**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Interview and Record Review, the facility failed to hire and maintain a current and active license for a Registered Nurse (RN) and allowed that RN to work unlicensed upon hire. The Findings Include: On [DATE] at 11:50 AM, While doing the background check review, one of the facility's RNs (V4) was found to have an expired license and has been working at facility since hired on [DATE]. On [DATE] at 11:52 AM, V1, Administrator, stated I did the background checks on (V4, RN), and I never noticed that her license was expired. I just called (V4) who told me that she thought she renewed her license, but she doesn't have a receipt to prove it. (V4) was calling the Illinois Department of Financial and Professional Regulation (IDFPR) to discuss this with them and will let me know of the outcome. On [DATE] at 12:35 PM, V6, Business Office Manager, stated There are three of them who do the background checks for new employees, V1, herself, and V7, Medical Records. On [DATE] at 12:37 PM, V7 stated We run fingerprints on date of hire or before, but since it takes a while to get them back, we usually accept the acknowledgment email from state indicating they received it, and that the employee is eligible to work with nothing flagged so far. On [DATE] at 12:45 PM, V1 stated I am the one who did (V4's) background check and I printed them out, and never saw the expiration date on her RN license. (V4) has been taken off the schedule. (V4) called the state who told her they never received a check to pay for the license renewal, therefore, it was not renewed and (V4) will have to send a letter indicating what happened and the board will review the issue and get back with her. On [DATE] at 1:45 PM, V1 stated The facility is staffed with two Nurses and five CNAs for Days and Evenings, then one to one and half Nurses and three CNAs for Nights. (V4) only works on Hall-Two with rooms 14 through 36. V4 was hired on [DATE] with a IDFPR License check completed upon hire. This License check indicated that V4's RN License expired on [DATE], prior to V4 being hired by the facility. The Facility's Nursing Schedules from [DATE], through [DATE], were reviewed with V4, RN, working 35 shifts as an RN on the floor. V4 cared for R2, R3, R4, and R5 during her shifts. R2's, R3's, R4's, and R5's Medication Administration Record (MAR), dated [DATE], documents V4 administered medications to each resident on the shifts that she has worked at the facility. The Facility's Policy and Procedure Abuse and Neglect, undated, documents Employee Screening and Training: Before new employees are permitted to work with residents, references provided by the prospective employee will be verified as well as appropriate board registrations and certifications regarding the prospective employee's background. Licensed Staff: The facility will not employ or otherwise engage a licensed professional who has a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, and exploitation, mistreatment of residents or misappropriation of resident property. A criminal background check will be conducted on all prospective employees as provided by the facility's policy on criminal background checks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to follow the Facility Policy by ensuring an abusive and neglectful incident did not occur as well as not notifying all required parties for 1 of 2 residents (R99), reviewed for abuse/neglect, in the sample of 25. Findings include: The Facility's Abuse and Neglect Policy undated documents, A board member, licensee, administrator, licensed nurse, employee or volunteer of a nursing home shall not physically, mentally or emotionally abuse, mistreat or neglect a resident. Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation or misappropriation shall immediately report to the nursing home administrator. The nursing home administrator or designee will report abuse to the state agency per state and federal requirements. Nursing Home 1150B Rules and Regulations state all employees are required, to any reasonable suspicion of a crime committed against a resident, to call 911 or (local) Sheriff. The Policy continues to define; Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Abuse includes verbal abuse, sexual abuse, physical abuse and mental abuse, including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. It continues to define: Verbal abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Verbal abuse includes, but is not limited to: threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again. Mental abuse includes but is not limited to, humiliation, harassment, threats of punishment or deprivation. Mistreatment- Inappropriate treatment or exploitation of a resident. Neglect- The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. It further documents, It is the policy of (Facility) Memorial Home that each resident will be free from abuse. Abuse can include verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The resident will also be free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. The facility will strive to educate staff and other applicable individuals in techniques to protect all parties. R99's Facesheet dated 9/11/2024 documents R99 was admitted to the facility on [DATE] with multiple diagnoses including but not limited to; osteoporosis, anxiety and post traumatic stress disorder. R99's Progress Notes dated 7/7/2024 documents R99 was attempting to self transfer out of her recliner, in her room and fell to the floor. It further documents R99 began complaining of right hip pain. R99's Minimum Data Set (MDS) dated [DATE] documents R99 was moderately cognitively impaired and required substantial assistance for chair transfers. On 9/9/2024 at 12:56 Pm, V9, Certified Nursing Assistant (CNA) stated, I was going through taking people (residents) back to their rooms. I heard screaming and plates breaking. I saw (R99) on the floor and her recliner was tipped up. I said 'hold still, don't move'. The nurse (V5, Licensed Practical Nurse, LPN) came and automatically was like, 'I'm tired of your shit. If you don't like it, you can go home'. He didn't evaluate her before he mistransferred (incorrectly transferred) her, instead of checking her, grabbed her up by the arms and put her back in her chair. He then walked out of the room. She (R99) wanted to call the cops. (R99) was still complaining of pain, worked up and upset. (R99) kept asking for the cops and an ambulance. (V5) was not nice, abusive in my opinion. The way he (V5) picked her up by her arms. It was rough and you could feel the aggression. He was yelling at her (R99). I called (V1), like a minute after. (V1) was super busy and had me call (V6, Assistant Director of Nursing, ADON). V9's Statement, undated, documents V9 found R99 on the floor with her chair reclined forward, R99 asked for help and V9 went to get V5. It continues to state, As soon as he (V5) came into the room, he (V5) started telling her 'She needs to stop her shit and that if she doesn't f*****g like it here, go home'. He then asked me to help transfer her, but before I could help he grabbed her by the arms and put her in her chair. Then he walked out. It further documents V9 stayed with R99 to make sure she was ok or if she hurt anywhere, to which R99 stated she had hip and leg pain. It continues to document V9 told V5 about R99's complaints of pain, he went to check her out, and said she was fine. It further documents, She (R99) rung (used her call light) and asked for (V5) to stay away from her and to call the police. Then she wanted a(n) ambulance as well. I told (V12) and she told me to call the admin (administrator, V1). On 9/10/24 at 12:38 PM, V9 stated, I told her what I told you (see above interview). She fell and he (V5) came in. He (V5) was mean to her. I called (V1) as soon as I Ieft her (R99's) room, after calming her down. I did mention him (V5) being rough and not assessing her. They had me write statement and send to them. (R99) wanted the cops called. The cops never came. On 9/10/2024 at 11:25 PM, V6 stated, (V5) called and told me she fell and had no injuries. (V9) called and said (R99) wanted to go to the hospital, was upset with (V5) and didn't want him back in the room. We suspended (V5) because we had conflicting stories. Also, a family member called (V1) and said (V5) was yelling at (R99). On 9/10/24 at 11:35 AM, V1 stated she was unsure if V9 talked to V1 or V6, reported V5 used profanity and said if R99 wasn't going to do what she needs, why doesn't she go home. V1 stated she does not feel that is acceptable behavior. V1 stated a family member (V21) called and reported the same thing V9 reported. V1 also stated the police were not called/informed. The Facility's Illinois Department of Public Health Report documents, Abuse Investigation for (R99) for 7-7-2024: (R99), a female resident of (Facility), has a PMH (Past Medical History) of lung cancer, renal mass, osteoporosis, osteoarthritis, (and) skin cancer. Resident had a fall with injury that occurred on the afternoon of July 7th. This was reported as well. The CNA on the floor that assisted the nurse with the fall called to report verbal abuse on resident from the nurse caring for this resident. Per CNA, nurse came into the room and said to resident You need to stop your shit. If you don't fu*&ing like it here, go home. After putting (R99) in her recliner, he walked out of the room. She was requesting to go to the ER. Nurse told resident she was fine. The nurse from the other hall informed the administrator that the resident wanted to be sent out and that the nurse responsible for (R99) thought that she was fine. This is when the administrator let the nurse know that if the resident was complaining of pain and requesting to be sent out, especially after a fall, that is what we need to do. The administrator suspended the nurse pending investigation. POA (Power of Attorney) was notified. (V5), LPN, is the nurse in question. His statement is that he did not yell at the resident. He states that the resident was yelling at him and being combative. He informed the administrator that the Emergency Medical Technician's might report him because they were lecturing him about calling 911 in front of the resident and he asked them to transport the resident to the hospital like he called them to do. The CNA that reported the abuse (V9) says that the resident was not yelling or combative, but had been yelling and being disruptive earlier in the AM (morning). She was recently started on a prn (as needed) antianxiety medication to try to help her. The resident's roommate was asked for a statement. She is A&O x 4 (Alert and oriented to person, place, time and event). She reports that the nurse treated her with respect and did not yell or raise his voice at (R99). She reports that he did mumble something on his way out after getting her up off the floor. The CNA that reported the nurse and the nurse have had previous issues in the past. Administration wondered if that had a play in this situation. Regardless of the outcome of this investigation, the nurse was going to be required to complete further training regarding properly assessing residents after a fall, as well as respecting their requests to be sent to the hospital for an evaluation at any time. On the morning of July 8th, the administrator received a call from a concerned family member that was visiting on July 7th, in the room next to (R99). She reports hearing the nurse yelling at the resident as well as arguing with the EMTs. A member of this family has also had an issue with [NAME] in the past. The family member had been talking with her hands and pointing in the nurse's face and the nurse was upset. So, there is a history with this family member as well. Administrator attempted to call resident in the hospital to obtain a statement. She was not coherent enough to obtain a statement. Nurse was terminated. Nurse and roommate say that resident [V1 verified this was supposed to say (V5)] did not yell. A CNA and family member who have had issues with the nurse in the past say the nurse did. To prevent any further incidents with this nurse, felt it was in our best interest to terminate the relationship. The Report does not document the local police were notified. On 9/11/2024 at 1:24 PM, V1 stated she did not feel what V5 said to R99 was intimidation, but she (V1) would not have said it in that manner. V1 stated it was inappropriate and against their Facility policy. When asked how V1 thought a verbal altercation occurring at that time made R99 feel, V1 replied, Not good. When asked if the police should have been called, V1 stated she did not know how to answer the question. On 9/11/2024 at 2:47 PM, V19, CAN, stated, (R99) said, 'Please don't leave me. He (V5) just picked me up and threw me. I asked, 'Who?' and she said, 'that mean man'. (R99) grabbed me like she was scared. I held her hand. I figured it was (V5). (R99) asked me to call the police. I didn't know protocol since I couldn't tell the nurse since he was the one she was talking about. (V9) informed the other nurse. (R99) was asking about calling the ambulance and police. (V5) came back and asked (R99) why he should get the police called. Every time he (V5) walked past, (R99) said he was mean man. everything she told me, she (R99) told the EMTs. (V5) and the EMTs got into it (a verbal altercation). (R99) was right there. I intervened by asking if they needed help transferring (R99) on the stretcher. (V5) eventually walked off. I wish it would have been handled differently. On 9/12/2024 at 9:23 AM, V21, R11's niece and witness to the incident, stated, He (V5) didn't see me in the room (R11's). He was in the room next door. I could hear him screaming. I was actually kind of afraid of him. He was very angry and belligerent. I asked the CNA the nurses name and they said (V5). (V5) definitely does not belong in nursing. Poor little thing (R99) had fallen and he was screaming at her. She was confused and said she wanted the police. He screamed, 'what have I ever done to you?' They let him go. Being a nurse myself, I would have considered it verbal abuse for sure. (V5) yelled, 'If you don't want to stay here, why are you here?'. It was so demeaning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and observation, the facility failed to follow a physicians order for wound dressing for 1 of 1 resident (R25) in the sample of 25 reviewed for wounds. Findings include: 1. R25's Facesheet documents R25 was admitted to the facility on [DATE] with diagnosis of systolic and diastolic congestive heart failure, diabetes, atherosclerotic heart disease of native coronary artery, diabetic retinopathy, acquired absence of left great toe, moderate protein-calory malnutrition, polyneuropathy, glaucoma, phantom limb syndrome with pain, gastro-esophageal reflux disease, generalized anxiety disorder, acquired absence of right leg above knee, hypertension, and hyperlipidemia. R25's Minimum Data Set, (MDS) dated [DATE] section C documents R25 has severe cognitive decline with a Brief Interview Mental Score, (BIMS) of 3. Section GG documents R25 requires use of a wheelchair and is dependent on staff for all care areas. Section H documents V25 is always incontinent of bowel and bladder. R25's Care plan dated 7/24/24 documented that R25 has problems related to activities of daily living, (ADL) self-care performance deficit, rejects care at times and becomes verbally abusive, impaired visual function, risk for impaired gas exchange, impaired nutritional status, and high fall risk. A problem for impaired skin integrity is included with a goal to be free of any avoidable pressure injuries. Interventions include to encourage to change position every 2 hours, check skin weekly and follow current treatment orders as written. R25's Physician Order Sheet dated 8/23/24 stated to cleanse umbilicus wound with wound cleanser, apply xeroform to wound bed, and cover with dry dressing. R25's August 2024 Treatment Adminstration Record documented R25's umbilicus dressing change was not performed on August 1 2024, which was left blank. On 9/10/2024 at 10:00 AM R25's Umbilicus wound was observed open to air with creamy white drainage noted. When asked V7, CNA, about the fact that there was no dressing on the umbilicus wound, V7 stated that staff had been letting it air out, especially since R25 has been picking at the dressing. V7 stated she did not know if the dressing was present ealier this morning because night shift had gotten him up. 09/11/24 10:55 AM V16, Registered Nurse (RN) stated the wound care orders for the umbilicus wound is performed by evening shift and are to apply xeroform and a dry dressing. V16 stated she put a dressing on the wound this morning because there was not one there. V16 stated R25 is constantly picking the dressing off and touching the wound. R25's Progress notes dated 8/22/24 at 11:24 AM documented that R25 continues with open area to navel. R25 picking at navel, arms, and head. Lotion applied to skin daily. R25 picks at skin often and per baseline. Open area to navel measures 2.5 x 1.8 x 0.1 cm. Wound bed is granulation tissue with scant/light serosanguineous drainage noted. R25 removes dressing often. R25's Progress notes dated 8/30/24 at 10:09 AM documented that an open area to navel measures 1.2 x 1 x 0.1 cm. Normal peri-wound. Wound bed is white/pink. Light serosanguineous drainage present. Xeroform and dry dressing continues. R25 picking at skin less this week. R25's Progress notes dated 9/5/24 at 10:00 AM, documented that an open pen area to navel measures 2 x 1.3 x 0.2 cm. Normal peri-wound. Wound bed is white/pink. Scant to light serosanguineous drainage present. R25 noted to be picking at skin less. Treatment same. 09/11/24 11:30 AM Spoke with V6, Licensed Practical Nurse (LPN) Assistant Director of Nursing (ADON), regarding R25's wound. When asked about R25's umbilicus wound, she stated that R25 continuously picks the dressing off. V6 stated that V15, (R25's) physician, is aware and provided a copy of an order dated 9/11/2024 from V15 that he had been informed that R25 has continued to pick at skin and open area to umbilicus continues as R25 removes the dressing often. V15 wrote an order for Aquaphor to skin areas. The not dated policy titled, (Facility Name) Policy for Skin Issues and Pressure Ulcers documents, Policy: It is the policy of (facility name) that all skin issues, pressure ulcers, and areas of concern related to skin will be documented in PCC (point click care).

Based on observation, interview and record review, the Facility failed to employ a Full Time Director of Nursing (DON). This failure has the potential to affect all 43 residents residing in the Facility. Findings include: On 9/9/2024 at 8:45 AM, V1 Administrator, stated, I have been doing it (performing DON duties) until we can get someone hired. We have been looking since February (2024). We have interviewed but they wanted $70 an hour. We can't do that. V1 stated she work 65-70 hours a week doing care plans and other DON duties. During this investigation, there was no observations of a DON. The Facility provided a list of Quality Assurance Members, undated, which did not include a staff member as DON. The Facility's Central Management Services (CMS) Form-671 dated 9/9/2024 documents there are 43 residents residing at the Facility.

Based on interview and record review the facility failed to ensure antibiotics used, are effective to treat the organisms causing the infections for 2 of 20 residents (R27 and R22) reviewed for antibiotic stewardship in the sample of 35. Findings include: 1. R27's undated Care Plan documents R27 has an ADL self-care performance deficit related to chronic kidney disease, atherosclerotic heart disease, major depression disorder, glaucoma, generalized weakness, incontinence, and poor mobility. The Infection Control Surveillance Log for March 2023 documents R27 had a Urinary Tract Infection (UTI) on 3/11/2023 but no organism was documented and 'No growth was documented on the surveillance log for the use of any antibiotics. R27's Physician Order Sheet (POS) for March 2023 documents, Cefdinir 300 MG (milligrams), give 1 capsule by mouth two times a day for urinary tract infection. R27's Medication Administration Record (MARS) dated 3/2023 documents Cefdinir 300 MG (milligrams), give 1 capsule by mouth two times a day for urinary tract infection. R27's MAR was documented as receiving cefdinir (antibiotic) for 5 days. On 8/24/2023 at 3:24 PM, a Culture and Sensitivity Report was requested for R27. No Culture and Sensitivity Report was provided but a Clinical Laboratory Report was provided that documents, on 3/11/2023 a urine culture was taken and documents, No further testing (including susceptibility) will be performed. The Lab Report does not document and information regarding Sensitivity or if Cefdinir would be appropriate or indicated for the use of Cefdinir. 2. R22's undated Care Plan documents she has an ADL self-care performance deficit related to acute respiratory failure with hypoxia, congestive heart failure, partial intestinal obstruction with colostomy status, anxiety disorder, spinal stenosis, transient cerebral disorder, incontinence, generalized weakness and poor mobility. R22's POS dated January 2023 documents Cipro Tablet 250 MG (milligrams) (Ciprofloxacin HCL) give 1 tablet by mouth two times a day related to urinary tract infection for 5 days. The Infection Control Log for the month of January 2023 does not document any infections or urinary tract infections for R22. R22's MAR dated January 2023 documents she was taking 250 milligrams of Cipro two times a day related to a urinary tract infection, 1 tablet my mouth, two times a day for 5 days. The MAR documents R22 only received 9 out of the 10 doses for the Cipro and misses a dose on 1/2/2023. R22's Progress notes does not document R22 was sent out to the hospital or was not in the facility for January 2, 2023, to January 6, 2023. On 8/25/2023 at 10:13 AM, V2, Director of Nursing stated, We provided you with all of the C & S reports that we had. If we did not provide them, then we do not have them. I would expect all urinary tract infections to have the organism documented on the infection control surveillance log. The antibiotic Stewardship Policy with an effective date of 8/18/2023 documents, Therapeutic decisions regarding antibiotic statements from clinical and academies societies) that is appropriate for the care of Long-term care facility residents.

Based on observation, interview and record review, the facility failed to ensure that medications are administered using nursing standards of practice for 14 of 14 residents (R1, R4, R6, R7, R8, R16, R19, R25, R26, R30, R32, R34, R240 and R243) reviewed for pharmacy services in the sample of 35. Findings include: On 8/24/23 at 3:00 PM the medication cart for the 100-Hall was observed with V19, Registered Nurse, RN. There were 14 clear medication cups stacked 2-3 cups deep with each cup containing multiple pills and/or capsules. There were last names on these cups, but no date or time of when they were set up or when they were to be administered. V19 identified the cups as the evening medications that she had pre-set up for her evening medication pass for the following residents: R1, R4, R6, R7, R8, R16, R19, R25, R26, R30, R32, R34, R240 and R243. V19 stated she is per-diem and stated she always pre-sets up her evening medication pass, or it would take her a longer time to do her medication pass. She stated she did not know this was not alright. She stated, I don't know if you have ever worked in a nursing home or not, but it's a lot of work to pass medications to this many residents. It's either set up their medications or it will take longer for them (residents) to get them. V19 stated she passes medications to 14 residents on this hall. On 8/24/23 at 3:59 PM V1, Administrator, confirmed there are two evening shift nurses on that shift. On 8/25/23 at 9:19 AM V2, Director of Nursing, stated pre-setting up medications before it is time for them to be administered is never condoned. She stated medications should be popped out of cards as the nurse is preparing to give them to the resident. The facility's undated policy, (The Facility's) Liberal Medication Pass Policy documents, Policy: It is the policy of (Facility) to assure that medications are administered safely and accurately to residents for whom they are prescribed in accordance with good nursing practices. Purpose: To establish a mechanism to ensure accuracy in medication administration while providing quality of life. The liberal medication pass program, in order to provide a homelike environment for the resident, will adopt a time pass according to the following. Time sensitive medications must be prepared and administered within one hour of the designated standard administration. During the Medication Pass-Nursing should always check the 5 R's a. Right Resident-before administering medication, identify resident according to facility policy b. Right Drug-verify that correct drug is being given using med card, label and EMR (Electronic Medical Record) c. Right Dose-verify that correct dosage is being given using med card, label, and EMR d. Right time-administer drugs per liberal med pass policy e. Right Route-verify that medication is being given by correct route using med card, label and EMR If the comparison is correct, the medication is to be punched from the bubble card into the medication cup with appropriate technique. Nursing must initial EMR for appropriate medication, date, and time.

Based on observation, interview and record review the Facility failed to ensure infection control guidelines were being followed and staff were using the correct Personal Protective Equipment (PPE) on contact isolation for 4 of 4 residents (R5, R35, R190, R191) reviewed for infection control in the sample of 35. Findings include: 1.On 08/22/23 at 8:36 AM on R190's door was open and on the door was a sign posted documenting, Enhanced Barrier Precautions, clean hands, including before entering when leaving room, Providers and staff must also wear gloves and gown. R191's Door had Personal Protective Equipment hanging over the door with gloves, and gowns. V13, Certified Nursing Assistant (CNA), exited R191's room and was not wearing any gloves or gowns, without washing or disinfecting her hands. V13 had just came from the room and was carrying out a breakfast tray. V13 left R190's room and proceeded to check on residents on the 200-hall. A list of residents in the facility with contact isolation was provided and R190 was identified as having C-diff (Clostridioides difficile) a highly contagious infection. 2.On 08/22/23 at 8:46 AM on R191's room on the door was a sign posted documenting, Enhanced Barrier Precautions, clean hands, including before entering when leaving room, Providers and staff must also wear gloves and gown. R191's Door had Personal Protective Equipment hanging over the door with gloves, and gowns. V13, entered R191's without washing or disinfecting her hands. V13 had just came from R190's room. On 8/22/2023 at 8:50 AM, V13 provided care to R5 after she had finished with R191. On 8/22/2023 at 8:59 AM, V13 was observed not to wash her or disinfectant her hands and or follow the CDC guidelines for infection control and entered R35's room and brought him fresh drinking water. On 8/22/2023 at 9:11 AM, V13 stated, I did not wear any gowns when giving care to R191, but I should have followed the guides and disinfected my hands and wore a gown. It was just a mistake. I was in a hurry and forgot. On 8/25/2023 at 9:28 AM, V2, Director of Nursing stated, I would expect staff to always disinfectant their hands when coming and going into any room when the resident is on contact isolation and to wear gowns at all at times when a resident is positive for C-diff. The Facility undated Infection Control Policy Guidelines for Contact Precautions in Addition to Standard Precautions documents It is the policy of (Facility) to follow contact precautions as ordered in addition to standard precautions for residents on contact isolation. Wash hands with soap and water before wearing gloves. Gloves should be worn when entering the room. Gown when entering the room if you anticipate your clothing will come in contact with resident or environmental services such as doorknobs, bed rails or facet handles.

Based on observation, interview and record review, the facility failed to label multi dose vials of medication and multidose insulin pens when accessed. This has the potential to affect all 38 residents in the facility. Findings include: 1. On 8/24/23 at 2:50 PM V19, Registered Nurse (RN) removed a multi-dose vial of Tuberculin Purified Protein Derivative from the refrigerator in the medication room on the 100-Hall. The multi-dose vial was opened but did not have a date on the box or the vial indicating when the vial was opened. The instructions on the label on the box documented, Discard opened product after 30 days. V19 stated, I only work per diem. I don't know when this bottle was opened but I may be able to find out. 2. On 8/24/23 at 3:00 PM during observation of the 100-Hall medication cart with V19, there was an opened insulin pen with the label indicating it contained Novolog 70/30 insulin in the top drawer. This insulin pen had R32's last name only on it, but no label with medication instructions, dosage or prescription number, and there was no date on the pen documenting when it was opened. V19 stated she did not know there needed to be a label on the pen since R32's last name was written on it. She stated R32's spouse brings her medication into the facility from an outside pharmacy, and they send multiple pens in one box each time. V19 stated the pen should be discarded 30 days after being opened. On 8/24/23 at 3:37 PM V1, Administrator, sent an email which documented, The resident with the outside pharmacy-regarding the insulin pens; I called them and they said moving forward they can individually label each pen. I called her husband as well. He said he will make sure they do when he picks them up every time. I know it doesn't matter now, but I just wanted you to know that moving forward it will be fixed. On 8/24/23 at 4:30 PM V1 sent another email which documented, The pharmacy also called us back. They cannot legally open the box to label all of the pens, but they will send extra labels for us to use. On 8/25/23 at 9:19 AM V2, Director of Nursing (DON) stated she would expect any multi-dose bottles or vials to be dated as soon as they are opened and discarded per the instructions on the label. V2 stated the R32's insulin pen should have had a label on it with her name on it, and should have been dated when it was opened, and the Tuberculin test solution should also have been dated when it was opened because both of these medications are to be discarded after 30 days of opening them. V2 stated the TB test solution has the potential to be used for any resident requiring a TB test when admitted or an annual TB test if needed. On 8/24/23 at 4:05 PM V1 provided the facility's undated policy, Pharmacy Services Policy, which documents, (Facility) provides routine and emergency medications to all residents. (Facility) has a contracted pharmacy that delivers on a routine and emergent basis. Residents are free to utilize any pharmacy of their choosing and are made aware that if chosen pharmacy does not deliver, it will be the family's responsibility to bring all medications. Medications are labeled in accordance with accepted professional principles and include the expiration date when applicable. All medications are stored in locked compartments under proper temperature controls. The schedule II medications are stored in a separate, locked compartment. The facility's Resident Census and Conditions of Residents form, CMS 672, dated 8/22/23, documents there are 38 residents residing in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow fall interventions and provide safe transfers for 2 of 5 residents (R11, R28) reviewed for accidents/incidents in the sample of 24. Findings include: 1. R28's Care Plan, dated 8/8/22, documents (R28) has had actual falls with no injuries occurring 10/6/19, 10/30/19, 11/26/19, 11/10/20, 12/29/20, 4/6/22, 6/12/22 related to poor balance, unsteady gait, and visual deficit. Interventions: Please use a mechanical sit to stand for my transfers as needed. Especially when I am feeling weak, I require a walker and extensive staff assistance for all pivot transfers to assist my balance. Continue interventions on the at-risk plan, assist me in developing a restorative program to improve and maintain my ambulation and gait. Encourage me to participate, non-skid strips have been applied on the floor in front of my recliner. Encourage/educate me to utilize them when I am transferring. Remind me to wear grippers, tennis shoes, or appropriate footwear prior to any transfers. It continues (R28) is at moderate risk for falls related to deconditioning, gait/balance problems, vision deficit, a high score on fall risk assessment, and generalized weakness. Interventions: Be sure my call light is within reach and encourage me to use it for assistance as needed, follow facility fall protocol. Update my fall assessment quarterly and PRN (as needed.) Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT (interdisciplinary team) as to causes. It continues (R28) has an ADL (Activities of Daily Living) self-care performance deficit related to generalized weakness, osteoarthritis, limited mobility, and right ankle fracture as evidenced by requiring assistance with ADLs. Interventions: I require extensive assist by two staff members for all transfers. If I am having difficulty, please use a mechanical sit to stand with two staff assistance. I use my motorized wheelchair for mobility. R28's Minimum Data Set (MDS), dated [DATE], documents that R28 is cognitively intact and requires extensive assistance from one staff member for bed mobility, transfers and toilet use. R28 requires limited assistance from one staff member for personal hygiene, bathing and dressing. R28 is occasionally incontinent of urine and always continent of bowel. R28's Fall Risk, dated 5/25/21, documents that R28 is a high fall risk with a score of 10. R28's Fall Risk, dated 8/4/22, documents that R28 is a high fall risk with a score of 15. R28's Restorative Nursing Program, dated 1/21/21, documents Program Goal: Standing Balance; 1. Introduce self and explain what you want her to do. 2. Apply gait belt and secure chair. 3. Instruct her to stand once balance obtained instruct on exercises. 4. Resident to complete BUE (bilateral upper extremities) of cards, pegs, or cones in standing. 5. Resident to tolerate standing for one to three minutes. R28's Restorative Note, dated 1/27/22, documents Ambulation program was discontinued related to resident refusal to participate. Limited assist with most ADL's. Transfers unsteady at times. Uses motorized scooter for locomotion. Encouraged to participate in UE (upper extremities)/LE (lower extremities) exercises one to two times weekly as tolerated. Stand and pivot for transfers. R28's Post Fall Evaluation, dated 4/6/22, documents Date/Time of Fall: 4/6/22 at 4:10 AM. Activity at time of fall: Transferring bed to chair. Was the reason for the fall evident? Yes, Reason for fall: Lost balance, feeling weak. Pre-Fall Risk Score 10, Post-Fall Risk Score 12. Fall Details Note: Resident lowered to ground by staff during transfer from bed to wheelchair. States she is feeling weak. VS (vital signs) 112/60, 97.6, 102, 22. Conclusion: Did resident's current medical condition contribute to the fall? Yes. Current medical conditions: Weakness, Recent Hospitalization. Does the resident have a history of prior falls: Yes, at Facility. There is no documentation whether a gait belt was used. R28's Restorative Note, dated 4/30/22, documents Due to fracture to RLE (right lower extremity) ADL assistance is extensive/total at this time. (Full body mechanical) lift for most all of transfers times two staff. Using bed pan with extensive/total assist times one or two staff. Extensive times two staff for bed mobility. Limited/extensive assist with dressing. Bed baths given related to cast on RLE. A&O (Alert and Oriented) per baseline. ROM encouraged to other extremities. R28's Post Fall Evaluation, dated 6/12/22, documents Date/Time of Fall: 6/12/22 at 9:20 AM, Activity at the time of fall: Pivot Transfer. Was the reason for the fall evident? Yes, Reason for fall: Lost balance pivot transferring with staff assist. Pre-Fall Risk Score 12, Post-Fall Risk Score 15. Fall Details Note: Resident lost balance pivot transferring with staff times one assist. Resident began to fall causing staff to fall with resident landing on staff member. Bruise noted to resident left hand. Staff uninjured. ROM (Range of Motion) WNL (within normal limits). Resident skin assessed including back of head with no deformity/injury noted excluding bruise to hand. MD (Medical Doctor) and POA (Power of Attorney) notified. Contributing factors: Resident states knee gave out during pivot transfer. Conclusion: Did resident's current medical condition contribute to the fall? Yes. Current medical conditions: Weakness to left knee. Does the resident have a history of prior falls: Yes, at facility. There is no documentation whether a gait belt was used. R28's Restorative Note, dated 7/29/22, documents Limited with most ADL's. Uses scooter for locomotion. Pivot for transfers with extensive one or two staff assistance. Provides own oral care and hand/face washing. Extensive assist with bed mobility one or two staff. Feeds self after setup. Walking boot to RLE related to fracture. Refuses to participate in programs often. ROM to tolerated joints encouraged daily. R28's Restorative Note, dated 8/24/22, documents Walking boot was discharged several days ago per Ortho MD. Continues to be limited/extensive assist with transfer, but balance has improved some with boot off. Encouraged to complete AROM (Active Range of Motion) daily as tolerated. Does not ambulate. Scooter used for mobility. Limited assist with most ADL's (Activities of Daily Living). Independent with oral care and face/hand washed. Extensive assist with perineal-care. On 9/6/22 at 2:10 PM, R28 stated I have fallen since I have been here and even prior to being here. The staff does assist me with my transfers. The staff has used a belt around me before, but they don't use it very often. On 9/6/22 at 12:05 PM, V10, CNA (Certified Nursing Assistant), assisted R28 from her electric wheelchair to her recliner with no gait belt used. R28 stood up and pivoted herself to the recliner with V10 standing by and not holding onto R28. R28 appeared to be weak and having difficulty in the transition from her wheelchair to her recliner. On 9/8/22 at 10:25 AM, V1, Administrator, stated The staff do use the gait belt on some residents. On 9/12/22 at 2:00 PM, V39, CNA, stated We should be using a gait belt when assisting (R28). She is becoming weaker lately and we are now using a sit-to-stand with her for transfers. I asked therapy if they could assess her again to help with her strength. 2. R11's Care Plan, dated 8/28/2022, (R11) has had an actual fall on 3/3/22, 4/23/22, 5/4/22, 8/3/22, 8/6/22, 8/28/22 with no injuries r/t (related to) dementia, terminal prognosis of Parkinson's disease, generalized weakness, poor mobility, and incontinence. It continues (Fall 3/3/22) I have an electronic bed alarm. Please ensure it is functioning correctly. It also documents (Fall 5/4/22) Please do not put the footrest of my recliner in the up position. This is a safety hazard for me. R11's Diagnosis sheet, not dated, documents Parkinson's disease as a diagnosis. R11's Incident Note, dated 8/27/2022 at 1:45 AM, documents, Note Text: Upon entering into room (R11) was sitting cross legged on the floor in her room, her alarms were not sounding. She was awake and alert, she denied hitting her head, she denied losing consciousness, she informed me that she was attempting to take herself to the bathroom unassisted and without using her walker. Upon exam, there are no gross deformities, [NAME] (moves all extremities) per her baseline, grip strengths are weak but equal bilat (bilateral), there are no obvious signs of injury seen, no abrasions, no hematoma, all skin surfaces are intact. Initial VS (vital signs)are WNL, see neuro check flow sheet. She was then assisted to her feet by 2 staff members, given her walker then assisted to the bathroom. R11's Post Fall Evaluation, dated 8/27/2022, documents R11 had a fall in her room on 8/27/2022 at 1:30 AM. The fall was unwitnessed and personal alarm was not sounding. On 9/12/2022 at 11:15 AM, observed R11 sitting in recliner, chair alarm in place with frayed wiring, legs elevated with the footrest of the recliner in the up position. On 9/12/22 at 11:03 AM, V36, Registered Nurse (RN) stated that he was the nurse when R11 fell. V36 stated that he came down the hall and R11 was sitting on the floor. V36 stated that R11 had been in the bed prior to the fall. V36 stated that the alarm was not sounding. V36 stated that he was not sure why was it wasn't working. V36 stated that he usually checks the alarms, but he had not checked R11's. On 9/12/2022 at 11:25 AM, V37, CNA, stated that R11 does make attempts to transfer herself. V37 stated that R11 has Parkinson's disease and that when she stands up sometimes, she gets stuck. V37 stated that she was not here when R11 fell. V37 stated that R11 had a history of turning off her alarm. V37 stated she is not sure if that is what happened. V37 stated that the alarm that R11 was using in the reclining chair was the one that she knows how to turn off. V37 stated that he was sure if the alarm was working. On 9/12/2022 at V18, CNA, stated that R11 makes attempts to transfer self. V18 stated that R11 is difficult to redirect. V18 stated that maintenance needs to take a look at the cord to the alarm because they are frayed. The facility's Fall Policy, dated 5/26/16, documents It is the policy of (facility) to provide Fall Management and provide a plan in an effort to reduce fall risk. Interventions will be utilized as needed to encourage reduced risk. Those interventions may include, but are not limited to, a fall risk assessment completed upon admission and quarterly, implementing appropriate interventions for those residents at risk, and addressing risks in the plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R5's Care Plan, dated 8/25/22, documents (R5) has an ADL self-care performance deficit related to history of CVA (Cerebral Vascular Accident) with left sided deficit, poor mobility, DM-II (Diabetes Mellitus two), neuropathy, and generalized weakness. Interventions: I require extensive assist by two staff with turning and repositioning. I am flaccid on my left side, so be careful when you assist me, I require extensive assist by two staff with toileting. I prefer to use a bedpan. I require total assist by one staff with all perineal care. I am incontinent of urine and continent of bowel. Please assist me with staying clean and dry at least every two hours and PRN(as needed), I require a mechanical lift with extensive assist by two staff with all transfers. I require total assist with all mobility and transportation in wheelchair. It continues (R5) has impaired skin integrity related to incontinence, DM II, CVA with left sided weakness, and poor mobility. R5's MDS, dated [DATE], documents that R5 is cognitively intact and is totally dependent on two staff members for transfers, toilet use and bathing. R5 requires extensive assistance from two staff members for bed mobility and dressing. R5 is frequently incontinent of urine and occasionally incontinent of bowel. On 9/12/22 at 1:05 PM, V1, Administrator, stated I would expect staff to provide complete and timely incontinent care for residents who are incontinent and/or needing assistance after using the toilet. On 9/7/22 at 10:25 AM, R5 was sitting on bed pan in bed and ready to get cleaned up. V10, CNA, had a bucket of water and wash cloths ready and donned gloves. V10 wiped once from top down the middle of R5's vagina and once from top down each groin. V10 did not dry the areas. R5 turned to left side, bedpan removed and V10's buttocks and anal area wiped once while reaching between R5's legs from front to back. Without drying the areas, an incontinence brief was applied. R5 was rolled to her right side and the incontinence brief was secured and pulled up with no further cleaning. 3. R16's Care Plan, dated 7/1/22, documents (R16) has an ADL self-care performance deficit related to deconditioning, poor mobility and balance, and generalized weakness. Interventions: I require extensive assist by two staff with toileting and perineal care. I am incontinent at times and require total assist by one staff for perineal care when I am in bed. Please assist me with staying clean and dry every two hours and PRN, I require a mechanical Sit-to-stand lift with two staff assistance for transfers. It continues (R16) has impaired skin integrity related to pressure ulcer, immobility, incontinence, and a low Braden score. R16's MDS, dated [DATE], documents that R16 is cognitively intact and requires extensive assistance from two staff members for most of her ADL's. R16 is always incontinent of urine and occasionally incontinent of bowel. On 9/7/22 at 10:40 AM, R16 put her call light on as she was done using the restroom. V10 and V17, CNA, in to assist R16 using a sit-to-stand lift. R16 was lifted off the toilet. While standing and holding onto the lift device handles, V17 wiped R16's buttocks and anal area. V17 then reached between R16's legs and wiped from front to back once with no cleaning of R16's front side and no drying done after all cleansing. V17 doffed her soiled gloves and donned clean ones. An incontinent brief was then placed on R16. 4. R32's Care Plan, dated 8/2/22, documents (R32) has an ADL self-care performance deficit related to multiple pelvic fractures, Osteoarthritis of bilateral knees, generalized weakness, and history of falls. Interventions: I require extensive assist by one staff with toileting and perineal care. I am occasionally incontinent of B&B (bowel and bladder). I require total care with perineal care during incontinence episodes. Ensure I am remaining clean and dry at least every two hours and PRN, I require a Mechanical sit to stand with extensive assist by two staff for all mobility. It continues (R32) has impaired skin integrity related to generalized weakness, incontinence, and poor mobility. R32's MDS, dated [DATE], documents R32 is cognitively intact and requires extensive assistance from one staff member for toilet use. R32 is frequently incontinent of urine and always continent of bowel. 9/07/22 at 10:010 AM, V10 and V17 assisted R32 from the toilet to her recliner using a sit-to-stand lift. Both CNA's donned gloves. R32 held onto the lift device bar as V10 was lifting her off the toilet. V17 wiped R32's buttocks and reached between R32's legs and wiped once from front to back and did not wipe the front pubic area of R32. There was no drying of R32 after cleansing her. An incontinence brief was put on R32. V17 doffed her gloves after wiping and no new gloves applied. The facility's Perineal Care Policy and Procedure (female perineal care), undated, documents It is the policy of (facility) to do perineal care on incontinent female residents every two hours when toileting and PRN to reduce the risk of infection and maintain hygiene. It continues, Procedure: 13. Separate the labia and clean downward from front to back with one stroke. Discard and get clean washcloth repeating steps for right and left side of the labia using a clean washcloth for each stroke. No more than three strokes between glove removal and hand sanitizing. Discard all used washcloth into the soiled linen bag. 14. Remove gloves and wash/sanitize hands. 15. [NAME] clean gloves. 16. Pat the area with a clean towel. 17. Help resident turn onto side away from you. 18. Roll soiled linen under resident, remove gloves and sanitize hands. 19. [NAME] clean gloves and place clean linens under resident. 20. Apply perineal wash to washcloth. 21. Cleanse perineal rectum from front to back with one stroke starting at vagina and moving towards anus. Discard and get a clean washcloth repeating the same step until area clean. No more than three strokes between glove removal and hand sanitizing. Discard all used washcloths into the soiled linen bag. 22. Apply perineal wash to wash cloth. 23. Cleanse the visible posterior thigh and buttock using a front to back motion with one stroke per washcloth until area clean. No more than three strokes between glove removal and hand sanitizing. 24. Remove gloves and wash/sanitize hands. 25. [NAME] clean gloves. 26. Pat the area dry with a clean towel. 27. Help resident turn to the opposite side. 28. Remove soiled linen roll previously placed, remove gloves and sanitize hands. 29. [NAME] gloves and pull through clean linen previously placed. 30. Repeat the same technique to cleanse opposite buttock and posterior thigh as listed in step 23. 31. Sanitize hands and don clean gloves. 32. Pat areas dry with clean towel and apply barrier cream. Based on observation, interview and record review the facility failed to appropriately perform incontinent care and perform complete care for 5 of 5 residents (R5, R16, R18, R25, R32) reviewed for incontinence in the sample of 24. Findings include: 1. R18's Care Plan, revision date 2/22/2021, documents (R18) has an ADL (activities of daily living) self-care performance deficit r/t (related to) Dementia, generalized weakness, and Osteoarthritis. It also documents TOILET USE: I require extensive assist by 1-2 staff with toileting and peri-care. Ensure I am remaining clean and dry at least every 2 hours & PRN (as needed). R18's Minimum Data Set (MDS), dated [DATE], documents that R18 is occasionally incontinent of urine. On 9/7/2022 at 1:45 PM, observed V18, CNA (Certified Nursing Assistant), assisted R18 with toileting. V18, and V19, SSD (Social Service Director)/CNA, transferred R18 from the wheelchair to the toilet using the standup lift. V18 worked the remote to assist R18 into the standing position revealing R18's heavily soiled pants. V18 placed R18 in front of the toilet and removed R18's heavily urine soiled brief and pants. V18 assisted R18 onto the toilet. Upon completion of toileting, V18 assisted R18 into the standing position, using the standup lift, and performed peri care. V18 used wash cloths with spray cleanser to cleanse R18's outer labia with one wipe from behind. V18 used a separate towel to cleanse R18's buttocks and anus. V18 pulled up R18's clean undergarment and pants. V18 did not cleanse the perineum, the inner labia, and thighs. On 9/12/2022 at 3:22 PM, V2, Registered Nurse (RN), stated that when a resident is incontinent, she expects the staff to clean all areas of incontinence. V2 stated that if a resident is incontinent and then goes to the toilet, she expects the staff to perform incontinent care and cleanse all areas of incontinence. 5. R25's MDS dated [DATE] documents R25 is incontinent of bowel and bladder and requires extensive assist with toileting. On 9/6/2022 at 10:47 AM, R25 stated she was hurting down there. On 9/6/2022 at 11:05 AM, V17, CNA, and V38, CNA, were performing incontinent care. V38 stated, We have a big 'bowel movement/mess'. It is all the way up her back. At this time, there was feces in R25's groin folds and pubic area. V17 wiped R25's groin with a washcloth. V17 used the same washcloth with feces on it to wipe R25's labia. V17 then turned R25 over, removed her gloves, but did not use hand hygiene. V17 then began cleaning R25's buttocks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure complete documentation of Pneumococcal vaccine administration and/or refusal in 4 of 4 residents (R15, R18, R22, R28) reviewed for immunizations in the sample of 24. Findings include: 1. R15's Face Sheet documents R15 is (age 82) and was admitted to the facility on [DATE]. R15's Minimum Data Sheet (MDS) dated [DATE] documents R15 is cognitively intact. R15's Immunization Report, dated 9/7/2022, documents Pneumovax Dose 1 and Pneumovax Dose 2 (Pneumococcal vaccines) were refused. The facility did not provide documentation for these refusals. 2. R18's Face Sheet documents R18 is (age 93) and was admitted to the facility on [DATE]. R18's MDS dated [DATE] documents R18 is moderately cognitively impaired. R18's Immunization Report dated 9/7/2022 does not document any Pneumonia vaccine being offered or administered. The facility did not provide documentation that the first or second Pneumonia vaccines were offered. 3. R22's Face Sheet documents R22 is (age 81) and was admitted to the facility on [DATE]. R22's MDS dated [DATE] documents R22 is cognitively intact. R22's Immunization Report dated 9/7/2022 documents R22 refused Pneumovax Dose 1. The facility did not provide any documentation regarding this refusal, or a second dose being offered. 4. R28's Face Sheet documents R28 is (age 89) and was admitted to the facility on [DATE]. R28's MDS, dated [DATE], documents R28 is moderately cognitively impaired. R28's Immunization Report, dated 9/7/2022, documents Pneumovax Dose 1 Refusal. No documentation of refusal was provided by facility. The Immunization Report does not document Pneumovax Dose 2 being offered or administered. On 6/9/22 at 2:43 PM, V4, Infection Control Prevention Nurse, stated, I was working here when (R15), (R18), and (R28) refused their Pneumonia shots. It was just a verbal refusal, so I did not document anything about that. Perhaps that is a practice I need to start. The Facility's Policy and Procedure for Influenza, Pneumococcal, and COVID-19 Immunizations which is not dated documents, Upon admission every resident will be offered all immunizations. If a resident has previously received the vaccination, a record will be obtained if possible and added to chart. The Pneumococcal vaccine will be offered to all residents over 65 years in age or with aged 19-64 with certain underlying medical conditioner per CDC (Centers for Disease Control) recommendations and resident's MD (Medical Doctor) policy. Pneumococcal vaccines will be monitored by Infection Control Nurse. If a resident has not had an immunization, Infection Control Nurse will obtain a consent from the resident/POA (Power of Attorney).

Based on interview and record review, the Facility failed to use the services of a Registered Nurse (RN) to serve as Director of Nursing (DON) on a full-time basis. This has the potential to affect all 40 residents living in the facility. Findings include: On 9/6/22 at 10:35 AM, V1, Administrator, stated (V2) was our DON but she stepped down on 2/22/22 and only works floor shifts. She is still considered our DON though. We also have two ADON's (Assistant Director of Nursing) who are only LPN's (Licensed Practical Nurse), but they are taking care of the responsibilities of the DON until we can find another DON. On 9/7/11 at 11:35 AM, V1 stated, We have not had a full time DON since last December. The interim DON always works the floor. We are trying to hire a full time DON. On 9/7/22 at 1:52 PM, V4, ADON, stated, I do not believe we have a policy regarding DON staffing. We just follow the regulations. The Facility's Resident Census and Conditions of Residents form, (CMS 672), dated 9/6/22, documents the Facility had a census of 40 residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. R5's Care Plan, dated 8/25/22, documents (R5) has an ADL (Activity of Daily Living) self-care performance deficit related to history of CVA (Cerebral Vascular Accident) with left sided deficit, poor mobility, DM-II (Diabetes Mellitus two), neuropathy, and generalized weakness. Interventions: I require extensive assist by two staff with turning and repositioning. I am flaccid on my left side, so be careful when you assist me, I require extensive assist by two staff with toileting. I prefer to use a bedpan. I require total assist by one staff with all perineal care. I am incontinent of urine and continent of bowel. Please assist me with staying clean and dry at least every two hours and PRN (as needed), I require a mechanical lift with extensive assist by two staff with all transfers. I require total assist with all mobility and transportation in wheelchair. R5's Minimum Data Set (MDS), dated [DATE], documents that R5 is cognitively intact and is totally dependent on two staff members for transfers, toilet use and bathing. R5 is frequently incontinent of urine and occasionally incontinent of bowel. On 9/12/22 at 1:09 PM, V1, Administrator, stated I would expect the staff to complete hand hygiene before resident care, after glove changes, and after care of the resident. On 9/7/22 at 10:25 AM, R5 was sitting on bed pan in bed and ready to get cleaned up. V10, CNA, and V17, CNA, was assisting R5 with perineal care. There was no hand hygiene done by either CNA prior to care. Both CNA's donned gloves. V10 performed incontinent care. V10 removed her soiled gloves and with no hand hygiene done, donned clean gloves on. R5's pants were then put on her, gloves doffed with no hand hygiene after care was done. 8. R32's Care Plan, dated 8/2/22, documents (R32) has an ADL (Activities of Daily Living) self-care performance deficit related to multiple pelvic fractures, osteoarthritis of bilateral knees, generalized weakness, and history of falls. Interventions: I require extensive assist by one staff with toileting and perineal care. I am occasionally incontinent of B&B (bowel and bladder). I require total care with perineal care during incontinence episodes. Ensure I am remaining clean and dry at least every two hours and PRN (as needed) R32's MDS, dated [DATE], documents R32 is cognitively intact and requires extensive assistance from one staff member for toilet use. R32 is frequently incontinent of urine and always continent of bowel. On 9/07/22 at 10:010 AM, V10 and V17 assisted R32 from the toilet to her recliner using a sit-to-stand device. Both CNA's donned gloves with no hand hygiene prior to, R32 held onto device bar as V10 was lifting her off the toilet. V17 doffed her gloves after cleansing R32 and no new gloves applied. The sit-to-stand device was moved into the hall and was not wiped off after R32 was holding bars while on the toilet. The device was then pulled into R16's room. No hand hygiene was done by either CNA after gloves removed. The manufacturer's Instructions for use, dated 6/2018, documents It is recommended that equipment, accessories and slings supplied by (company) are regularly cleaned and/or disinfected between each resident use if necessary, or daily as a minimum. If the slings and equipment need cleaning, or are suspected of being contaminated, follow the cleaning and/or disinfection procedures recommended below, before re-using the equipment. This is especially important when using the same equipment for another resident, to minimize the risk of cross infection. The facility's Perineal Care Policy and Procedure (female perineal care), undated, documents It is the policy of (Facility) to do perineal care on incontinent female residents every two hours when toileting and PRN to reduce the risk of infection and maintain hygiene. It continues, Procedure: 5. Wash hands. and 11. [NAME] gloves. 13. Separate the labia and clean downward from front to back with one stroke. Discard and get clean washcloth repeating steps for right and left side of the labia using a clean washcloth for each stroke. No more than three strokes between glove removal and hand sanitizing. Discard all used washcloth into the soiled linen bag. 14. Remove gloves and wash/sanitize hands. 15. [NAME] clean gloves. 16. Pat the area with a clean towel. 17. Help resident turn onto side away from you. 18. Roll soiled linen under resident, remove gloves and sanitize hands. 19. [NAME] clean gloves and place clean linens under resident. 20. Apply perineal wash to washcloth. 21. Cleanse perineal rectum from front to back with one stroke starting at vagina and moving towards anus. Discard and get a clean washcloth repeating the same step until area clean. No more than three strokes between glove removal and hand sanitizing. Discard all used washcloths into the soiled linen bag. 22. Apply perineal wash to wash cloth. 23. Cleanse the visible posterior thigh and buttock using a front to back motion with one stroke per washcloth until area clean. No more than three strokes between glove removal and hand sanitizing. 24. Remove gloves and wash/sanitize hands. 25. [NAME] clean gloves. 26. Pat the area dry with a clean towel. 27. Help resident turn to the opposite side. 28. Remove soiled linen roll previously placed, remove gloves and sanitize hands. 29. [NAME] gloves and pull through clean linen previously placed. 30. Repeat the same technique to cleanse opposite buttock and posterior thigh as listed in step 23. 31. Sanitize hands and don clean gloves. 32. Pat areas dry with clean towel and apply barrier cream. 33. Discard all soiled linens in trash bag and secure closed, discard all trash items in trash bag and secure closed. 36. Wash hands and offer fluids. The facility's CMS form 672 dated 9/6/2022 documents that there are 40 residents residing at the facility. 2. R35's Care Plan, dated 8/12/2022, documents (R35) is at risk for COVID-19. It continues initiate quarantine isolation precautions x (times) 14 days upon admission or re-admission to facility unless resident is fully vaccinated or has fully recovered from COVID-19 infection in previous 90 days. Monitor every shift for s/s (signs and symptoms) of COVID-19 such as fever, cough, shortness of breath, fatigue, loss of taste or smell, sore throat, or congestion. Notify MD (medical doctor) and follow facility protocol if symptoms appear. Obtain rapid COVID-19 antigen test or SARS-CoV-2 RT PCR (lab testing) as required and as needed by facility guidelines for infection control. The Facility's COVID-19 testing log, not dated, documents R35 tested positive for COVID on 9/1/2022. R35's Orders - Administration Note, dated 9/1/2022 at 11:56 AM, documents Note Text: BinaxNOW COVID-19 Ag Card Kit 1 kit in each nostril as needed for COVID-19 PRN (as needed) Administration was: Effective Test result is positive. R35's Health Status Note, dated 9/5/2022 at 10:56 PM, documents Note Text: Pt (patient) positive for COVID. Complaints of occasional cough, runny nose and lethargy. Pt afebrile. Quarantine cont. (continued). R35's Infection Note, dated 9/6/2022 at 2:20 AM, documents Note Text: Monitoring continues r/t (related to) positive COVID-19 status. T (temperature) 97.8. Lungs clear bilaterally. SpO2 (oxygen saturation) 97% ORA (on room air). Respirations even and non-labored. Occasional non-productive cough continues. Isolation precautions maintained r/t COVID-19. On 9/6/2022 at 9:33 AM, observed R35 in reclining chair in room. R35's room door open. No signage on the door or near room indicating type of precautions and what personal protective equipment required to enter room and provide care for resident. On 9/8/2022 at 2:33 PM, R35 sitting in recliner in room. R35's room door open to hallway. On 9/8/2022 at 2:33 PM, R35 sitting in recliner in room. R35's room door open to hallway. 3. R20's Care Plan, documents that (R20) is at risk for COVID-19. It also documents Initiate quarantine isolation precautions x 14 days upon admission or re-admission to facility unless resident is fully vaccinated or has fully recovered from COVID-19 infection in previous 90 days. Monitor every shift for s/s of COVID-19 such as fever, cough, shortness of breath, fatigue, loss of taste or smell, sore throat, or congestion. Notify MD and follow facility protocol if symptoms appear. R20's Progress Notes, dated 9/5/2022 1:21 AM, documents Late Entry: Note Text: Pt (patient) tested positive for COVID during routine testing. Asymptomatic. Pt notified POA (Power of Attorney) himself and POA called this nurse back for information R20's Infection Note, dated 9/6/2022 at 2:25 AM, documents Note Text: Isolation precautions-maintained r/t positive COVID-19 status. Resident remains asymptomatic at this time. T 98.3. SpO2 96% ORA. Respirations even and non-labored. No distress noted at this time. R20's Medication Administration Record (MAR) documents that R20 was having symptoms of COVID on 9/6/2022. The Facility's COVID-19 Testing log, not dated, documents that R20 tested positive for COVID on 9/5/2022. On 9/6/2022 at 9:35 AM, observed R20 in reclining chair in room with two red trash cans in the room. No signage on the door or near room indicating type of precautions and what PPE required to enter room and provide care for resident. No PPE located outside of R20's room. PPE located on a cart across the hall outside of another resident doorway. No sign on the cart indicating what resident to utilize on and what PPE to use. On 9/6/2022 at 9:35 AM, R20 stated that he is on isolation but does not know why. R20 stated that he did test positive for COVID. R20 stated that he had symptoms and the facility tested him yesterday or the day before and, he was positive. R20 stated that the staff comes in with mask but not sure about the eyewear. R20 stated that the staff does not always wear the gown and gloves. On 9/7/2022 at 9:15 AM, observed two signs posted on R20's door documenting 1. STOP Airborne Precautions Everyone must: Clean their hands, including before entering and when leaving the room. Put on a fit-tested N-95 or higher-level respirator before room entry. Remove respirator after exiting the room and closing the door. Door to room must remain closed. 2. Stop Contact Precautions Everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. 4. R31's Care Plan, revision date 11/18/21, documents (R31) is at risk for COVID-19. It also documents Initiate quarantine isolation precautions x 14 days upon admission or re-admission to facility unless resident is fully vaccinated or has fully recovered from COVID-19 infection in previous 90 days. Monitor every shift for s/s of COVID-19 such as fever, cough, shortness of breath, fatigue, loss of taste or smell, sore throat, or congestion. Notify MD and follow facility protocol if symptoms appear. The facility's COVID-19 Testing log, not dated, documents that R31 tested positive for COVID on 9/1/2022. R31's MAR documents that R31 was having symptoms of COVID in the month of September. On 9/6/2022 at 9:37 AM, R31 observed in chair in room. R31's room door open to hallway. No signage on the door or near room indicating type of precautions and what personal protective equipment required to enter room and provide care for resident. On 9/7/2022 at 9:15 AM, observed two signs posted on R20's door documenting 1. STOP Airborne Precautions Everyone must: Clean their hands, including before entering and when leaving the room. Put on a fit-tested N-95 or higher-level respirator before room entry. Remove respirator after exiting the room and closing the door. Door to room must remain closed. 2. Stop Contact Precautions Everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. On 9/8/2022 at 2:30 PM, R31 sitting in recliner in room. R31's room door open to hallway. On 9/12/2022 at 12:25 PM, observed R31 sitting in recliner in room. R31's room door open to hallway. 5. On 9/6/22 at 12:10 PM, V11, Dietary Aide, was passing lunch trays to residents on the hall going in and out of every room with his N-95 mask under his nose, no hand hygiene between residents' tray delivery and set up. 6. The facility provided a list of unvaccinated residents. R7, R12, R22, R36, and R37 were listed as residents that were unvaccinated. R7, R12, R22, R37, and R36 were in quarantine. No signs indicating quarantine or isolation observed outside their doors. On 9/6/2022 at 9:30 AM, R7, R12, R22, R36 and R37 were observed in their rooms. No precautions in place. On 9/6/2022 at 2:00 PM, V4, ADON (Assistant Director of Nursing), verified that the facility had 5 COVID positive residents. When asked how would visitors know what PPE to wear when entering rooms? V4 stated that you would be talking about signs on doors. V4 stated he would make sure they are put in place. On 9/8/2022 at 11:06 AM, V23, [NAME] County Health Department, stated that they were not aware of the facility having an active outbreak or that the facility had multiple resident's positive for COVID. V23 stated V4 notifies them of the outbreaks, but the current outbreak has closed. V23 stated that the Department was unaware of any subsequent outbreaks since 7/22/22 or there being five COVID positive residents in building. V23 stated that she had given guidance to the facility in the past. V23 stated that the residents that tested positive for COVID should be placed on a unit. V23 stated that for the residents that are unvaccinated, precautions should be put in place due to exposure. On 9/8/2022 at 2:28 PM, V4, ADON, stated that the facility did not move the residents to a specific location. V4 stated that the unvaccinated residents are on precautions. When asked how is that communicated? V4 stated that each nurse's station had a list. V4 stated that the facility is treating COVID as facility wide and each resident is in their own private room. V4 stated that unvaccinated residents should be quarantined. V4 stated that there is a list of those residents at the nurse's station. V4 stated that I guess we would need some signage posted so visitors will know what to do as far as PPE. On 9/8/2022 at 2:36 PM, V21, Registered Nurse (RN), stated that she did not have a list of unvaccinated residents on quarantine. On 9/8/2022 at 2:38 PM, V13, Receptionist, stated that she does not have a list of unvaccinated residents that are on quarantine. V13 stated that the residents on isolation or quarantine have a sign on their door. The facility's COVID-19 Policy and Procedure, not dated, documents COVID outbreak response: The facility will split into 3-color coded sections (e.g. Red/Yellow/Green) to assist with isolation and maintaining the spread of COVID-19 throughout the facility. Red Unit: Section of the facility designated to temporarily house residents with confirmed or suspected COVID-19. Initial designation of Red unit begins at the east end of 100 hall and will be known as the COVID care unit. It also documents that Residents should only be placed on the COVID-19 Care unit (Red) if they have confirmed COVID-19 infections. The facility's Infection Control Policy-Guidelines, not dated, documents Isolation Precautions: Transmission Driven Isolation Precautions are utilized in addition to Universal Precaution. If a resident is on isolation, a card placed outside the residents room indicates the need to see the nurse before entering. Based on observation, interview and record review, the facility failed to perform hand hygiene, post signage for isolation, wear PPE (personal protective equipment) appropriately and keep the doors of COVID positive residents closed to prevent/control the spread of COVID-19. This failure has the potential to affect all 40 residents residing in the facility. Findings include: 1. The Facility provided a list that documents, At this time, there is five residents who are positive for COVID. It further documents those residents are R6, R14, R20, R31 and R35. On 9/6/2022 at 8:45 AM, R6's door was open. There was no signage on the door to indicate type of precautions and what personal protective equipment required to enter room and provide care for resident. On 9/7/2022 at 10:30 AM, R6's door was open. On 9/8/2022 at 2:30 PM, R6's door remained open. 2. On 9/6/2022 at 8:45 AM, R14's door was open. There was no signage on the door to indicate type of precautions and what personal protective equipment required to enter room and provide care for resident. On 9/7/2022 at 10:30 AM, R14's door was open. On 9/8/2022 at 2:30 PM, R 14's door remained open.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to conduct routine COVID-19 testing of all employees to assist in preventing transmission of COVID-19 into the facility. This has the potential to affect all 40 residents in the facility. Findings include: On 9/6/22 at 8:00 AM, upon entry to the facility there was a sign on Facility's Visitor Entrance door that read, We are COVID positive at this time. The Facility's Contract Tracing form, undated, documents there was a COVID positive staff member, V34, Maintenance Director, on 8/25/2022. The Facility's COVID-19 test results printed on 9/8/22 at 10:45 AM, document three residents (R14, R31, R35) tested positive for COVID on 9/1/22, and two residents (R6, R20) tested positive for COVID on 9/5/2022. The Facility's COVID-19 Staff Vaccination Status for Providers provided by the Facility on 9/6/22, documents the Facility has 54 employees. The Facility's Staff Testing list documents a total of 36 staff members were tested for COVID one or more times during the week of 8/25/22 to 9/1/22. On 9/6/22 at 2:01 PM, V4, Infection Control Preventionist (ICP), stated, I realize the number of staff on the testing log does not match the number of staff in the facility. It falls short. On 9/7/22 at 10:28 AM, V16, Contracted Physical Therapist stated, I have only been working in the facility for about a month. I have not yet tested in the facility because my days here do not coincide with the facility's test dates. I had COVID in January 2022 but have not had it since. My employer has not been testing me either. On 9/7/2022 at 1:30 PM, Facility's Staff COVID-19 Testing Log was reviewed. V16 is not documented as having been tested since outbreak began on 8/25/22. On 9/7/22 at 1:52 PM, V4 stated, I follow the broad-based approach when we have an outbreak. I have no good answer for the contracted employee testing. I will fix it and make sure it is right going forward. On 9/8/22 at 11:07 AM, V23, [NAME] County Health Department, stated Testing should be done at least weekly for everyone during the outbreak unless they have had COVID-19 in the last 90 days. The Facility's COVID-19 Policy & Procedures, updated 7/29/22, documents, COVID Outbreak Testing Protocol: Broad Based Approach: This approach requires testing of all residents and HCP (Healthcare Personnel) regardless of vaccination status when a single cases of COVID-19 is identified in the facility. Continue to test all residents and HCP every 3-7 days until there are no more positive cases for 14 days. The Resident Census and Condition of Residents Form (CMS 672), dated 9/6/2022, documents that the facility has 40 residents living in the facility.