eye condition with shingles covering the entire eye lid and the right eye would not open. The medical director said she was unaware Resident #45 had not seen an eye specialist related to the shingles to the right side of the face and eye. The medical director said she expected the facility to obtain an appointment promptly due to the risk of blindness with ocular shingles. <BR/>During an observation and interview on 02/28/2023 at 3:45 p.m., LVN P applied a warm compress to Resident #45's right eye. LVN P asked Resident #45 to open his right eye, and he could not open the eye at all. Resident #45 said his right eye was hurting and LVN P immediately stopped and said she would administer a pain medication. LVN P said she would notify the physician. Resident #45 now had isolation signs and PPE outside of the room.<BR/>Record review of a nurses note dated 02/28/2023 at 12:57 p.m., Resident #45 had an appointment scheduled for March 2, 2023, at 3:15 p.m. The note indicated Resident #45's son was notified of the appointment related to shingles to the right eye. <BR/>Record review of a nurse note dated 02/28/2023 at 8:03 p.m., the ADON wrote Resident #45's family was notified of the lab results of the Herpes Simplex IgM result of 0.66 and the new order received from the physician for Clindamycin 300 mg one three times and day and discontinue the acyclovir. <BR/>Record review of a nurse note dated 02/28/2022 at 8:21 p.m., the DON wrote Resident #45's isolation was discontinued for shingle precautions and indicated Resident #45 had a new diagnosis of cellulitis and with a new medication ordered. The new order was Clindamycin 300 mg one capsule three times a day for 7 days. <BR/>Record review of a nurse note dated 02/28/2023 at 11:08 p.m., LVN B wrote Resident #45 was administered gentamycin eye drops. LVN B wrote Resident #45 face was red and swollen with blisters and scabs.<BR/>During an interview on 02/28/2023 at 8:55 a.m., the DON said the nurses did not realize Resident #45 required isolation for the shingles. The DON said Resident #45 should have been placed on contact isolation. <BR/>During an interview on 02/28/2023 at 10:07 a.m., the Interim Administrator said she was unaware of Resident #45 having shingles. The Interim Administrator said shingles should be isolated in so not to spread to other residents.<BR/>Record review of Resident #45's March 2023 electronic medical record indicated he had Gentamicin Sulfate Ophthalmic Ointment 0.3% instill one application in the right eye two times a day for 7 days starting on 03/01/2023, Ofloxacin Ophthalmic Solution 0.3% instill one drop in right eye at bedtime for 7 days starting on 02/27/2023; Doxycycline monohydrate 100 milligrams one capsule twice daily for cellulitis until 03/07/2023; and Clindamycin 300 mg one capsule by moth three times a day for cellulitis for 7 days; and Acyclovir 800 milligrams one tablet by mouth 5 times a day for 5 days for possible shingles starting on 03/01/2023. <BR/>Record review of a nurse note dated 03/01/2023 at 1:24 a.m., LVN B documented Resident #45 had a diagnosis of cellulitis, day 2 of isolation, acyclovir was discontinued, day 2 of 7 on ofloxacin and gentamicin eye drops, day 3 of 7 on doxycycline with no adverse reactions. The note indicated Resident #45 had redness, swelling, and scabs to his face with warm compresses used.<BR/>During an interview on 03/01/2023 at 8:34 a.m., the Regional Corporate Nurse said after digging deeper the lab result for an IgM level was 0.66 which was negative. The Regional Corporate Nurse said Resident #45 was negative for shingles but was being treated for cellulitis. <BR/>During an observation and interview on 03/01/2023 at 9:18 a.m., Resident #45 said his right eye was hurting. Resident #45 had a very minimal opening between his eye lids and there was yellow stingy material in the opening. Resident #45's isolation precautions remained removed. <BR/>During an interview on 03/01/2023 at 2:57 p.m., the medical director indicated initially Resident #45's rash appeared to be shingles. The medical director indicated the IgM test (antibody test for an infection) was negative. The medical director said she would complete a PCR HSV and VSV, and place Resident #45 back on isolation. The medical director said she would order a PCR HSV and VSV (testing for Herpes simplex virus and varicella simplex virus) because the test would be the most accurate test according to CDC recommendation.<BR/>Record review of a nurses note dated 03/01/2023 at 6:10 p.m., LVN G placed Resident #45 back on isolation precautions further pending laboratory results. <BR/>Record review of a nurses note dated 03/01/2023 at 6:24 p.m., ADON wrote she notified the Resident #45's son of the new orders to restart Acyclovir 800 milligrams five times daily x 5 days, PCR HSV and VZV lab (laboratory test for herpes simplex and varicella zoster), and reinstate the isolation precautions. <BR/>Record review of an incident report dated 03/02/2023 at 3:30 p.m., indicated Resident #45 slid from his wheelchair to the floor. The ADON wrote there were no injuries noted but Resident #45 was sent to the emergency room.<BR/>Record review of an After Visit Summary dated 03/02/2023 indicated Resident #45 was provided instructions related to shingles and minor head injury. The summary indicated his diagnoses included an unspecified fall, facial contusion, and herpes zoster (shingles). The educational material included in the Visit Summary report indicated:<BR/>*If the shingles affects your eye the doctor may cover your eye with a bandage<BR/>*Infections of the eye and the skin around the eye were other health problems to treat<BR/>*To prevent the shingles do not share towels, go swimming, or play contact sports with people who have shingles if you never had chicken pox.<BR/>*Do not touch or scratch your rashes, if you do wash your hand afterwards.<BR/>2) Record review of a face sheet dated 03/02/2023 indicated Resident #74 was an [AGE] year-old female who admitted on [DATE] with the diagnoses of spondylolisthesis (disorder of which a bone vertebra slips forward onto the bone below), eating disorder, and high blood pressure. <BR/>Record review of a Baseline care plan dated 01/24/2023 at 8:39 a.m., the ADON did not document Resident #74 had a recent history of Clostridium Difficile (infection of the colon from bacteria), diarrhea, or isolation precautions needed for on-going symptoms. <BR/>Record review of the comprehensive care plan dated 02/07/2023 indicated Resident #74 was at risk for Covid 19 infection but did not mention Clostridium Difficile or the need for isolation precautions. <BR/>Record review of an admission MDS dated [DATE] indicated Resident #74 was usually understood and usually understands. The MDS indicated Resident #74 BIMS score was a 13 indicating cognitively intact. The MDS indicated Resident #74 required extensive assistance of one staff with bed mobility, transfers, locomotion, toilet use, personal hygiene, and bathing. The MDS indicated Resident #74 was frequently incontinent of bowel and was not on a toileting plan. <BR/>Record review of the February 2023 electronic medical record indicated Resident #74 received Colestipol 1 gram twice daily for treating diarrhea since 01/24/2023, lactobacillus capsule one capsule by mouth twice daily, and Lomotil 2.5-0.025 milligrams one tablet every 6 hours as needed for diarrhea since 01/24/2023. The electronic medical record indicated Resident #74 had 8 doses in the month of February and two doses were unknown if effective. <BR/>Record review of a nursing progress note dated 01/24/2023 documented by LVN T indicated Resident #74 was post Clostridium Difficile .<BR/>Record review of a nursing progress note dated 01/31/2023 at 1:22 a.m., indicated LVN V administered Lomotil for diarrhea, but the medication was ineffective. The note did not indicate the physician was notified.<BR/>Record review of a nursing progress note dated 01/31/2023 at 12:24 p.m., LVN F documented Resident #74 was administered Lomotil for diarrhea.<BR/>Record review of a skilled nurses note dated 02/01/2023 at 12:48 a.m., indicated Resident #74 was post Clostridium Difficile.<BR/>Record review of a progress note dated 02/01/2023 at 1:30 a.m., indicated Resident #74 was administered Lomotil for diarrhea by LVN M. <BR/>Record review of a nursing note dated 02/03/2023 at 5:40 a.m., LVN T documented an administration of Lomotil for diarrhea was provided to Resident #74. <BR/>Record review of a nurses note dated 02/04/2023 at 3:32 a.m., LVN R documented Resident #74 was post clostridium difficile. <BR/>Record review of a nurses note dated 02/04/2023 at 3:32 a.m., LVN R documented Resident #74 was post clostridium difficile.<BR/>Record review of a nurses note dated 02/06/2023 at 8:37 a.m., indicated LVN S documented Resident #74 was post clostridium difficile. <BR/>Record review of a nurses note dated 02/06/2023 at 11:18 p.m., LVN T documented Resident #74 required the administration of Lomotil for diarrhea. <BR/>Record review of a nurses note dated 02/07/2023 at 11:40 p.m., LVN T documented Resident #74 required Lomotil administration related to diarrhea. <BR/>Record review of a nurses note dated 02/15/2023 at 9:42 p.m., LVN T documented Resident #74 required administration of Lomotil for diarrhea.<BR/>Record review of a nurses note dated 02/24/2023 at 12:54 a.m., indicated Resident #74 continued to have been monitored for diarrhea none noted on this shift. <BR/>Record review of a nurses note dated 02/25/2023 at 6:41 a.m., LVN T indicated Resident #74 had 3 diarrhea bowel movements with Lomotil given and effective at present. The note indicated Resident #74's peri area was very red.<BR/>Record review of a nurses note dated 02/25/2023 at 6:43 p.m., LVN B documented Resident #74 required Lomotil for diarrhea and the medication was effective. <BR/> During an observation on 02/27/2023 at 10:08 a.m., Resident #74 said her brief needed changing due to having a very large diarrhea bowel movement. Resident #74 was assisted to activate her call light for assistance. CNA C answered the call light and left the room. CNA C returned with bed linen and incontinent care supplies. CNA C washed her hands then initiated care to Resident #74. CNA C opened Resident #74's brief, then wiped down the left side of her groin, and then across Resident #74's abdomen. CNA C removed her gloves and applied new gloves. Then CNA C took a roll of trash bags and unrolled a bag for use with the same gloves on. CNA C removed gloves and washed her hands. She returned to Resident #74 applied new gloves then removed the soiled brief. CNA C touched the wipe bag and obtained more wipes to cleanse Resident #74's buttocks. CNA C dropped the new brief on the floor. CNA C removed her soiled gloves, opened Resident #74's door and exited the room without washing her hands. CNA C returned to the room with a new brief. CNA C then washed her hands and laid the new brief on top of soiled linen she had rolled up underneath Resident #74. CNA C touched the foot of the bed and moved the bed out to walk around the bed to provide care. CNA C then walked to end of the bed, moved the bed back against the wall and continued with the care. CNA C removed her gloves and donned more gloves applying a barrier cream to Resident #74's buttocks. Resident #74's room had no isolation signs posted or PPE (personal protective equipment).<BR/>Record review of a nurses note dated 02/27/2023 at 5:55 p.m., LVN F documented Resident #74 made the statement she thought she needed to return to the hospital due to the ongoing diarrhea. LVN F documented he informed Resident #74 he had a stool sample waiting for pickup. <BR/>During an interview on 02/28/2023 at 7:47 a.m., CNA C said she made a lot of mistakes with incontinent care. CNA C said she should have closed Resident #74's blind, should have washed hands with glove changes. CNA C said Resident #74 has had diarrhea since she admitted . <BR/>During an interview on 02/28/2023 at 7:51 a.m., the Housekeeping Supervisor said she was unaware there were residents with possible Clostridium Difficile. The housekeeping supervisor said for Clostridium Difficile there was a special tablet to add to the water for cleaning of these rooms. The housekeeping supervisor said she was also unaware of Resident #74 or Resident #45 having communicable disease processes requiring special laundry procedures. The housekeeping supervisor said when the laundry receives linen in the yellow bags the laundry personnel would be alerted to wash this linen separate from the general linen. <BR/>During an interview on 02/28/2023 at 3:26 p.m., the Medical Director said Resident #74 had Clostridium Difficile in the recent past. The Medical Director said she was not notified Resident #74 had on-going diarrhea since admission. The Medical Director said Resident #74 could be a carrier of Clostridium Difficile. The medical director said Resident #74 could still be infectious up to 6 weeks and should have been isolated to prevent the spread of a potential reinfection. The Medical Director said she was unaware Resident #74 was the neighbor to a resident who had non-Hodgkin's lymphoma (cancer of lymphatic system) and recently had a stem cell transplant.<BR/>Record review of a nurses note dated 02/28/2023 at 4:00 p.m., the Marketer QQ documented the medical director was notified of ongoing loose stool and ongoing since admission. The note indicated Marketer QQ notified the medical director of the negative C-diff lab test prior to admission on [DATE] and Resident #74 having Lomotil as needed. The note indicated a new order was received for Imodium 2 mg three times daily until C-diff test returns negative. <BR/>During an interview on 03/01/2023 at 10:58 a.m., LVN S said Resident #74's stool sample result was not back.<BR/>During an observation on 03/01/2023 at 9:18 a.m., Resident #74 was in the therapy gym with other residents present. Resident #74's room had isolation precautions signs and PPE available. <BR/>During an interview on 03/01/2023 at 11:17 a.m., LVN S said if Resident #74 does have clostridium difficile she was told the germ would be contained in her brief. LVN S agreed Resident #74 was incontinent of stool.<BR/>During an interview on 03/01/2023 at 11:30 a.m., the occupational therapist assistant said she checked with LVN S and was advised Resident #74 although on isolation precautions could come to the gym for therapy.<BR/>During an interview on 03/01/2023 at 11:36 a.m., the DON said Resident #74 should have not been allowed in the therapy gym increasing the risk to spread the communicable disease. <BR/>During an observation on 03/02/2023 at 9:48 a.m., Resident #74's neighbor next door had a sign placed beside her entrance indicating she was now in enhanced barrier precautions. The sign indicated everyone must:<BR/>*Clean hands before entering room<BR/>*All personnel must wear gloves, gown, with high care activities such as dressing, bathing, showers, and transfers<BR/>*Changing linen<BR/>*Providing hygiene<BR/>*Changing brief/toileting<BR/>*Device care<BR/>*Wound care.<BR/>This was determined to be an Immediate Jeopardy (IJ) situation on 02/28/2023 at 4:47 p.m. The Interim Administrator and the Regional Corporate Nurse was notified. The Administrator was provided with the IJ template on 02/28/2023 at 4:58 p.m.<BR/>The following Plan of Removal submitted by the facility was accepted on 03/03/23 at 1:21 p.m. and included the following:<BR/>Immediate Action:<BR/>*On 02/27/2023 Resident #45 was placed in contact isolation<BR/>*On 02/28/2023 Resident #74 was placed in contact isolation<BR/>*On 02/28/2023 Resident #45 was removed from contact isolation per physician's order, related to a negative Herpes Simplex IGM test on 02/21/2023, Medical Director ordered Acyclovir treatment which was administer per physician's order<BR/>*On 03/01/2023 after Medical Director spoke to the survey team, the Medical Director ordered Resident #45 to be placed back in isolation, restart Acyclovir, and PCR (Polymerase chain reaction) testing for HSV (herpes simplex virus) and VZV (varicella-zoster virus).<BR/>*On 03/01/2023 Resident #45 was placed back on contact isolation<BR/>*On 02/28/2023 Regional Nurse Consultant completed an assessment of resident #74 to validate Resident had no negative outcome from alleged improper peri-care.<BR/>Facility's plan to ensure compliance quickly:<BR/>*On 02/28/2023 DON/designee began training on Transmission Based Precautions to guide the center on when and what precautions to take to prevent transmission of pathogens base on mode of transmission including linen handling, storage, and sanitation for residents with presumed or confirmed infections, with all staff on duty. This education was completed on 02/28/2023with 20 of 89 staff trained. On 03/01/2023 at 2:00 p.m., no staff will be allowed to work until his education was completed.<BR/>*The DON/Designee was responsible for ensuring residents were placed on appropriate isolation precautions.<BR/>*On 03/01/2023 the DON was provided 1:1 education on Transmission Based Precautions to guide the center on when and what precautions to take to prevent transmission of pathogens based on mode of transmission, on monitoring, tracking, trending of infections by Regional Nurse Consultant. <BR/>*On 03/01/2023 an additional 8 staff were trained prior to working<BR/>*Again, no staff would be allowed to work until the education had been completed<BR/>*On 03/01/1023 DON/designee began performing Hand Hygiene Skills Validation with Nurse Assistants. The skill competencies were completed on 02/28/2023 at 10:00 p.m., with 19 of 89 staff trained. NO staff would be allowed to work until the skills competency was completed.<BR/>*On 03/01/2023 DON/designee began performing Hand Hygiene Skills Validation with all staff with an additional 39 of 89 staff trained.<BR/>*On 02/28/2023 DON/designee began performing Peri-Skills Validation with Nurse Assistants. The skills competencies were completed on 02/28/2023 at 10:00 p.m. with 11 of 29 Nurse Assistants trained. No Nurse Assistants would be allowed to work until the education was completed. <BR/>*On 03/01/2023 DON/designee began performing Peri-Skills Validation with Nurse assistants with an additional 10 of 29 staff trained.<BR/>*On 03/01/2023 housekeeping staff completed deep thorough cleaning/disinfection of resident #'s 45, 74, and 1 other identified resident's room. The cleaning included halls and common areas. <BR/>Quality Assurance:<BR/>*Medical Director was notified on 02/28/2023 at 8:00 p.m. of the Immediate Jeopardies.<BR/>*On 03/01/2023 an Ad Hoc QAPI meeting was conducted to discuss identified issues and to develop plan for sustaining compliance. <BR/>In-services Conducted:<BR/>Transmission Based (Isolation) Precautions dated 10/24/2022 indicated it was the policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' mode of transmission. For training and quick referencing purposes a summary of precautions was contained at the end of the policy.<BR/>Airborne Precautions refer to actions taken to prevent or minimize the transmission of infectious agents/organisms that remain infections over long distances when suspended in air.<BR/>Contact precautions refer to measures that were intended to prevent transmission of infectious agents which were spread by direct or indirect contact with the resident or the resident's environment.<BR/>Droplet precautions refer to actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions.<BR/>Transmission-based precautions (aka Isolation Precautions) refer to actions implemented in addition to standard precautions that were based upon the means of transmission (airborne, contact, and droplet) in order to prevent or control infections. <BR/>Policy Explanation and Compliance Guidelines:<BR/>1.Facility staff will apply Transmission-Based Precautions, in addition to standard precautions, to residents who were known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission.<BR/>2.The facility would use standard approaches, as defined by the CDC, for transmission-based precautions: airborne, contact, and droplet precautions. The category of transmission-based precautions will determine the type of personal protective equipment to be used.<BR/>3.When implementing transmission-based precautions, the facility will consider the following: <BR/>a. The identification of resident risk factors <BR/>b. The provision of a private room .<BR/>c. Cohorting .<BR/>d. sharing a room with a roommate with limited risk factors.<BR/>4. Residents on transmission-based precautions should remain in their rooms except for medically necessary care.<BR/>5. High touch objects and environmental surfaces should be cleaned and disinfected with an EPA-registered disinfectant .<BR/>6. Prompt recognition of need<BR/>Type and Duration of transmission-based precautions recommend for selected infections and conditions:<BR/>Clostridioides difficile formerly Clostridium difficile requires contact precautions, for the duration of the illness and hand hygiene with soap and water.<BR/>Herpes zoster (shingles) requires airborne (if disseminated), contact I if resident was immunocompromised, standard (if localized).<BR/>Validation Checklist Hand Hygiene:<BR/>*Necessary supplies present<BR/>*Water turned on with clean, dry towel; temperature adjusted for comfort<BR/>*Soap applied to hands<BR/>*Hands rubbed together vigorously with antimicrobial soap<BR/>*Friction applied to all surfaces of the hands and fingers<BR/>*Hand hygiene activity continued for 20-30 seconds<BR/>*Hands rinsed thoroughly under running water<BR/>*Hands kept lower than level of wrist during procedure<BR/>*No contact with the inside of the sink<BR/>*Stood away from sink to prevent splashing of uniform/clothing<BR/>*Hands dried thoroughly with paper towels<BR/>*Clean, dry paper towels used to turn off faucet<BR/>*Towels discarded into trash receptacles<BR/>*Alcohol gel used as adjunct<BR/>*Understands the use of gloves and when they were to be used<BR/>*Appropriate use of alcohol-based products.<BR/>Validation Checklist Perineal Care:<BR/>*Reviewed plan of care<BR/>*Gathered needed supplies<BR/>*Summoned for assistance if needed<BR/>*Knock and gained permission to enter resident's room<BR/>*Identified self, explained the procedure, provided privacy and asked permission to proceed<BR/>*Set up needed supplies on the bedside stand in easy reach<BR/>*Positioned the bed at a comfortable working position<BR/>*Washed hands correctly<BR/>*Avoided over exposure of resident while placing linens in proper place<BR/>*Filled wash basin half full of water<BR/>*Donned appropriate personal protective equipment<BR/>*Placed waterproof pad under resident if necessary<BR/>*Followed correct procedure for removing fecal material<BR/>*Performed correct procedure for female<BR/>*Performed correct procedure for male<BR/>*Followed infection control protocol<BR/>*Placed call-light device within easy reach of the resident<BR/>*Cleaned wash basin and returned to storage area<BR/>*Cleaned bedside stand<BR/>*Returned the door and blinds open if resident desired<BR/>*Recorded/reported appropriate data<BR/>*Maintained clean technique and observed any isolation precautions.<BR/>Monitoring included:<BR/>During Interviews on 03/03/2023 from 3:08 p.m. until 3:54 p.m., the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the IJ by:<BR/>Interview with the DON indicated she was [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.Record review of Resident #59's admission record dated 03/02/23 indicated the resident was a 94year old female who admitted to the facility on [DATE] with the diagnosis of dementia, anxiety, mood disorder, diabetes, high blood pressure, and kidney disorder.<BR/>Record review of Resident #59's annual MDS dated [DATE] indicated under Section B, Hearing, Speech, and Vision, B0700 was coded as a 2 indicating she sometimes understood and B0800 was coded as a 2 indicating she was sometimes understood by others. Section C, Cognitive Patterns, under section C0500 Brief Interview for Mental Status, which indicated a score of 02 for severe cognitive impairment. Section G, Function Status, under section G0110 indicated she needed extensive assistance with toileting, personal hygiene, and bathing, limited assistance with bed mobility and dressing, supervision with transfers, and independent with eating.<BR/>Record review of Resident # 59's medication administration record dated 3/2/23 indicated that for the month of February 2023 Resident #59 had an order for Haldol Injection 5MG/ML (Haldol lactate) Inject 2.5mg intramuscularly every 8 hours as needed for agitation for 12 days that started 02/08/23 at 1230 (12:30 p.m.) and discontinued 02/08/23 at 1234 (12:34 p.m.) with no administration. It also indicated Resident #59 had an order for Haldol Injection 5MG/ML (Haldol lactate) Inject 2.5mg intramuscularly every 8 hours as needed for agitation that started on 02/06/23 at 1700 (5:00 p.m.) and discontinued on 02/08/23 at 1218 (12:18 p.m.) with no administration. <BR/>Record review of the facility's patient dispense history dated 03/01/23 for dates 02/01/23-02/28/23 indicated Resident #59 had Haloperidol Lac 5MG/ML 1ML with quantity of 5 dispensed to the facility on [DATE].<BR/>Record review of Resident #59's Order Summary Report dated 03/14/23 indicated that resident had an order for Haldol Injection 5MG/ML (Haldol lactate) Inject 2.5mg intramuscularly every 8 hours as needed for agitation that started on 02/06/23 and discontinued, and Resident # 59 had order for Haldol Injection 5MG/ML (Haldol lactate) Inject 2.5mg intramuscularly every 8 hours as needed for agitation for 12 days that started 02/08/23 and ended on 02/20/23. <BR/>During an interview on 03/02/23 at 01:32p.m. CNA LL said she had been working for the facility for 30 years. She said she had never known Resident #59 to be given any injections. <BR/>During an interview on 03/02/23 at 01:34p.m. LVN MM said she was never aware of Resident #59 having an injection given. She said she never knew the resident had an order for Haldol at all. She said she thought Haldol injections should have been in the narcotic lock box on the cart and counted daily. LVN MM said she would have reported to the DON if the medication had been removed or missing from the cart. <BR/>During an interview on 03/03/23 at 10:08a.m. LVN L said she knew Resident #59 had an order for Haldol, but never knew of the resident being administered Haldol because it was discontinued soon after it was ordered. LVN L said Resident #59 never had any anxiety or agitation noted. <BR/>During an interview on 03/03/23 at 11:02 a.m. the DON said she could not locate the Haldol medication that was sent to the facility. She said she had looked through her closets and all discontinued medications. The DON said she had notified the police on 03/01/23 to report the Haldol medication as missing. The DON said her, and the floor nurses had completed a search through all medication carts, as well as the medication rooms on 03/01/23. She said the charge nurses were responsible for removing discontinued medications from the cart and giving the narcotic medications to her or placing regular medications in the medication room's discontinued medication box. The DON said she was responsible for monitoring and logging the medications, as well as ensuring the medications were in the correct place. The DON said the risk to Resident #59 medication being misplaced was the medication being abused or the resident not getting the medication administered as needed. The DON said the missing medication was considered to be misappropriation or resident property. <BR/>During an interview on 03/03/23 at 04:58 p.m. the Interim Administrator said the Haldol medication was missing. She said her, nor the DON had been able to determine who had taken the medication nor where it was located. The Interim Administrator said she had confirmed that the medication was delivered on 02/06/23, and it was discontinued on 02/08/23. She said the DON was responsible for ensuring all medications were received and discarded in the proper locations. The Interim Administrator said the Haldol missing could have placed Resident #59 at risk for not receiving the proper medication if needed. <BR/>A record review of the facility's Abuse policy, originally dated 02/2005, reviewed 02/01/2021, indicated, Residents have the right to be free of abuse, neglect, misappropriation of resident property, and exploitation, physical and chemical restraint not required to treat the resident's symptoms, involuntary seclusion and corporal punishment.<BR/>A record review of the facility's Drug Diversion policy, dated 02/23/2017, indicated, The following recommendations are designed to reduce and limit drug diversions: <BR/>1. <BR/>Do not sign for receipt of controlled substances until you have inspected the delivery from the pharmacy that all ordered medications have arrived.<BR/>2. <BR/>The narcotic count sheet should be signed and quantity received should be indicated.<BR/>3. <BR/>Medications should be put in storage areas immediately and not left at nurses station or on medication room counters.<BR/>4. <BR/>Controlled substances should be stored in a double locked compartment at times including discontinued and overstocked medications.<BR/>5. <BR/>A drug count must be done at each shift change and should be done whenever the keys to the narcotic storage areas are exchanged from one staff to another. ALL controlled substances should be counted including those in the lock box in the refrigerator and overstock narcotics in medication room.<BR/>6. <BR/>Access to refrigerator lock box and overstock narcotics in medication room should be limited.<BR/>7. <BR/>Signing the narcotic shift count sheet means you are accepting responsibility for the controlled substances. Therefore, do not sign unless you are certain that all of the controlled substances are present and have not been adulterated/tampered with or altered in any way.<BR/>8. <BR/>Document usage both on MARs and narcotic count sheet as soon as possible after administration of medication.<BR/>9. <BR/>Document administration of PRNs controlled substances on the MARs including dose, date, time, route and effectiveness of medication.<BR/>1O. Do not return capsule or tablet to a container or a medication card once it has been removed. NEVER USE TAPE ON A MEDICATION CONTAINER OR<BR/>BLISTER PACK.<BR/>o <BR/>Do not use white-out or obliterate an entry if you make an error. Draw one line thru the error and provide an explanation with your signature.<BR/>o <BR/>Do not use the double locked storage areas to store personal items (keys, cash, resident/personal property, etc ).<BR/>o <BR/>Check medication containers and cards for signs of tampering or drug substitution (ie. tape on back of blister cards)<BR/>o <BR/>Check ampules to make certain they have not been opened and glued back together.<BR/>Record review of the facility's policy, Narcotic Reconciliation, dated 08/2014, indicated .Medications included in the state and federal Drug Enforcement Administration classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the nursing care center in accordance with federal, state, and other applicable laws and regulations . 1. The director of nursing and the consultant pharmacist monitor for compliance with federal and state laws and regulations in the handling of controlled medications .<BR/>Record review of the facility's policy, Medications Storage in the Facility, dated March 2011, indicated .Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier . Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal and reordered from the pharmacy if a current order exists .<BR/>Based on observation, interview and record review, the facility failed to establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records are in order and that an account of all controlled drugs are maintained and periodically reconciled for 1 of 22 residents (Resident #59) and 1 of 5 medications carts. (Station #2 medication aide cart). <BR/>The facility failed to remove expired prostat liquid (concentrated liquid protein), expired melatonin, and 3 bottles of expired eye drops from station #2's medication aide cart.<BR/>The facility failed to keep a record of receipt of controlled medications awaiting disposition to allow accurate and periodic reconciliation. <BR/>The facility failed to ensure the security of Resident #59's Haldol medication upon delivery of medications on 02/06/23.<BR/>These failures could put residents at risk for misappropriation of medication, drug diversion, not receiving the therapeutic benefit of medications, adverse reactions to medications, or harm by indigestion. <BR/>Findings included:<BR/>1. During an observation on 02/28/23 beginning at 09:10 a.m., the station #2 medication aide cart revealed the following expired medications:<BR/>*Two OTC lubricant eye drops with an expiration dates of 11/22<BR/>*One OTC artificial tears eye drops with an expiration date of 09/22.<BR/>*One bottle of OTC melatonin 3mg with an expiration date of 01/23.<BR/>*One bottle of OTC Prostat liquid with an expiration date of 02/25/23.<BR/>During an interview on 02/28/23 at 09:19 a.m., CMA E said the nurses and medication aides were responsible of ensuring the carts are checked for expired medications a least daily. CMA E said the resident was a risk for receiving an expired medication and could cause them to become sick or the medication could not work as intended. <BR/>During an interview on 02/28/23 at 09:30 a.m., the ADON said she expected the expired medications be pulled off the cart as soon as it was noticed the medication was expired. The ADON said the resident was at risk for the medications not to work properly. The ADON said the nurses and medication aides were responsible for removing expired medications from the carts. The ADON said the carts were to be checked daily. The ADON said the DON and herself were responsible for overseeing there were no expired medications on the carts.<BR/>During an interview on 03/02/23 at 10:50 a.m., the DON said she expected the nurses and medication aides to audit their carts at least monthly to check for expired medications. The DON said it was her responsibility to oversee that was being done. The DON said the residents were at risk for medications to be ineffective. <BR/>During an interview on 03/03/23 at 11:05 a.m., the Interim Administrator said she expected for the medication carts to not have any expired medications. The Interim Administrator said the carts were checked by the pharmacist consultant and the nurse managers. The Interim Administrator said the resident was at risk for receiving an expired medication that could be ineffective.<BR/>2. During an observation and interview on 03/01/23 beginning at 1:33 p.m., the DON showed this surveyor where she stored controlled medications awaiting disposal, and inside the storage appeared to be at least 100 different medications including medication cards, medication bottles and narcotic medications. The DON said some of the medication was already there when she started on 01/31/23. When asked how she reconciled medication brought to her to be disposed, the DON said she did not have a log. The DON said the nurse and herself signed off on the narcotic sheet how much medication was left and placed with the medication in the locked cabinet until the pharmacist told her how they would want it done at the facility. The DON said the pharmacist had not been there since she started.<BR/>Record review of the facility's pharmacy medication destruction form indicated last medication destruction was completed on 01/23/23.<BR/>During an interview on 03/01/23 at 02:59 p.m., the DON said the facility does not keep a log here for expired or discontinued narcotics. The DON said they use a scanning system to log the narcotic medications but does not have access to that system and the corporate nurse does not know how to access the system either. The DON said she does not have access to her policies and procedures and was not allowed by the corporate nurse to access those policies.<BR/>During an interview on 03/02/23 at 10:50 a.m., the DON said her expectations for narcotic reconciliation was for the nurses to pull the expired or discontinued narcotic medications off the cart and be given to her so she could log and lock them until the pharmacist came for drug destruction. The DON said there was a risk drug diversion or abuse for not logging the narcotic medications. The DON said it was her responsibility to ensure the narcotic medications were logged and locked. <BR/>During an interview on 03/03/23 at 11:05 a.m., the Interim Administrator said she expected the discontinued narcotics to be double locked and logged. The Interim Administrator said by not logging the narcotic medications, some medications could end up missing. The Interim Administrator said it was the DON's responsibility to ensure that narcotic medications were kept logged until she gained access to the scanning system.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to secure all drugs and biologicals in locked compartments, including the storage of schedule II-V medications in separately locked, permanently affixed compartments, permitting only authorized personnel to have access for 4 of 6 medication carts. (Stations #1, #2, #3, and #4)<BR/>The facility failed to ensure only authorized personnel had access to the facility's medication carts containing narcotics. <BR/>The facility failed to ensure medication carts with narcotics, were kept double locked.<BR/>These failures could place residents at risk of drug diversion and misuse of medication.<BR/>Findings included: <BR/>During an observation on 01/31/23 at 05:02 AM, two medication carts located near Nurse's station 1 were unattended and the outer lock was open.<BR/>During an interview on 01/31/23 at 5:02 AM, LVN A said both carts should be locked because they contained narcotics and should be under double lock.<BR/>During an observation on 01/31/23 at 5:13 AM, a medication cart located near Nurse's station 3 was unattended and unlocked.<BR/>During an interview on 01/31/23 at 5:15 AM, LVN B said the cart should be always locked because there were narcotics in the cart. LVN B said during the night shift LVN B and LVN A share the keys to the medication cart because not all the medications were in each cart. <BR/>During an observation and interview on 01/31/23 at 5:20 AM, the cart 3 was locked. When asked to open the cart, LVN B said she did not have the key and used her hand to pat the top of the notebook on top of the cart looking for the keys. LVN B said she must have left them in her jacket and walked toward Station 3. LVN A walked toward the cart and said she had the keys. LVN A handed the keys to LVN B. LVN B unlocked the cart showing narcotics inside the cart. <BR/>During an interview on 01/31/23 at 5:21 AM, LVN A said she normally left the keys inside the narcotic count book on top of the medication cart. LVN B said she sometimes left the keys in the book. <BR/>During an interview on 01/31/23 at 6:20 AM, the ADON said all narcotics should be stored under double lock according to facility policy. The ADON said carts should be secured any time they were unattended, and keys should never be left on top of the cart. The ADON said the facility had some recent drug diversions.<BR/>During an observation 02/02/23 at 5:11 AM, Station 4 medication cart was locked. Two sets of keys were on top of the cart in plain view. Surveyor approached the cart, NA A, looked at Surveyor, reached for the keys and pulled her hand back rapidly. Surveyor walked to station 3, the cart was locked. Surveyor turned around and went back to the cart on station 4 the keys were no longer on the cart. <BR/>During an interview on 02/02/23 at 5:14 AM, NA A said LVN C motioned for her to get the keys when she saw the surveyor coming. When asked how she knew LVN wanted her to get the keys, NA said, Because she was standing down the hall in front of room [ROOM NUMBER] and pointed to the cart and felt of her pockets. NA A said she should not have keys to the medication cart. <BR/>During an interview on 02/02/23 at 5:15 AM, LVN C said it was a mistake to leave the keys on top of the cart. LVN C said normally she does not leave the keys. LVN C said the keys on top of the cart were for the medication cart and the nursing cart for Hall 1. LVN C said she motioned for NA to move her cart.<BR/>During an observation and interview on 02/02/23 at 5:15 AM, Surveyor asked LVN C to unlock the nursing cart on Station 1. LVN C felt her pockets and said, I don't have the keys. NA A must have them. LVN C asked NA A for the keys. LVN C got the keys from NA A, opened the Nurse's cart on Station 1 revealing 20 containers of narcotics in the cart. <BR/>During an observation on 02/02/23 at 5:25 AM, station 2 medication cart was unlocked inside a room next to the nurses' station. LVN D walked into the unlocked room.<BR/>During an interview on 02/02/23 at 5:26 AM, LVN D said she was just around the corner restocking the other cart. LVN D said she left the cart unlocked when she took supplies to the other cart that was in the hallway, just around the corner. <BR/>During an observation on 02/02/23 at 5:26 AM, LVN D opened the Narcotic lock box for station 2 and seven cards of narcotics were inside the box. <BR/>Record review of a policy titled medication storage dated 01/20/21 showed .1. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication room) under proper temperature controls. B. Only authorized personnel will have access to the keys to locked compartments . 2. Narcotics and Controlled Substances: a. Scheduled II drugs and back-up stock of Schedule III, IV and V medications are stored under double-lock and key. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for 1 of 4 residents reviewed for baseline care plans. (Resident # 131)<BR/>The facility failed to address Resident #131's communication, daily preferences, ADLs, devices, health conditions, medical conditions, safety risks/falls, skin, smoking, dietary, and therapy on the computerized base-line care plan.<BR/>This deficient practice could place residents at risk for missed care.<BR/>Findings included:<BR/>Record review of a face sheet dated 03/02/2023 indicated Resident #131 was an [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses of respiratory failure, pneumonia related to Covid-19, Covid-19 virus, and major depressive disorder.<BR/>Record review of Resident #131's electronic medical record on 02/28/2023 revealed the MDS assessment was not completed.<BR/>Record review of the Baseline Care Plan dated 02/27/2023 at 10:56 a.m., indicated Resident #131's care plan was blank in all the sections except the area of Section C: Social Services completed by the Social Worker.<BR/>Record review of Resident #131's electronic medical record on 02/28/2023 revealed the comprehensive care plan was not completed in place of the baseline care plan.<BR/>During an interview on 03/03/2023 at 11:00 a.m., the DON said ultimately, she was responsible for the baseline care plan. The DON said a baseline care plan was needed to properly care for the resident. The DON said she had not had the time to document on the baseline care plan due to the survey process. The DON said Resident #131 admitted over the weekend and she had not had time to review her admission.<BR/>During an interview on 03/03/2023 at 11:15 a.m., the Interim Administrator said she believed the ADON was completing the baseline care plans. The Interim Administrator said a baseline care plan was needed to know the care needs of the resident.<BR/>Record review of a Baseline Care Plans policy with a revised date of 05/13/2021 indicated the purpose was to provide a person-centered baseline care plan developed and implemented for new admission and readmission residents. Baseline care plans are developed and implemented within 48 hours of a resident new admission and /or readmission. Baseline care plans are developed by Registered Nurses and other healthcare team members. The LVNs and other healthcare team members execute baseline care plans. The overall care coordination of the resident is evaluated by the DON/designee.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure, at the time each resident was admitted , there were physician orders for the resident's immediate care for 1 of 3 (Resident #131) reviewed for admission physician orders. <BR/>The facility failed to ensure Resident #131 had a physician's order for the use of oxygen.<BR/>This failure could place residents at risk of not receiving appropriate care, treatment services, and at risk for low oxygen and/or high oxygen levels. <BR/>Findings included:<BR/>Record review of Resident #131's face sheet dated 03/02/2023 indicated she was an [AGE] year-old female who admitted on [DATE] with the diagnoses of respiratory failure, Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breath), Covid-19, and pneumonia due to Coronavirus-19.<BR/>Record review of Resident #131's electronic medical record on 02/28/2023 revealed the MDS assessment was not completed.<BR/>Record review of the baseline care plan dated 02/27/2023 indicated Resident #131 did not use any special treatments such as oxygen.<BR/>Record review of the consolidated physician's orders dated 03/02/2023 created by the ADON indicated Resident #131 had a new order dated 03/02/2023 for oxygen 2-4 liters per minute per a nasal cannula as needed for shortness of breath.<BR/>During an observation on 02/27/2023 at 3:00 p.m. revealed , Resident #131 was sitting on the edge of her bed. She had oxygen infusing at 3 liters per minute via the nasal cannula. Resident #131 said she had never used her oxygen set at 3 liters and she stated she would like the nurse to lower the administration. <BR/>Record review of the EMR indicated on 03/02/2023 the ADON documented Resident #131 was having shortness of breath lying flat. <BR/>During an observation and interview on 03/02/2023 at 10:19 a.m. revealed, Resident #131 had oxygen infusing from an oxygen concentrator via a nasal cannula at 3.5 liters per minute. The oxygen cylinder on her wheelchair was set on 3 liters per minute. The ADON said she was unaware of Resident #131's current order for oxygen. The ADON, after reviewing the physician's orders, said Resident #131 did not have an order for oxygen. The ADON said the admitting nurse was responsible for ensuring Resident #131 had an order for oxygen upon admission. The ADON said there were risk of having low oxygen levels or too much oxygen. <BR/>Record review of a Transcribing or Noting and Discontinuing Orders policy with a review date of 02/10/2021 indicated the purpose was to provide a guideline for the process of physician order management for transcribing or noting and discontinuing orders. <BR/>During an interview on 03/03/2023 the Regional Corporate Nurse was asked to provide an admission policy and one was not provided at the time of the exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 1 of 7 resident (Resident #131) reviewed for PASRR Level I screenings.<BR/>The facility failed to ensure the accruecy of the PASRR Level 1 screening for Resident #131. The PASRR 1 Level screening did not indicate a diagnosis of mental illness, although the diagnosis was present upon admission. <BR/>This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needs.<BR/>Findings included:<BR/>Record review of a face sheet dated 03/02/2023 indicated Resident #131 was an [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses of respiratory failure, pneumonia related to Covid-19, Covid-19 virus, and major depressive disorder.<BR/>Record review of Resident #131's electronic medical record indicated on 03/03/2023 the admission MDS and comprehensive care plan was not completed.<BR/>Record review of the consolidated physician's orders dated 02/25/2023 indicated Resident #131 was administered Remeron 15 milligrams every evening for major depressive disorder.<BR/>Record review of a PASRR Level 1 Screening dated 02/23/2023 indicated in Section C0100 there was not any evidence, or an indicator Resident #131 had a mental illness.<BR/>During an interview on 03/03/3023 at 10:45 a.m., the Social Worker indicated she should have indicated Resident #131 had a mental illness. The Social Worker indicated she believed she had to indicate the same answers as the discharging facility. The Social Worker stated she resubmitted a corrected PASRR for Resident #131 indicating she had a mental illness of major depressive Disorder on 03/03/2023.<BR/>During an interview on 03/03/2023 at 11:00 a.m., the DON said the Social worker was responsible for the PASRR being accurate. The DON said the Resident #131 could miss out on services from the local authority. The Social Worker said she had been completing PASRR screening for years and was provided PASRR education.<BR/>During an interview on 03/03/2023 at 11:15 a.m., the Interim Administrator said the Social Worker was responsible for the PASRR screens. The Interim Administrator indicated major depression was a mental illness and if the PASRR was not correct Resident #131 could miss out on services. <BR/>Record review of Preadmission and Screening Resident Review (PASRR) Rules and Guidelines, dated 04/26/16, and last revised on 06/03/20, indicated:<BR/>Guideline<BR/>It is the intent of facility to meet and abide by all State and Federal regulations that pertain to resident Preadmission and Screening Resident Review (PASRR) Rules .<BR/> .Procedure<BR/>Referring Entity completes a PL1 .<BR/> .If Positive:<BR/> .AND admission is NOT Exempted Hospital Discharge or Expedited . The PL1 is faxed to LIDDA/LMHA prior to admission

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1 of 4 residents (Resident #12) reviewed for accuracy of assessments.<BR/>The facility failed to accurately code the 04/30/25 MDS for an in-dwelling catheter (tube inserted into the bladder to drain urine) used for Resident #12.<BR/>This failure could put residents at risk for lack of proper care and decreased quality of life.<BR/>Findings included:<BR/>Record review of a facility face sheet dated 5/14/25 for Resident #12 indicated he was a [AGE] year-old male admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnosis of cerebrovascular disease (heart disease).<BR/>Record review of a Comprehensive MDS assessment dated [DATE] for Resident #12 indicated he had a BIMS score of 12, which indicated moderately impaired cognition. Question H0100 did not indicate he had an indwelling catheter. <BR/>Record review of a comprehensive care plan dated 3/13/25 for Resident #13 indicated that he had a urinary catheter.<BR/>Record review of a physician's order summary report dated 5/14/25 for Resident #13 indicated he had the following physician's order dated 4/24/25: .Urinary catheter 24 FR 20 CC bulb to gravity (BSD). Change the catheter if it becomes occluded, to obtain a urine specimen, or if the closed system has become compromised . <BR/>During an observation on 5/12/25 at 12:13 pm Resident #12 was observed lying in bed. He was observed to have a Foley catheter.<BR/>During an interview on 5/14/25 at 11:00 am MDS Nurse was not receptive to questioning. <BR/>During an interview on 5/14/25 at 11:15 am DON said the MDS nurse was responsible for MDS accuracy. She said MDS assessments were responsible for the payments to the facility. She said she did the care plans and nothing on the care plan was missed due to the MDS being inaccurately coded. She said going forward she would have a system of checks to ensure MDS assessments are coded correctly.<BR/>During an interview on 5/14/25 at 11:35 am Administrator said if MDS assessments are coded incorrectly it could possibly cause payment issues. She said going forward there would be multiple reviews and meetings to discuss the residents to hopefully prevent this from happening.<BR/>Record review of a facility policy titled MDS Completion dated 2/10/21 read: .According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the State .

Based on observations, interviews, and record reviews, the facility failed to ensure it formulated, adopted, and enforced policies regarding smoking, smoking areas, and smoking safety that also consider non-smoking residents for 1 of 1 smoking area reviewed for smoking safety.<BR/>The facility failed to ensure cigarette butts were not discarded into a regular trash can that also contained paper trash on 5/12/25 causing a fire hazard.<BR/>The facility failed to ensure regular trash was not discarded into the red metal ashtray container on 5/12/25 causing a fire hazard.<BR/>This failure could place residents at risk of injury, burns, and an unsafe smoking environment.<BR/>Findings included:<BR/>During an observation on 5/12/25 at 10:50 am a red metal ashtray container was observed with paper trash in it. A metal trash can was also observed in the smoking area with a clear plastic liner in it. Observation revealed that can was full of cigarette butts along with cigarette boxes and regular trash.<BR/>During an interview on 5/13/25 at 1:50 pm DON said there was not one specific person responsible for emptying the ashtrays in the smoking area, but whoever took the residents out to smoke should be emptying the ashtrays into the ashtray container. DON said she would get with the maintenance man to correct this issue.<BR/>During an interview on 5/13/25 at 2:00 pm Maintenance man said staff that take residents out to smoke should be emptying the ashtrays into the red metal can. He said there was no one specific person responsible for this. He said ashtrays should not be emptied into the regular trash can, due to it being a fire hazard. Maintenance man said it was also a fire hazard for regular trash to be emptied into the red metal can. <BR/>Record review of a facility policy titled Smoking Policy dated 4/12/23 read: .It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees as related to smoking .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for 1 of 4 residents reviewed for baseline care plans. (Resident # 131)<BR/>The facility failed to address Resident #131's communication, daily preferences, ADLs, devices, health conditions, medical conditions, safety risks/falls, skin, smoking, dietary, and therapy on the computerized base-line care plan.<BR/>This deficient practice could place residents at risk for missed care.<BR/>Findings included:<BR/>Record review of a face sheet dated 03/02/2023 indicated Resident #131 was an [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses of respiratory failure, pneumonia related to Covid-19, Covid-19 virus, and major depressive disorder.<BR/>Record review of Resident #131's electronic medical record on 02/28/2023 revealed the MDS assessment was not completed.<BR/>Record review of the Baseline Care Plan dated 02/27/2023 at 10:56 a.m., indicated Resident #131's care plan was blank in all the sections except the area of Section C: Social Services completed by the Social Worker.<BR/>Record review of Resident #131's electronic medical record on 02/28/2023 revealed the comprehensive care plan was not completed in place of the baseline care plan.<BR/>During an interview on 03/03/2023 at 11:00 a.m., the DON said ultimately, she was responsible for the baseline care plan. The DON said a baseline care plan was needed to properly care for the resident. The DON said she had not had the time to document on the baseline care plan due to the survey process. The DON said Resident #131 admitted over the weekend and she had not had time to review her admission.<BR/>During an interview on 03/03/2023 at 11:15 a.m., the Interim Administrator said she believed the ADON was completing the baseline care plans. The Interim Administrator said a baseline care plan was needed to know the care needs of the resident.<BR/>Record review of a Baseline Care Plans policy with a revised date of 05/13/2021 indicated the purpose was to provide a person-centered baseline care plan developed and implemented for new admission and readmission residents. Baseline care plans are developed and implemented within 48 hours of a resident new admission and /or readmission. Baseline care plans are developed by Registered Nurses and other healthcare team members. The LVNs and other healthcare team members execute baseline care plans. The overall care coordination of the resident is evaluated by the DON/designee.