Based on interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan for elopement risk and the use of a departure alert system. This failure affects two (R1 and R3) of three residents reviewed for supervision in the sample list of three. Findings include: The facility Exit Seeking list dated April 2025 documents R1 and R3 as exit seeking. 1. A Progress Note dated 4/3/25, documents R1 found wandering near door at approximately 10pm with door alarming. Further documents R1 assisted back to bed and departure alert system placed around right ankle. R1's Care Plan (current) does not document R1 as an elopement risk or R1's use of a departure alert system until 4/29/25. R1's Physician Orders (current) documents the following order dated 4/29/25: check placement and functionality of departure alert system daily in evening. R1's Exit Seeking/Wandering Assessments dated 10/15/24 and 4/7/25 documents R1 is at risk for exit seeking/wandering. R1's Behavioral Notes dated 8/29/24, 12/28/24, 3/1/25 and 4/13/25 documents R1's wandering behaviors. 2. R3's Care Plan (current) does not document R2 as an elopement risk or R2's use of a departure alert system until 4/29/24. R3's Physician Orders (current) documents the following order dated 4/22/24: check departure alert system placement on right wrist every shift. R3's Exit Seeking/Wandering Assessments dated 12/2/24 and 2/26/25 document R3 is at risk for exit seeking/wandering. On 4/29/25 at 12:48pm, V10 MDS/Care Plan Coordinator confirmed R1 and R3's care plan was updated today (4/29/25) to include elopement risk/wandering/exit seeking and the use of a departure alert system. On 4/29/25 at 12:57pm, V11 Social Services Director stated it is the responsibility of V10, V11 and nursing for the care plans. V11 stated V11 was not able to put R1's elopement risk/wandering/exit seeking on R1's care plan until the Physician's order for the departure alert system is in place. V11 stated the order is what triggers the care plan to be updated. V11 confirmed the order was just placed today for R1's departure alert system and that is why R1's care plan did not include that care area and interventions. The facility Missing Resident/Elopement Policy dated July 2024 documents the following: Cognitive assessments and concerning activity log may be utilized to customize individual service/support plans. This information will be documented in the resident's medical record and used in the service/support planning process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide one staff assistance to prevent a fall for one (R1) of three residents reviewed for accidents in the sample list of five. Findings include: R1's Facility Census documents R1 was admitted to the facility on [DATE] and has the following medical diagnosis, Malignant Neoplasm of Endometrium, Chronic Pain Syndrome, Weakness, Overactive Bladder, Age-Related Osteoporosis, GERD, Encounter for Palliative Care and Anemia. R1's Minimum Data Set (MDS) dated [DATE] documents R1's Brief Interview for Mental Status (BIMS) score 8, moderate cognitive impairment, needs substantial/maximum assistance with Activities of Daily Living. R1's Care Plan dated 8/17/23 documents R1 is at risk for falls due to limited physical mobility related to chronic pain syndrome and Osteoarthritis. Interventions. Transfers: R1 transfers with one staff assist/gait belt and rolling walker. R1's Health Status Note dated 4/1/25 at 7:33pm documents V4 Certified Nursing Assistant notified V3 Registered Nurse (RN) that R1 was on the floor. Found R1 lying on right side with head toward toilet and facing shower. Right arm was behind R1. Knees bent and toward the shower and feet toward bathroom door. [NAME] in front of toilet. R1 assessed by V3 and V5 Nurse Manager. R1 able to move all extremities with some pain to the right leg. R1 was turned onto R1's back and three assisted to wheelchair without difficulty. Vital Signs - Temperature-98.2, Pulse-94, Respirations-18, Blood Pressure-177/125. Neuros started and within normal limits (WNL). V4 reported that R1 was assisted off toilet and then R1 was walking toward the door when R1 fell. R1 did not remember how it happened. V6 Physician notified at 11:30pm and recommended that resident go to Emergency Department (ED). V7 R1's Power of Attorney/Daughter POA (refused) did not want to send resident to ED. R1 had multiple injuries. 1-Right side of head 6.0-centimeter x 4-centimeter hematoma, 2- Right shoulder 8.0-centimeter x 4.0-centimeter bruise, 3-Right elbow 1.5-centimeter x 0.1-centimeter skin tear, 4-Right hand 0.5-centimeter x 0.1 centimeter skin tear and 1.0-centimeter x 1.0-centimeter bruise, 5- Right lower leg 3.0-centimeter x 2.0-centimeter skin tear. V4 Certified Nursing Assistant (CNA) witness statement dated 4/1/25 at 11:00am documents at 10:45am V4 took R1 to the restroom, used walker for transfer, when R1 was done, used the rail to get off seat and wiped R1, pulled R1's brief up and pants up. V4 was standing in front of R1's walker waiting for R1. R1 grabbed R1's walker. V4 walked to the bathroom door, stood and waited for R1. R1 was walking towards V4, then suddenly fell backwards. V4 thinking R1 lost R1's footing. V4 went and got the nurse. On 4/19/25 at 11:30am V1 stated that on 4/1/25 R1 had a witnessed fall after being assisted off the toilet. V1 stated V1 interviewed V4 Agency Certified Nursing Assistant who informed V1 that V4 assisted R1 onto the toilet and when R1 was finished, V4 assisted R1 to a standing position using the grab bar on the wall. V1 stated that V4 further informed V1 that V4 cleaned R1, pulled up R1's brief and pants and gave R1, R1's walker. V1 stated that V4 then stood in front of R1's door waiting for R1 to ambulate out of the bathroom, at which time R1 fell backwards onto the floor. V1 stated R1 should not have been positioned in front of R1, due to R1 being a one staff gait belt assist. V1 stated that V4 should have been behind R1 holding R1's gait belt in case R1 needed assistance. V1 stated V4 was in no position to assist in lowering R1 to the floor. On 4/19/25 at 1:22pm V11 Certified Nursing Assistant stated the proper way to ambulate a resident who requires a one staff assist with gait belt/walker is to position yourself either on the resident's left or right side. V11 stated, V11 positions V11's self this way so that V11 can have one hand on the back of the resident's gait belt and the other on the walker. V11 stated at no time would V11 be in front of the resident, because there would be no way to assist the resident if they were to fall or needed assistance. On 4/21/25 at 11:07am V3 Registered Nurse stated on 4/1/25 at 10:45am V3 was notified by V4 Agency Certified Nursing Assistant that R1 had fallen in the bathroom. V3 stated V3 responded and observed R1 lying on R1's right side with R1's head toward the toilet and facing the shower. V3 stated R1's right arm was behind R1, R1's knees were bent and toward the shower, R1's feet were toward the bathroom door, and R1's walker was in front of the toilet. V3 stated V4 told V3 that V4 assisted R1 the off toilet, cleaned R1 and gave R1, R1's walker. V3 stated that V4 then walked out of the bathroom and let R1 walk without V4 assisting R1 and R1 fell backwards onto the floor

Based on observation, interview and record review the facility failed to maintain resident's furniture in a clean manner for two of 24 residents (R74, R61) reviewed for clean, comfortable, homelike environment in the sample list of 44. Findings include: On 10/20/24 at 9:36 AM, there is a light tan fabric chair in the sitting area of R74 and R61's room. This chair has dark brown stains and light brown stains on at least half of the seat of the chair. On 10/23/24 at 3:56 PM, V13 Housekeeping Supervisor stated that they clean resident's chairs in the resident's rooms every once in awhile. V13 stated that she just had most of them cleaned by an outside company a few months ago. V13 stated she was not aware that the chair in R74 and R61's sitting area was stained. On 10/23/24 at 9:05 AM, R74 and R61's chair had been removed from the sitting area in their room. On 10/23/24 at 9:07 AM, V28 Housekeeper stated that she does not know what happened to their chair. On 10/23/24 at 9:27 AM, V13 confirmed R74 and R61's sitting room chair was stained with what she thought was coffee. V13 stated she had the chair removed to be cleaned and stated it will be returned to their room after it is cleaned. The facility's Fabric Furniture Cleaning policy dated 11/1/12 documents, This procedure will be used as required whenever furniture fabric becomes soiled. Remove chair from normal area and take to cleaning area. When the entire surface has been scrubbed and vacuumed, allow the chair to dry. It is recommended that the chair dry at least 24 hours before being put back into service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident was free from restraint by not having a Physician's Order, a signed consent form for a restraint and to complete restraint reduction attempts. This affects one of one resident(R74) reviewed for restraints in the sample list of 44. Findings include: On 10/20/24 at 10:14 AM and 12:51 PM, R74 was in his wheelchair and had a lap cushion across the front of his lap. On 10/21/24 at 9:35 AM and 10:43 AM, R74 was in his wheelchair and had a lap cushion on his lap. R74's diagnosis list documents diagnoses including Unspecified Dementia, Unspecified Severity with Mood Disturbance, Muscle Weakness, Polymyalgia Rheumatica and Muscle Wasting and Atrophy. R74's Physician's Orders dated 10/21/24 do not document an order for the use of a soft lap cushion as a restraint nor as a therapeutic intervention. R74's Care Plan dated 10/7/24 documents R74 utilizes a lap cushion as a comfort device. This Care Plan documents R74 is able to place and remove lap buddy on his own and he is not always able to remove it upon verbal command due to cognitive function. R74's Minimum Data Set, dated [DATE] documents under the section Physical Restraints that R74 uses other devices in a chair or out of bed daily. R74's Physical Device/Psychoactive Medication Initial and Quarterly Evaluation dated 1/2/24 documents the device used as a lap cushion while in wheelchair and to release every two hours. R74's medical record does not contain a signed consent form for the use of a lap cushion restraint. On 10/21/24 at 10:16 AM, V1 Administrator stated that they do not have a consent for R74's lap cushion because he can remove it himself. On 10/21/24 at 10:44 AM V29 Certified Nursing Assistant asked R74 to remove his lap cushion and R74 stated I don't know if I can or not. R74 was feeling around the outside of the lap cushion with his fingernails and mumbling to himself. R74 was not able to remove the lap cushion when asked to do so. On 10//21/24 at 10:50 AM, V6 Care Plan Coordinator stated that she was not aware that he could not remove it when asked. On 10/21/24 at 2:12 PM V2 Director of Nursing stated that they went and asked him to remove it and he just tugged and pulled at it and could not remove it. V2 stated they called the V3 Nurse Practitioner and requested an order for the lap cushion restraint. and called the Power of Attorney and obtained verbal consent for the lap cushion restraint. V2 stated that they also completed a new restraint assessment on this day. The facility's Nonemergency Use of Physical Restraints Policy/Procedure dated 3/1/11 documents, Physical restraints shall be used when required to treat a resident's medical symptoms or as a therapeutic intervention, as ordered by a physician. A physical Restraint will be used only with the informed consent of the resident, the resident's guardian, or other authorized representative. The plan of care will contain a schedule or plan of rehabilitative/habilitative training to enable the most feasible progressive removal of physical restraints or the most practicable progressive use of less restrictive means to enable the resident to attain or maintain the highest practicable physical, mental or psychosocial well being. The Restraint Program Policy and Procedure with a revised date of 11/10/15 documents, If a restraint is necessary, physician and POA (Power of Attorney) are notified and a Restraint Consent is completed. Reduction attempts are documented. Some examples of interventions may include, but are not limited to: a. Therapy consultation b. Environmental modifications c. Positioning d. Activity programming e. Toileting programming

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement hearing devices and develop a care plan for hearing loss for one (R39) of one resident reviewed for communication in the sample list of 44. Findings include: R39's Minimum Data Set, dated [DATE] documents R39 has minimal difficulty hearing when using hearing aide/device and R39 has moderate cognitive impairment. R39's admission nursing assessment dated [DATE] documents R39 uses left and right hearing aides. R39's Care Plan dated 10/10/24 documents R39 is hard of hearing and only uses one hearing aide to the right ear. There is no documentation that R39's care plan addressed R39's hearing loss and hearing aide use prior to 10/10/24. R39's Concern Form dated 10/15/24 documents R39's family reported R39's left hearing aide has been missing since Sunday (10/13/24) and the right hearing aide was also missing. This form documents the right hearing aide was found on 1016/24, the facility will replace R39's hearing aide, and an appointment has been scheduled on 10/22/24. On 10/20/24 at 9:53 AM attempts were made to interview R39, but R39 had difficulty understanding/hearing questions. On 10/21/24 at 2:24 PM V5 administered R39's medications into R39's gastrostomy tube. V5 spoke to R39 during R39's cares, but R39 did not verbally respond. R39 was not wearing hearing aides. There was a sign on the wall near R39's sink that documented the hearing aide with red lettering goes in the right ear and the aide with blue lettering goes in the left ear. V5 was asked about R39's hearing aides. V5 instructed to check the hearing aide box on R39's sink, which only contained one hearing aide with red lettering. V5 applied R39's hearing aide. R39 was then able to answer questions, and appropriately responded when R39 was asked her name. R39 stated R39's left hearing aide has been missing for over a week and R39 was unsure if there had been any follow up. On 10/22/24 at 9:00 AM V8 Certified Nursing Assistant stated V8 has not been applying R39's hearing aide since she lost the other one last week. V8 stated R39 removes the hearing aides and V8 did not want R39 to lose her other hearing aide. On 10/22/24 at 11:50 AM V2 Director Of Nursing stated staff should be applying R39's hearing aide every day and especially when interacting with R39. V2 stated V2 thought R39 had two hearing aides for the same ear, but not one for each ear. V2 stated one of R39's hearing aides was broken and the family had it repaired. At 12:25 PM V2 stated the facility is going to replace R39's missing left hearing aide. V2 stated the hearing aide facility is not open, so staff will call tomorrow to schedule an appointment. At 12:43 PM V2 confirmed R39 did not have a care plan for R39's hearing loss and devices prior to 10/10/24 and should have.

Based on observation, interview, and record review the facility failed to check and record gastric residual volume to verify gastrostomy tube placement, and administer and record water flushes and enteral feeding amounts for one (R39) of one resident reviewed for gastrostomy tube in the sample of 44. Findings include: On 10/20/24 at 8:58 AM R39 was lying in bed asleep with Osmolite 1.5 Cal (calorie) infusing at 60 milliliters (ml) per hour via gastrostomy tube (g-tube). The mechanical pump also contained a bag of water and was set to infuse 200 ml of water every four hours. On 10/21/24 at 10:27 AM V5 Registered Nurse stated R39's feeding pump is set to administer a certain amount of feeding, and it stops infusing and beeps when it has reached the set amount. V5 stated if the pump is shut off early it is documented, but we don't record the total volume infused. On 10/21/24 at 2:24 PM V5 checked R39's g-tube placement by inserting 20 ml of air via syringe and listening with a stethoscope. V5 dissolved each medication (which were already crushed prior to observation) that was in three separate medication cups, in 5 ml of water and administered these medications into R39's g-tube. V5 did not check gastric residual volume prior to medication administration. V5 used a total of 50 ml of water to flush R39's g-tube before/after medication administration and between each separate medication administered, which was confirmed with V5. V5 stated V5 also used a total of 25 ml to dissolve R39's medications. V5 stated V5 flushes R39's g-tube with water when disconnecting R39's feeding. V5 stated gastric residual should be checked before administering R39's feeding, but V5 does not check residual prior to medication administration since V5 uses the air rush technique. V5 stated there is another resident whose residual checks are recorded on the Medication Administration Record and orders to hold feedings based on residual parameters, but V5 was unsure if this is done for R39. R39's Care Plan dated 1/11/24 documents R39 requires g-tube feeding and includes an intervention to check tube placement and gastric contents/residual volume per the facility's protocol, and record. R39's October 2024 Medication and Treatment Administration Records document to administer Osmolite 1.5 Cal at 60 ml per hour for a daily total of 750 ml and 200 ml water flushes every four hours, and does not document total feeding and water flush amounts administered each day. There are no orders prior to 10/22/24 to routinely check R39's gastric residual, gastric residual volumes, parameters to hold feeding based on gastric residual volumes, and water flushes needed for medication administration. R39's Nutrition Note dated 7/27/2024 at 12:44 PM recorded by V26 Registered Dietitian documents R39's weight as stable, R39 receives Osmolite 1.5 at 60 ml per hour for a daily total of 750 ml and 200 ml water flushes every four hours. This note documents a recommendation to give 100 ml of free water flushes while Osmolite infuses and adjust fluids based on physician recommendations. On 10/22/24 at 10:00 AM V2 Director of Nursing stated the total g-tube feeding volumes are not recorded since the volume is stated in the order. V2 stated the nurses should be checking g-tube placement by checking gastric residual volume, not air rush, prior to feeding administration and medication administration. V2 confirmed this should be documented on the Medication/Treatment Administration Records. On 10/22/24 at 12:25 PM V2 stated there should be water flush orders based on the dietitian's recommendations and V2 expects the nurses to follow the facility's policy for water flushes needed during g-tube medication administration. V2 confirmed the only water flush ordered for R39 is the 200 ml every four hours while R39's feeding infuses. The facility's Medication Administration Via A Feeding Tube policy dated 5/1/05 documents to check the tube for proper placement prior to medication administration, and to flush the feeding tube with 30 ml of water before and after medication administration, dilute medications separately in water, and flush the tube with 5 ml of water between each medication. This policy documents to record the water flush amount infused. The facility's Enteral/Tube Feeding Policy dated 2/26/15 documents the physician will prescribe the water flush amount and frequency which will be noted on the monthly physician's order sheet. This policy documents to document tube placement checks prior to feeding, medication, and water flush administrations. This policy documents to accurately record the amount of feeding and water flushes for each administration. This policy documents to use a syringe to withdraw gastric contents and evaluate the color of the contents, and a residual of 150 ml indicates the need for the feeding to be held unless otherwise ordered by the physician.

Based on observation, interview, and record review the facility failed to label, store, and change oxygen and nebulizer tubing for three (R17, R39, R84) of three residents reviewed for respiratory care in the sample of 44. Findings include: 1.) On 10/20/24 at 9:55 AM R17 was asleep in his room. The undated and uncovered oxygen tubing was on top of R17's bed and connected to the oxygen concentrator. R17's Physician Order dated 9/30/24 documents titrate oxygen via nasal cannula to keep saturation above 90 %. There is no order to routinely change R17's oxygen tubing and there is no documentation in R17's medical record that R17's oxygen tubing is routinely changed. R17's ongoing oxygen saturation log documents R17 used oxygen on 13 days between 9/23/24 and 10/21/24. 2.) On 10/20/24 at 9:00 AM R39's undated and uncovered nebulizer mask and tubing was on R39's night stand and connected to a nebulizer machine which had splatters of a brown substance. R39's October 2024 Medication Administration Record (MAR) documents R39 receives Aformoterol Tartrate 15 micrograms per 2 milliliters (ml) and Budesonide 0.5 milligrams per 2 ml nebulizer inhalation twice daily, and to change nebulizer tubing and mask weekly on Wednesdays. This MAR does not document the nebulizer tubing/mask was changed on 10/16/24 as scheduled. 3.) On 10/20/24 at 9:03 AM R84 was in bed wearing oxygen via nasal cannula at 3 liters per minute. R84's oxygen tubing was dated 10/10/24. R84 stated R84 was unsure how often the oxygen tubing is changed. R84's Treatment Administration Record (TAR) documents to change oxygen tubing weekly on Thursdays and this is signed as being completed on 10/17/24. On 10/20/24 at 2:28 PM-2:40 PM V5 Registered Nurse stated oxygen and nebulizer mask/tubing should be labeled with dates and changed weekly by night shift staff. V5 stated after nebulizer use, the tubing and mask should be cleaned and stored in a plastic bag when not in use. V5 stated oxygen tubing should be stored in a plastic bag when not in use. V5 confirmed R39's nebulizer mask and tubing was unlabeled and uncovered, R17's oxygen tubing was undated and uncovered, and R84's oxygen tubing was dated 10/10/24. The facility's Oxygen Administration policy dated 1/15/24 documents to change nasal cannulas, tubing, and humidifiers weekly and label with the date, and store oxygen cannula or mask in a plastic bag when not in use. The facility's Aerosol Treatments dated August 2009 documents to change nebulizer equipment weekly and as needed, and disassemble the hand held unit, shake dry, and place in a plastic bag.

Based on observation, interview, and record review the facility failed to administer medications timely and according to physician's orders and manufacturer's instructions for four (R17, R61, R42, R4) of seven residents reviewed for medication administration in the sample list of 44. These failures resulted in eight medication errors out of 25 opportunities, a 32% medication error rate. Findings include: 1.) On 10/21/24 at 10:36 AM V5 Registered Nurse (RN) stated V5 is behind on the morning medication pass, and there are still morning medications that need to be given. On 10/21/24 at 10:59 AM V5 stated V5 still has scheduled morning medications that need to be administered. On 10/21/24 at 10:51 AM V5 administered R17's medications which included Lantus insulin 15 units, Macrobid (antibiotic) 100 milligrams (mg), Tylenol 650 mg, and Metoprolol Tartrate (cardiac medication) 25 mg. V5 did not prime the Lantus insulin pen prior to administration. R17's October 2024 Medication Administration Record (MAR) documents to administer Lantus 18 units daily at 8:00 AM starting on 10/9/24, Macrobid 100 mg by mouth twice daily at 8:00 AM and 4:00 PM from 10/20/24-10/23/24, Metoprolol Tartrate 25 mg by mouth twice daily at 8:00 AM and 4:00 PM, and Tylenol 650 mg three times daily at 8:00 AM, 12:00 PM and 4:00 PM. This MAR documents R17's noon dose of Tylenol was not administered on 10/20/24 and 10/21/24. R17's Electronic Medication Administration Detail Reports dated 10/22/24 document on 10/21/24 R17's scheduled 4:00 PM doses of Metoprolol Tartrate and Macrobid were given at 5:20 PM. There is no documentation in R17's nursing notes that R17's physician was notified of the late administration and missed doses of R17's medications. On 10/22/24 at 10:48 AM V2 Director of Nursing stated medication administration has an hour window before and after the scheduled administration time. V2 stated if the medication is given late, the nurse should notify the physician and document in the nursing notes. The Lantus manufacturer's instructions dated August 2022 documents to take this medication at the same time every day and to prime (remove air from the needle) the pen prior to each administration. 2.) On 10/21/24 at 10:59 AM V5 stated there were scheduled morning medications that still needed to be administered. On 10/21/24 at 11:36 AM V5 obtained R61's blood glucose result of 108. V5 administered R61's medications including Humulin N insulin 14 units and Persantine (prevents blood clots) 25 mg. V5 did not prime the insulin pen prior to administration. R61's October 2024 MAR documents to administer Humulin N 14 units twice daily at 8:00 AM and 12 units at 8:00 PM and Persantine 15 mg by mouth twice daily at 8:00 AM and 4:00 PM. R61's Electronic Medication Administration Detail Report dated 10/22/24 documents on 10/21/24 R61's scheduled evening dose of Persantine was given at 5:51 PM. There is no documentation in R61's nursing notes that R61's physician was notified that R61's medications were administered late on 10/21/24. On 10/21/24 at 12:42 PM V5 confirmed V5 did not prime insulin pens prior to administration. V5 stated V5 was unaware that insulin pens needed to be primed prior before each administration. On 10/22/24 at 11:15 AM V2 reviewed R61's MAR and confirmed R61's missed dose of Tylenol on 10/21/24. The Humulin N Kwikpen Instructions for Use dated June 2022 to use 2 units to prime the insulin pen prior to each administration. 3.) On 10/21/24 at 11:30 AM V24 Licensed Practical Nurse obtained R42's blood glucose result of 202 and administered Admelog insulin 18 units. R42 was in bed and there was no food at R42's bedside. On 10/21/24 at 12:07 PM V8 Certified Nursing Assistant delivered R42's meal tray to R42's room and began feeding R42. R42's October 2024 MAR documents R42 receives Admelog 14 units scheduled three times daily and additional units based on sliding scale three times daily. The Admelog Instructions for Use dated August 2023 documents to administer this medication within 15 minutes prior to a meal or immediately after a meal. 4.) On 10/22/24 at 10:34 AM V25 RN administered Brimonidine Tartrate 0.2% on drop into R4's right eye. R4's October 2024 MAR documents to administer Brimonidine Tartrate 0.2% solution one drop to right eye twice daily at 8:00 AM and 5:00 PM. On 10/22/24 at 10:42 AM V25 confirmed R4's Brimonidine administration was the dose scheduled at 8:00 AM. V25 stated V25 was behind in her medication pass and this is a heavy hall. The facility's Medication Administration dated 1/11/10 documents to notify the physician of medication errors and missed doses of medications.

Based on interview and record review the facility failed to develop, implement, measure, act on or analyze a performance improvement program project in the last twelve months. This failure has the potential to affect all 85 residents who reside in the facility. Findings include: The facility provided long term care facility application for Medicare and Medicaid dated 10/20/24 documents 85 residents reside in the facility. The facility provided Quality Assessment Performance Improvement Policy dated 12/8/23 documents that the facility quality program will enable a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in the facility while involving all caregivers in practical and creative problem solving. Additionally, the policy documents that a systematic approach to determine underlying causes of problems, and development of corrective actions that will be designed to effect changes at the facility level to prevent quality of care, quality of life or safety problems and to facilitate and monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained. On 10/22/24 at 11:00AM, V1 Administrator stated that the facility did not have a performance improvement project in place for the last four quarters that included the front line staff or with measures to monitor effectiveness. V1 said that she was still learning and that performance improvement projects would become a part of the quality process for the next year.

Based on interview and record review the facility failed to store, handle, and launder linens that were potentially exposed to scabies. This failure has the potential to affect all 85 residents who reside in the facility. The facility also failed to follow enhanced barrier precautions for two (R4, R39) of six residents reviewed for enhanced barrier precautions from a total sample list of 44 residents. Findings include: 1.) The facility provided undated Scabies/Crusted Norwegian Scabies infection control policy documents that scabies are infectious diseases of the skin. Transmission occurs from brief skin to skin contact with items such as bedding, clothing, furniture, rugs carpeting, floors and other items that can become contaminated with skin scale and crusts shed by a person with Scabies. To avoid reinfestation, bedding and clothing used by residents with scabies would be collected and transported in plastic bag an emptied directly into the washer to avoid contaminating other surfaces and items. Machine wash and dry using the hot water and high heat cycle temps in excess of 122 degrees Fahrenheit for 10 minutes. Laundry staff should use appropriate person protective equipment when handling contaminated items. The facility provided Scabies/Crusted Norwegian Scabies surveillance log dated 9/19/24 documents eight residents (R20, R75, R10, R45, R63, R4, R57 and R2) with a positive case, a suspected case or was a roommate of one of the two. R20 was diagnosed with a positive case on 9/19/24. R10's rash began on 9/19/24. R63's rash began on 9/25/24 and R57's rash began on 9/30/24. No one was tested after R20 was diagnosed positive. All with symptoms and their roommates were treated for Scabies. All eight residents use items from the common laundry. On 10/21/24 at 2:18PM, V4 Infection Preventionist (IP) stated that when R20 came down with scabies in September of 2024, this was the second time that she had done so in two years. V4 IP stated that R20's family member brings clothing and other soft items for R20 and they believe based on investigation that R20's family member is bringing them into the facility. V4 IP stated that because of this, the facility had implemented a process where when V R20's family member brings in any soft items, the items are bagged at the front desk and then taken to laundry where V13 Housekeeping/Laundry Supervisor knows to put them in the isolation laundry, so that they don't go in with other people's clothing. On 10/21/24 at 3:15PM, V13 Housekeeping/Laundry Supervisor stated that she is aware that R20's family member brings items in to the facility for R20, but that she was not aware that R20's items from home are to be bagged, kept separate or washed in the isolation cycle. (R20's) things just go in to the sorting piles and then laundry with everyone else's things. None of my staff know about this. On 10/22/24 at 8:30AM, V4 IP stated that mixing the clothes could cause further infestation and infection. The facility provided Long Term Care Facility Application for Medicare and Medicaid dated 10/20/24 documents 85 residents reside in the facility. 2.) R4's Care Plan dated 1/2/24 documents R4 is on Enhanced Barrier Precautions (EBP) due to wounds and urinary catheter, and includes an intervention to follow the guidelines on the signage posted at R4's doorway. On 10/21/24 at 1:48 PM - 2:03 PM there was a sign posted on the outside of R4's doorway that indicated R4 was on EBP and to wear a gown and gloves for high contact resident care. There were isolation gowns and gloves in a container outside of R4's room. R4 was lying in bed. V16 and V17 Certified Nursing Assistants turned R4 while V5 Registered Nurse administered R4's pressure ulcer treatments. V16 and V17 dressed R4 and transferred R4 from the bed into her wheelchair with a full mechanical lift. V16, V17, and V5 were not wearing gowns during R4's cares. On 10/21/24 at 2:20 PM V16 and V17 confirmed gowns were not worn during R4's observed wound care, dressing and transfers V16 and V17 stated they are aware of EBP and confirmed a gown should have been worn during R4's cares. On 10/21/24 at 3:34 PM V4 Infection Preventionist stated V4 was aware that staff did not follow EBP during R4's cares. V4 confirmed gowns should be worn during high contact care as part of EBP. 3.) On 10/20/24 at 8:58 AM R39 was in bed with Osmolite 1.5 infusing at 60 milliliters per hour via enteral feeding tube. There was an EBP sign posted on R39's doorway and there was a cart containing personal protective equipment outside R39's room. On 10/21/24 at 2:24 PM V5 administered R39's medications into R39's gastrostomy tube. V5 was only wearing gloves and was not wearing a gown during R39's medication administration. R39's Care Plan dated 1/11/24 documents R39 is on EBP due to gastrostomy tube and includes an intervention to follow the barrier precaution guidelines on the signage that is posted at R39's doorway. The facility's Enhanced Barrier Precautions Protocol dated 4/8/24 documents refers to using gown and gloves during high contact resident care activities that provide the opportunity to transfer Multi-Drug Resistant Organisms to staff's hands and clothing. This policy documents dressing, bathing/showering, transferring, hygiene assistance, changing linens, incontinence cares/toileting assistance, feeding tube care, urinary catheter care, and wound care are considered high contact resident care activities that require gown and gloves to be worn.

Based on observation, interview, and record review the facility failed to implement infection control measures to prevent the spread of COVID-19 (Human Coronavirus Infection) by failing to stock isolation carts with N95 masks, ensure isolation signage was posted, and ensure staff discarded personal protective equipment (PPE) upon leaving COVID-19 positive resident rooms. The facility also failed to complete COVID-19 symptom monitoring for residents having COVID-19. These failures affect five (R1, R2, R4, R5, R6) of six residents reviewed for infection control in the sample list of eight. Findings include: The facility's COVID-19 Testing and Response Plan dated 9/1/24 documents monitor for clinical worsening including assessing for symptoms and vital signs for every four hours for COVID-19. This policy documents to discard respirator or mask and a new one should be applied after caring for a COVID-19 positive resident. The facility's General Approaches to Infection Prevention and Control Standard and Transmission-Based Precautions for Communicable Disease policy dated 10/17/22 documents to post isolation signage on the door or wall outside of the residen'ts room and make sure all PPE is readily available. 1.) On 9/19/24 at 9:40 AM and at 11:09 AM R1's room door was open and there was no isolation signage posted on R1's room door or wall. R1 and R5 shared the same room. The PPE cart outside of R1's room did not contain a supply of N95 masks. At 12:46 PM there was no isolation signage posted outside of R1's room. On 9/19/24 at 9:46 AM V5 Certified Nursing Assistant (CNA) was working on R1's unit, the South Pod, wearing an N95 mask. V5 stated R1 is the only COVID-19 positive resident on the unit. On 9/19/24 at 10:24 AM V7 (Housekeeper) was working on R1's unit. V7 stated V7 was unsure which residents on the South Pod were COVID-19 positive and the COVID-19 rooms are identified with contact/droplet isolation signage. On 9/19/24 at 11:23 AM V5 CNA was wearing an N95 mask and donned gown, gloves eye protection to enter R1's room. V5 provided incontinence cares for R1. At 11:30 AM V5 left R1's room and did not change V5's N95 mask. At 11:33 AM V5 confirmed V5 did not change her N95 worn in R1's room and confirmed the PPE cart outside of R1's room did not contain N95 masks. V5 stated V5 was unsure if N95 masks are suppose to be changed when leaving positive resident rooms, and V5 has not been changing her mask when leaving positive resident rooms. V5 stated there should be a supply of N95 masks in the PPE carts if they expect us to change them when leaving the rooms. V5 stated V5 was told in report that R1 tested positive and she was working the day R1 tested positive. V5 stated R1 didn't have an isolation sign posted yesterday and confirmed there is no sign posted today. V5 stated R1 is suppose to have an isolation sign posted and R5's daughter visits frequently who would also need to know of isolation precautions. At 11:39 AM V5 answered R4's call light and then R2's/R6's call light while wearing the same N95 mask worn in R1's room. These rooms were not COVID-19 positive rooms. On 9/19/24 at 12:50 PM V9 (Licensed Practical Nurse) stated R1 is the only COVID-19 positive resident on the unit. V9 stated V9 changes her N95 mask each time she leaves a COVID-19 positive room, but V9 has to leave R1's unit to get a new N95 mask from the South Hall since there isn't a supply of N95 masks in R1's PPE cart. V9 stated vital signs are taken daily for exposed and positive residents. R1's ongoing Diagnosis List documents R1 has diagnoses of Congestive Heart Failure, Emphysema, Atrial Fibrillation, and Type Two Diabetes Mellitus. R1's Nursing Note dated 9/17/2024 at 9:35 AM documents R1 was refusing to eat and had congestion, nasal drainage, and fatigue; R1 was tested and R1 tested positive for COVID-19. There are no documented symptom monitoring or respiratory assessments documented in R1's medical record after this note. R1's Physician Orders dated 9/17/24 document Contact/Droplet Isolation related to COVID-19 and obtain vital signs twice daily for 10 days. There is no documentation that R1's vital signs are monitored every four hours after testing positive. On 9/19/24 at 1: 04 PM V3 Infection Preventionist stated staff should apply gown, gloves, eye protection, and N95 masks when going into COVID-19 positive rooms and all PPE discarded when leaving the room. V3 confirmed isolation PPE carts should contain a supply of N95 masks. V3 stated contact/droplet isolation signs should be posted for COVID-19 positive rooms. V3 stated we are following doctor's orders for vital signs and symptom monitoring to be completed twice daily, and this should be documented in nursing notes, vitals section, or Medication/Treatment Administration Record. At 2:25 PM V3 stated after reviewing the facility's policy, COVID-19 positive residents should have vital signs and symptom monitoring every four hours. V3 confirmed R1's medical record does not document symptom monitoring and vital signs every four hours.

Based on observation, interview and record review the facility failed to assess two of two residents (R47, R58) reviewed for safe self-administration of medication in the sample list of 36. Findings Include: The facility's policy Self-Administration of medications reviewed 12/05 states if the resident wishes to self-medicate, the interdisciplinary team (IDT) must assess the resident's cognitive, physical, and visual abilities. 1.) On 9/12/23 at 9:50AM, R47 was in bed finishing breakfast. There was a pill cup with several pills on the bed side table. R47 dumped the pills in R47's mouth and swallowed them with water. R47 stated the nurse leaves my pills here so I can take them after I eat. On 9/12/23 at 10:00AM V6 (Registered Nurse/RN) stated I left (R47's) medication so (R47) could take it after (R47) was finished eating. I thought I could just keep an eye on (R47) from the hall. At the time R47 was observed taking (R47's) medication, V6 was at the nurse's station where she had no view of (R47). On 9/11/23 V2 (Director of Nursing/DON) stated (R47) is not on a self-medication program. It would be my expectation that the nurse administering (R47's) medication should observe (R47) taking all medications. 2.) On 9/12/23 at 8:00 AM, there was a bottle of menthol topical analgesic with a pump applicator sitting on the bedside stand in R58's room and R58 was sitting in R58's wheelchair next to the bedside stand. R58's Physician's Order dated 7/9/23 documents an order for menthol gel 4 % (percent) topical analgesic and apply to affected area topically every 12 hours as needed for pain. R58's medical record did not contain a self-administration of medication assessment. On 9/13/23 at 11:42 AM, V2 (DON) confirmed there was no order for R58 to keep the menthol gel at the bedside. V2 confirmed there was no self-administration of medication assessment. V2 stated there should be an assessment if the medication is kept in the room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to complete pressure ulcer risk assessments, routinely assess pressure ulcers, update a care plan to include a pressure ulcer and new pressure relieving interventions, and ensure a pressure ulcer was covered with a dressing for resident's wounds. This failure affects three of seven residents (R61, R10, R77) reviewed for pressure ulcers in the sample list of 36. Findings include: The facility's Wound and Ulcer Policy and Procedure revised 1/10/18 documents the Braden Scale will be used to determine the resident's risk for developing pressure ulcers and preventative measures may include addressing pressure, moisture, friction, and shearing. This policy documents Braden Assessments are completed upon admission, then weekly for four weeks, and then monthly thereafter. This policy documents residents who are at moderate and high risk will have care planned approaches, wounds assessments will be documented in the resident's medical record at least weekly and notify the physician of changes in the wound. This policy documents a pressure ulcer is a skin injury usually over a bony prominence and a result of pressure or a combination of pressure and shear. Unstageable pressure ulcers have full thickness tissue loss, the depth is unable to be determined due to being covered by slough or eschar, and treatment includes applying a topical debridement treatment daily. 1.) On 9/12/23 at 9:43 AM V21 (Certified Nursing Assistant/CNA) and V20 (Licensed Practical Nurse/LPN) entered R61's room to administer R61's wound treatment. R61 was lying in bed and R61 had a T shaped open wound to the coccyx/right buttock. The wound contained yellow tissue (slough) and two pinpoint black areas (eschar), and surrounding skin was red/pink. The wound was not covered with a dressing. V20 and V21 stated R61 did not have a dressing covering R61's wound when R61 was laid down, and night shift had last gotten R61 up earlier that morning. V20 stated V3 (Infection Preventionist/Wound Nurse) obtains the wound measurements/assessments. V20 stated there used to be two wounds, and V20 confirmed the wounds have now joined as one. V20 measured the wound upon request and stated there are two areas that are 0.2 centimeters (cm) deep, and the wound measured 3 cm long by 3 cm wide. V20 cleansed the wound, applied a skin protectant wipe, and covered with a hydrocolloid dressing. The facility's Pressure Ulcer Log dated 9/6/23 does not include R61's pressure ulcer. R61's Daily Skin Observations document an open area from 8/17/23-9/11/23, and indicates the wound is new on 8/17/23. R61's Minimum Data Set (MDS) dated [DATE] documents R61 has severe cognitive impairment, requires extensive assistance of two staff for bed mobility, and is dependent on two staff for transfers and toileting. This MDS documents R61 is always incontinent of bowel and bladder, has moisture associated skin damage (MASD), and receives hospice care. R61's Care Plan dated 1/21/23 documents R61 has two open areas on buttocks and is at increased risk for skin impairment. Interventions include documenting wound assessments weekly, but there are no new interventions listed after 1/21/23. R61's Physician Order dated 8/17/23 documents a Gluteal Cleft wound treatment to cleanse the wound, apply skin protectant, and cover with a hydrocolloid dressing every 3 days and as needed if dressing is soiled or dislodged. R61's Physician Order dated 5/25/22 documents to complete a Braden Assessment every 30 days. The last documented Braden Assessment in R61's medical record was on 7/19/23. R61's Wound/Ulcer Documentation dated 8/17/23 documents R61 has two facility acquired gluteal cleft wounds that measure 0.4 cm long by 0.8 cm wide by 0.1 cm deep and 0.5 cm by 0.6 cm by 0.1 cm. The wounds were macerated and red. There are no documented wound assessments after 8/17/23 in R61's medical record. On 9/12/23 at 9:43 AM V21 (CNA) stated R61 has had the wound for about 3-4 weeks. On 9/12/23 at 10:00 AM V20 (LPN) stated the wound was initially due to shearing and there was a barrier cream treatment in place prior to the hydrocolloid treatment. On 9/12/23 at 10:02 AM V3 stated R61's wound was last assessed by V3 on 8/17/23 and was considered MASD at that time. V3 stated V3 has not assessed R61's wound weekly since V3 did not consider the wound to be a pressure ulcer. V3 stated non-pressure wounds are to be assessed weekly by the floor nurse and wound assessments are documented under assessments in the resident's electronic medical record. V3 confirmed R61 does not have any documented wound assessments after 8/17/23. V3 confirmed R61's current treatment is hydrocolloid dressing applied/changed every three days and the wound should be covered with a dressing. V3 stated R61 previously had an air mattress, but it was discontinued when R61's prior wounds healed. V19 (Care Plan Coordinator) confirmed R61's care plan has not been updated since January 2023 to reflect R61's buttock wound and any new interventions. On 9/12/23 at 11:55 AM V19 stated V19 completed R61's Braden Assessment today. V19 confirmed Braden Assessments are ordered to be done monthly and R61 did not have a Braden Assessment after July 2023. V19 stated V19 just assessed R61's pressure ulcer, it is unstageable due to eschar and slough, and V19 obtained new treatment orders. On 9/13/23 at 8:45 AM V1 (Administrator) stated R61's wound should have been reported to V3 and then reviewed weekly. V1 stated V3 misunderstood V1 and V3 thought V3 was only to focus on pressure ulcers, rather than all wounds. 3.) R10's Care Plan updated 7/27/23 includes the following diagnoses Congestive Heart Failure Heart Disease, Peripheral Vascular Disease, Stage III Chronic Kidney Disease, and Cerebral Vascular Disease. R10's Minimum Data Set (MDS) dated [DATE] documents R10 is severely cognitively impaired, unable to walk, and requires extensive staff assistance of two or more staff to transfer. R10's Ulcer/Wound documentation dated 6/21/23 documents R10 developed a facility acquired Stage II pressure ulcer on the right gluteal fold measuring 1.4 centimeters by 1.3 centimeters by 0.2 centimeters deep with no necrosis or pain to the wound site. R10's Ulcer/Wound documentation dated 8/30/23 documents R10 continues to have the same pressure ulcer on the right gluteal fold now measuring 4 centimeters by 2.2 centimeters by 0.2 centimeters deep with no necrosis or pain to the wound site. R10's Ulcer/Wound documentation dated 8/30/23 documents R10 developed a second facility acquired Stage II pressure ulcer on the left gluteal fold measuring 3.0 centimeters by 1.9 centimeters by 0.1 centimeters deep with no necrosis or pain to the wound site. R10's Ulcer/Wound documentation dated 9/6/23 documents R10 continues to have the same pressure ulcer on the right gluteal fold now measuring 4.1 centimeters by 3.5 centimeters by 0.1 centimeters deep with 100% necrosis and pain to the wound site. R10's Ulcer/Wound documentation dated 9/6/23 documents R10 continues to have a second facility acquired Stage II pressure ulcer on the left gluteal fold measuring 2.6 centimeters by 1.3 centimeters by 0.1 centimeters deep with no necrosis or pain to the wound site. On 9/13/23 at 1:35PM V3 (Licensed Practical Nurse/Wound Nurse) performed wound care for (R10). The two pressure ulcers were cleansed with wound cleanser, patted dry, skin prep applied to the peri wound, calcium alginate to the wound bed, and covered with foam border dressing. Wound measurements were not obtained. The left gluteal wound appears unchanged from the 9/9/23 assessment. The right gluteal wound appears unchanged from the 9/6/23 assessment. (R10) cried out in pain during the treatment and stated, you are trying to kill me. The left wound has a foul odor. V3 stated this left wound is getting worse. It didn't have this odor before now. R10 was in bed lying on a plastic air mattress. The mattress was inflated with very little air. R10's body weight compressed the overlay on itself. V29 (Registered Nurse) stated The air mattress definitely needs to be inflated to be effective. V24 (Nurse Practitioner) stated This wound stays moist from incontinence. Should we consider a (indwelling urinary catheter). V3 replied we can only have catheters in the nursing home for very specific reasons. V24 stated I think wound healing is a valid reason. V3 replied we can check with the family. 2.) R77's Treatment Administration Record (TAR) dated 9/12/23 documents diagnoses that includes Diabetes Mellitus with Diabetic Neuropathy, Restless Legs Syndrome and Muscle Wasting with Atrophy. This TAR documents a treatment order dated 8/10/23 for the Left Heel to clean with soap and water or wound cleanser, apply calcium alginate to the wound bed, cover with a bordered foam dressing and change daily and PRN (as needed) if soiled or dislodged. R77's Ulcer/Wound Documentation dated 8/8/23 documents the wound was initially identified on 8/8/23 and measured 3 cm (centimeters) x (by) 2 cm and documents it as an abrasion. There are no other wound assessments for this wound in R77's medical record. On 9/13/23 at 8:48 AM, V2 (Director of Nursing) confirmed there are no other wound assessments for the left heel besides the one dated 8/8/23. On 9/13/23 at 1:50 PM, R77 was in R77's room in R77's recliner. V19 (Care Plan Coordinator) stated t R77's left heel wound started as a blister from a pair of shoes and then opened. V19 stated V19 does not know why it is documented as an abrasion. V19 confirmed that no one has been measuring or assessing this wound due to miscommunication. The wound was clean and appeared to be healing.

Based on interview and record review the facility failed to complete fall investigations, develop, and implement fall interventions for one of three residents (R77) reviewed for falls in the sample list of 36. Findings include: The facility's Fall Assessment and Management Policy with a revised date of April 2019 documents, Interventions will be based on the fall risk assessment and the circumstances surrounding the risk for injury or actual injury of fall. R77's Care Plan documents diagnoses including Restless Legs Syndrome, Insomnia, Obstructive Sleep Apnea, Dizziness and Giddiness, Muscle Wasting and Atrophy and Muscle Weakness. The Care Plan dated 5/17/23 documents R77 is at high risk for falls and has had actual falls r/t (related to) Confusion, Incontinence, Psychoactive Drug Use and unaware of safety. This Care Plan documents R77 had falls on 5/16/23, 6/5/2023, 6/11/2023, 6/16/2023, 7/17/2023, 7/23/2023, 8/19/2023, 8/24/2023, 9/6/2023 and 9/10/2023. There is no investigation for the fall on 6/16/23 and the investigation for the 9/6/23 fall is incomplete. On 9/12/23 at 2:52 PM, V2 (Director of Nursing) confirmed that there is no investigation for the fall on 6/16/23 and confirmed the investigation for the 9/6/23 fall is not complete at this time. R77's Care Plan does not document any fall interventions for the 6/11/23 fall and for the 6/16/23 fall. On 9/13/23 at 8:48 AM, V2 stated that the fall interventions should be on the Care Plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to secure R24's catheter and failed to provide R24 with hygienic perineal care during catheter care and failed to prevent R77's catheter from dragging on the floor for two of two (R24, R77) residents reviewed for catheter care and urinary tract infections from a total sample list of 36. Findings include: 1.) The facility provided Catheter Care/Incontinent Care Policy dated 8/1/2005 documents that after giving pericare (perineal care) and before starting catheter care, make sure and wash hands and obtain new supplies. If the resident is incontinent of bowels, rectal care may be given before performing incontinent or catheter care. Make sure to obtain new supplies and wash your hands. Catheter care is given every shift by the CNA (Certified Nursing Assistant) trained in the procedure. Cleanse downward from top to bottom giving care to cleanse the catheter when applicable. Incontinent care will be given with each episode of incontinence. R24's physician order dated 8/24/23 documents to keep indwelling urinary catheter in place for Neuromuscular Dysfunction of the Bladder. R24's physician order dated 8/20/23 documents to perform urinary catheter care twice daily. R24's physician order dated 8/15/23 documents Hiprex (Urinary Anti-Infective) one gram for urinary tract infections. R24's Minimum Data Set, dated [DATE] documents R24 as cognitively intact. R24's Minimum Data Set, dated [DATE] documents that R24 requires a two assist for toileting and documents that R24 is always incontinent. On 9/12/23 at 1:10PM, V12 and V13 Certified Nursing Assistants (CNAs) assisted R24 onto the bed using a mechanical lift. V12 CNA performed indwelling urinary catheter care without the catheter being secured by a leg strap or any other means. V12 CNA said that the catheter should be secured. V12 then, without securing the catheter or providing perineal care, placed the same brief on R24 that R24 had been wearing before the catheter care. When asked to see R24's boney prominence on R24's back, dried feces was stuck from the anus up to the top of the gluteal cleft. V12 CNA had to scrub R24's skin to get the stuck on feces off of R24's skin. V12 CNA used a towel and rubbed downward from the gluteal cleft, toward the catheter. On 9/11/23 at 2:40PM, R24 said that R24 has frequent urinary tract infections that have led R24 to the hospital in the recent past. On 9/12/23 at 1:20PM V14 CNA said that they are supposed to do perineal care whenever they do catheter care and wipe front to back. On 9/12/23 at 1:30 PM V2 Director of Nursing stated, I would expect perineal care done anytime catheter care is done.2.) R77's Physician's Orders document an order dated 7/27/23 for an indwelling (urinary) catheter. 18FR (French) 10ml (milliliter), change every 3-4 weeks. May irrigate 2-3 times as needed a week to prevent clogging. Dx: (Diagnosis) Severe Trabeculation and Retention, every night shift every 28 day(s) for Urinary Retention. R77's Care Plan dated 7/30/22 documents R77 uses an (indwelling urinary) catheter r/t Neurogenic Bladder Secondary to Cerebral Ataxia, Functional Quadriplegia and Severe Peripheral Neuropathy. On 9/13/23 at 10:59 AM, R77 was in R77's room in R77's wheelchair and the indwelling urinary catheter collection bag was dragging on the floor under the wheelchair. On 9/13/23 at 11:42 AM, R77 was in the dining room and the indwelling urinary catheter collection bag was dragging on the floor. On 9/13/23 at 11:45 AM, V2 Director of Nursing confirmed that the indwelling urinary catheter collection bag should not be dragging on the floor.

Based on observation, interview, and record review the facility failed to maintain a gastrostomy (G-tube) site in a clean sanitary manner for one resident (R38) of one resident reviewed for gastrostomy tubes in a sample list of 36. Findings Include: The facility's policy Enteral/ Tube Feeding Policy dated 2/26/15 states Routine care such as cleansing the healed insertion site and provision of oral hygiene may be performed by non-licensed staff under the supervision of licensed staff following facility procedure. This policy also states, To discourage the transmission of infection, residents receiving tube feedings will receive daily hygiene and skin care to site utilized for feeding. R38's Current physician's orders includes an order to Monitor stoma for cleanliness. Clean as needed. Resident (requires) two caregivers for cleaning care, make sure to talk (R38) through care and reassure (R38) that it will not hurt every day shift related to Dysphagia. On 9/11/23 at 11:57 AM R38's feeding tube disc was caked with crusty brown secretions. R38 was lying flat in bed. R38's lower teeth were covered with foul smelling dark thick matter. V7 (Certified Nurse Assistant/CNA) and V8 (CNA) were providing incontinence care for R38. Neither V7 or V8 offered or attempted to provide care to the G-tube site or oral care for R38. On 9/13/23 at 10:00AM V2 (Director of Nursing) stated My expectation would be (R38's) G-tube site would be kept clean and sanitary at all times and R38 should receive oral care at least once a shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to timely administer pneumococcal vaccines to ensure residents are up to date with pneumococcal vaccinations for five (R52, R12, R44, R64, R45) of seven residents reviewed for immunizations in the sample list of 36. Findings include: The facility's Pneumococcal Pneumonia Vaccination Policy dated April 2022 documents incidents of pneumococcal pneumonia will be reduced by administering pneumonia vaccines to residents who are at high risk or [AGE] years old or older and refers to the Pneumococcal Vaccination in Adults algorithm for the time frames of dose administration. The algorithm documents that pneumococcal vaccination is recommended for anyone over the age of 65. If the patient has no prior pneumococcal vaccination, then administer Prevnar20 or Vaxneuvance. If the patient previously had Pneumovax23 without Prevnar13, then administer Prevnar20 or Vaxneuvance. If the patient previously had Prevnar13 with/without Pneumovax23, then Prevnar20 or Vaxneuvance are not recommended. 1.) R52's Diagnoses List dated 9/12/23 documents R52 is over [AGE] years old and has Emphysema, Congestive Heart Failure, and Type 2 Diabetes Mellitus. R52's Vaccination Consent dated 6/5/23 documents consent to Pneumococcal vaccinations. R52's Immunization Record documents lists Pneumococcal polysaccharide vaccine (PPSV23) given on 1/1/2010 as the only documented pneumococcal vaccine administered prior to 9/12/23. Prevnar20 was not administered until 9/12/23. 2.) R12's Diagnoses List dated 9/12/23 documents R12 is over [AGE] years old and has Type 2 Diabetes Mellitus and Atherosclerotic Heart Disease. R12's Vaccination Consent dated 10/3/22 documents consent to Pneumococcal vaccinations. R12's Immunization Record documents PPSV23 given on 3/26/2007 as the only documented pneumococcal vaccine administered prior to 9/12/23. Prevnar20 was not administered until 9/12/23. 3.) R44's Diagnoses List dated 9/12/23 documents R44 is over [AGE] years old and has Alzheimer's Disease and a history of COVID-19. R44's Vaccination Consent dated 10/10/22 documents consent to Pneumococcal vaccinations. R44's Immunization Record documents PPSV23 given on 11/17/2021 as the only documented pneumococcal vaccine administered. 4.) R64's Diagnoses List dated 9/12/23 documents R64 is over [AGE] years old and has Type 2 Diabetes Mellitus and a history of COVID-19. R64's Vaccination Consent dated 10/2/22 documents consent to Pneumococcal vaccinations. R64's Immunization Record does not document R64 received any Pneumococcal vaccinations prior to 9/12/23 when Prevnar20 was administered. 5.) R45's Diagnoses List dated 9/12/23 documents R45 is over [AGE] years old and has Dementia and history of COVID-19. R45's Vaccination Consent dated 5/10/23 documents consent to Pneumococcal vaccinations. R45's Immunization Record does not document R45 has received any Pneumococcal Vaccinations. On 9/11/23 at 4:04 PM V3 (Infection Preventionist/IP) stated V3 took over as IP on 5/1/23, and V3 was not aware that V3 was supposed to be overseeing resident vaccinations until a few weeks ago, and the IP is responsible for following up on vaccination administration after consent is obtained. V3 stated V3 just started auditing resident Pneumococcal vaccinations within the last couple of weeks. V3 stated V3 is going to administer the Pneumococcal vaccines today. V3 provided a copy of the Prevnar20 Vaccine list. V3 confirmed residents listed were not up to date with Pneumococcal vaccines, have consents on file, and the Prevnar20 vaccine had not yet been administered. The facility's undated Prevnar20 Vaccine list includes R52, R12, R44, R64, and R45.

Based on interview and record review the facility failed to ensure quarterly Quality Assurance (QA) meetings included all required committee members. This failure affects all 81 residents residing in the facility. Findings include: The facility's Quality Assurance Performance Improvement (QAPI) policy dated as reviewed 3/30/23 documents the QAPI program will use a systematic approach to identify underlying causes of problems, develop corrective actions to create changes in order to prevent quality of care, quality of life and safety problems, and monitor the effectiveness of these changes. The QA meetings will be held at least quarterly and lists the Medical Director/Designee, Administrator, Director of Nursing (DON), Infection Prevention & Control Officer, Consulting Pharmacist, Minimum Data Set/Care Plan Coordinator/Restorative Nurse, Business Office Manager, Social Services Director, Activity Director, Certified Dietary Manager, Environmental Services Director, and Housekeeping/Laundry Supervisor as committee members. The facility's QA Quarterly Meeting sign in sheet dated 8/10/23 documents the months of April 2023-June 2023 were reviewed. The following committee members were present Administrator, Medical Director, DON, Infection Preventionist, and Regional Nurse Consultant. There are no other documented members in attendance. The facility's QA Quarterly Meeting sign in sheet dated 5/16/23 documents the months of January 2023-March 2023 were reviewed. The following committee members were present Administrator, Medical Director, Infection Preventionist, Consultant Pharmacist, and Student Pharmacist. There is no documentation that a DON or other members were in attendance. On 9/12/23 at 12:41 PM V1 (Administrator) reviewed the facility's sign in sheets for QA meetings and confirmed the meetings on 5/16/23 and 8/10/23 did not include all of the required members. V1 stated the facility did not have a DON at the time of the 5/16/23 meeting. The Resident Census and Conditions of Residents dated 9/11/23 documents 81 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to operationalize their abuse prevention policy by reporting failures and delay in investigation of alleged resident abuse. These failure affects (R1,) residing on the facility's Hall out of a sample list of 36. Findings include: The facility's Abuse Prohibition policy dated 3/15/18 documents, A facility employee or agent or covered individual who becomes aware of alleged abuse or neglect shall immediately report the matter to the Administrator. If the incident involves alleged abuse, neglect, or incident (sic, injury) of unknown origin, the incident will immediately be reported to the Administrator and the Administrator will provide the Illinois Department of Public Health (IDPH) with initial notice of the alleged abuse, neglect, or incident (sic, injury) of unknown origin by telefaxing to the Department a copy of a report of the incident completed immediately after the incident becomes known. Each covered individual/ facility Administrator shall report immediately but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. (Develop policy, requirements under CFR 42 Part 483.12(c)(1), F609, are to report within 2 hours if the events that cause the allegation involve abuse or serious bodily injury, or not more than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.) Employees or agents shall identify and report all incidents or allegations involving resident abuse, including physical, mental, and verbal, neglect, misappropriation of resident property, resident bruises and injuries of unknown origin, or use of involuntary seclusion immediately to the Administrator. After an initial report of suspected abuse or neglect is sent to IDPH, the Administrator or designee shall investigate all alleged incidents of abuse or neglect. When an allegation of suspected abuse is received that an employee of a long-term care facility is the perpetrator of the abuse, that employee shall be immediately barred from any further contact with residents of the facility, pending the outcome of any further investigation, prosecution, or disciplinary action against the employee. If the incident involves alleged abuse by an employee as the perpetrator of the abuse, then the Administrator shall immediately suspend the employee suspected to be involved with the alleged abuse without pay pending investigation of the incident. If an employee is the suspected perpetrator of the abuse, then the employee shall be kept separate from all residents until further orders. The suspected employee should be sent to an office or lounge away from all residents to await further instructions. On 7/18/23 at 8:10 am, V1, Administrator, stated, I have not had any recent reports or allegations of abuse. On 7/18/23 at 9:35 am, V4, Certified Nursing Assistant (CNA), stated, I worked the whole week around of the fourth of July. I did not witness anything but I did hear from one of the CNAs that one of the nurses had smacked at (R1's) hand. On 7/18/23 at 9:53 am, V10, CNA, stated, I did witness an incident between (V3, Registered Nurse) and (R1). I did report it to (V1, Administrator) by phone right when it happened on 7/5/23. I was told to write a report and put it under (V1's) door, and I wrote the report and put it under (V1's) door. On 7/18/23 at 11:35 am, V1, Administrator, stated, I did not receive any report or allegation about this incident until today, just now. My nurse manager (unidentified) came to me and said that (V10) mentioned about this incident between (V3) and (R1). My nurse manager asked me if I knew about it. I didn't know until today. V1 further stated, So I did just report to IDPH today and begin an investigation today and called the nurse (V3, Registered Nurse) today to suspend her. No one had reported anything about it to me and no one put any written statements under my door. V1 further stated, If any of my staff become aware of an allegation, even if it just hearsay, they should come to me and tell me what they heard and see if I am aware of it. On 7/18/23 at 3:05 pm, V10, CNA, stated, I definitely did write a statement and put it under (V1's) door. There were 2 nurses (V5 Licensed Practical Nurse, and V12 Registered Nurse) who at least saw me writing the statement. On 7/18/23 at 3:10 pm, V12, Registered Nurse, stated, I heard about the allegation that (V3, Registered Nurse) had smacked the hand of (R1). I was here at nursing station when (V10 and V13, CNAs) came and said what they had witnessed in the dining room. They said they came to the nursing station because (V3) was working on the other Hall. That was on 7/5/23. I said they needed to report that to (V1, Administrator). I did not report it to anyone because I didn't witness it, so I thought they should report it. V12 further stated, I did not personally witness (V10, CNA) writing a statement. On 7/18/23 at 3:20 pm, V5, Licensed Practical Nurse, stated, I usually work the this hall but that day (7/5/23) I was assigned to a different hall. I was at the nurses station when (V10 and V13, CNAs) came and said they had seen (V3, Registered Nurse) hit (R1). I told them they needed to report it to (V1, Administrator). I did see (V10) on the phone after that. (V10) also came and asked me for a piece of paper from the copier, and I did see (V10) writing on that paper. I couldn't swear about what (V10) wrote or what (V10) did with the paper after that, or who (V10) was talking to on the phone. V5 further stated, I did not report the incident to anyone because (V10 and V13) witnessed it and I thought (V10 and V13) should report it. On 7/18/23 at 3:45 pm, V10, CNA, voluntarily displayed her phone record. Between the text message record and the phone billing record, there was an outgoing call from V10's phone on 7/5/23 at 5:46 pm. V10 stated, This is when I first called (V1) but (V1) didn't answer so I sent this text. There was an outgoing text message on V10's phone on 7/5/23 at 5:48 pm documented as, Hey (V1's name) this is (V10's name). I need to report something to you that I witnessed. Call me back at your earliest convenience. There was an incoming phone call at 5:52 pm from ( same number as the outgoing call). V10 stated, This is when (V1) called me back and told me to write a statement and put it under her door. On 7/18/23 at 3:55 pm, V1, Administrator, stated, I did not receive any messages from any staff about this incident. I didn't get any phone calls or text messages, and no one put any report under my door. I don't know who (V10) spoke to but it wasn't me. V1 then stated, . The number matched the number on V10's phone displayed as the outgoing and incoming calls. V1 continued to state, None of the employees reported this to me, and it's not about (V10). (V13, Certified Nursing Assistant) was allegedly a second witness to the incident and didn't report it. V1 also acknowledged another CNA (V4) and 2 nurses (V5 and V12) who became aware of the allegation and also did not report it, by stating, Like I said earlier, any staff who even hear about an allegation of abuse should come to me and tell me what they heard to see if I am aware of it. V1 acknowledged reporting is a concern because (V3) worked 6 days and the investigation didn't begin until today. V3, Registered Nurse, and V13, Certified Nursing Assistant, were not available for an interview. V4's, Training Hours record dated 7/18/23 documents V4, CNA, received training for the facility's Abuse Policy on 4/5/23, and Preventing, Recognizing, and Reporting Abuse on 1/19/23. V5's Training Hours record dated 7/18/23 documents V5, Licensed Practical Nurse, received training on the facility's Abuse Policy on 5/17/23. V12's Training Hours record dated 7/18/23 documents V12, Registered Nurse, received training on the facility's Abuse Policy on 5/13/23, and for Preventing, Recognizing, and Reporting Abuse on 1/20/23. V13's Agency Staff Orientation dated 10/5/22 documents V13, CNA, by V13's signature, that V13 received training in the facility's orientation binder and employee handbook. V13's New Agency Employee Orientation Checklist dated 10/4/22 documents V13 received orientation for the facility's Abuse Policy. The facility's Daily Staffing Schedules document V3, Registered Nurse, worked the first shift from 6:00 am until 6:00 pm on the facility's South Hall on 7/5/23, 7/6/23, 7/12/23, 7/13/23, 7/15/23, and 7/16/23. The facility's Form 802 Resident Matrix dated 7/18/23, and the facility's Resident Roster (undated), documents R1, R2, and R4 through R36 reside on the facility's South Hall.

Based on interview, and record review, the facility failed to report an allegation involving abuse to the facility administrator and the Illinois Department of Public Health within the required 2 hour timeframe. This failure affects one resident (R1) out of 3 reviewed for abuse allegations on the sample list of 36. Findings include: On 7/18/23 at 9:53 am, V10, CNA, stated, I did witness an incident between (V3, Registered Nurse) and (R1). I did report it to (V1, Administrator) by phone right when it happened on 7/5/23. I was told to write a report and put it under (V1's) door, and I wrote the report and put it under (V1's) door. On 7/18/23 at 11:35 am, V1, Administrator, stated, I did not receive any report or allegation about this incident until today, just now. My nurse manager (unidentified) came to me and said that (V10) had just talked to (surveyor) and mentioned about this incident between (V3) and (R1). My nurse manager asked me if I knew about it. I didn't know until today. V1 further stated, So I did just report to IDPH today and begin an investigation today and called the nurse (V3, Registered Nurse) today to suspend her. No one had reported anything about it to me and no one put any written statements under my door. V1 further stated, If any of my staff become aware of an allegation, even if it just hearsay, they should come to me and tell me what they heard and see if I am aware of it. On 7/18/23 at 9:35 am, V4, Certified Nursing Assistant (CNA), stated, I did hear from one of the CNAs that one of the nurses had smacked at (R1's) hand. There was no report from V4 regarding the incident on 7/5/23. On 7/18/23 at 3:10 pm, V12, Registered Nurse, stated, I heard about the allegation that (V3, Registered Nurse) had smacked the hand of (R1). I was here at the nursing station when (V10 and V13, CNAs) came and said what they had witnessed in the dining room. They said they came to the nursing station because (V3) was working. That was on 7/5/23. I said they needed to report that to (V1, Administrator). I did not report it to anyone because I didn't witness it, so I thought they (V10 and V13) should report it. V12 further stated, I did not personally witness (V10, CNA) writing a statement. On 7/18/23 at 3:20 pm, V5, Licensed Practical Nurse, stated, I usually work the this hall but that day (7/5/23) I was assigned to the different hall. I was at the nurses station when (V10 and V13, CNAs) came and said they had seen (V3, Registered Nurse) hit (R1). I told them they needed to report it to (V1, Administrator). I did see (V10) on the phone after that. (V10) also came and asked me for a piece of paper from the copier, and I did see (V10) writing on that paper. I couldn't swear about what (V10) wrote or what (V10) did with the paper after that, or who (V10) was talking to on the phone. V5 further stated, I did not report the incident to anyone because (V10) witnessed it and I thought (V10) should report it. The facility's Abuse Prohibition policy dated 3/15/18 documents, A facility employee or agent or covered individual who becomes aware of alleged abuse or neglect shall immediately report the matter to the Administrator. If the incident involves alleged abuse, neglect, or incident (sic, injury) of unknown origin, the incident will immediately be reported to the Administrator and the Administrator will provide the Illinois Department of Public Health (IDPH) with initial notice of the alleged abuse, neglect, or incident (sic, injury) of unknown origin by telefaxing to the Department a copy of a report of the incident completed immediately after the incident becomes known. Each covered individual/ facility Administrator shall report immediately but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury.

Based on observation, interview, and record review, the facility failed to take measures to prevent the potential for further abuse or mistreatment of residents by not initiating an investigation of an allegation of abuse nor restricting access of an alleged perpetrator to residents. This failure has affected (R1,) residing on the facility's hall on a sample list of 36. Findings include: On 7/18/23 at 9:53 am, V10, CNA, stated, I did witness an incident between (V3, Registered Nurse) and (R1). I did report it to (V1, Administrator) by phone right when it happened on 7/5/23. I was told to write a report and put it under (V1's) door, and I wrote the report and put it under (V1's) door. On 7/18/23 at 11:35 am, V1, Administrator, stated, I did not receive any report or allegation about this incident until today, just now. My nurse manager (unidentified) came to me and said that (V10) mentioned about this incident between (V3) and (R1). My nurse manager asked me if I knew about it. I didn't know until today. V1 further stated, So I did just report to IDPH today and begin an investigation today and called the nurse (V3, Registered Nurse) today to suspend her. No one had reported anything about it to me and no one put any written statements under my door. V1 further stated, If any of my staff become aware of an allegation, even if it just hearsay, they should come to me and tell me what they heard and see if I am aware of it. On 7/18/23 at 3:45 pm, V10, CNA, voluntarily displayed her phone record. Between the text message record and the phone billing record, there was an outgoing call from V10's phone on 7/5/23 at 5:46 pm. V10 stated, This is when I first called (V1) but (V1) didn't answer so I sent this text. There was an outgoing text message on V10's phone on 7/5/23 at 5:48 pm documented as, Hey (V1's name) this is (V10's name). I need to report something to you that I witnessed. Call me back at your earliest convenience. There was an incoming phone call at 5:52 pm . V10 stated, This is when (V1) called me back and told me to write a statement and put it under her door. On 7/18/23 at 3:55 pm, V1, Administrator, stated, The number matched the number on V10's phone displayed as the outgoing and incoming calls. V1 acknowledged reporting is a concern because (V3) worked 6 days and the investigation didn't begin until today. The facility's Daily Staffing Schedules document V3, Registered Nurse, worked the first shift from 6:00 am until 6:00 pm on the facility's hall on 7/5/23, 7/6/23, 7/12/23, 7/13/23, 7/15/23, and 7/16/23. The facility's Form 802 Resident Matrix dated 7/18/23, and the facility's Resident Roster (undated), documents R1, R2, and R4 through R36 reside on the facility's hall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to conduct resident and staff COVID-19 (Human Coronavirus) testing during an outbreak. This failure has the potential to affect 17 (R1, R3, R4, R5, R29, R30, R31, R32, R33, R34, R35, R36, R37, R38, R39) of 49 residents reviewed for COVID-19 in the sample list of 53. Findings include: The facility's COVID-19 Testing and Response Plan revised on 11/21/22 documents: The facility will conduct COVID-19 testing of staff and residents every 3 to 7 days during an outbreak until 14 days has passed with no new positives. Testing is recommended at admission, and if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 0, day 3, and day 5. The facility's COVID-19 Monitoring Logs dated 12/6/22-12/19/22 document the facility's COVID-19 outbreak began on 12/6/22. 1.) There is no documentation in R3's medical record that R3 was tested at least weekly for COVID-19 between 12/6/22 and 12/21/22. R3's Nursing Notes document on 12/11/22 R3 was transferred to another room due to R3's room mate (R28) testing positive for COVID-19. 2.) R4's Census dated 12/27/22 documents R4 admitted to the facility on [DATE]. R4's nursing notes document R4 tested negative for COVID-19 on 12/10/22, and R4 tested positive for COVID-19 on 12/19/22. There is no documentation that R4 was tested for COVID-19 after 12/10/22 until testing positive on 12/19/22. 3.) R5's Census dated 12/27/22 documents R5 readmitted to the facility on [DATE]. There is no documentation in R5's medical record that R5 was tested for COVID-19 prior to 12/22/22. 4.) V25 Certified Nursing Assistant's (CNA) COVID-19 tests were requested. V1 Administrator provided the facility's COVID-19 testing logs on 12/22/22. These logs document that V25 had symptoms of body aches and tested negative for COVID-19 on 12/11/22, and tested positive on 12/13/22. The logs do not document that V25 was tested for COVID-19 after the outbreak began on 12/6/22 until 12/11/22. V25's Time Card documents V25 worked in the facility on 12/6/22 from 6:11 PM until 6:13 AM and on 12/7/22 from 10:09 PM until 6:19 AM. The facility's Daily Staffing Schedule dated 12/7/22 documents V25 worked on the South Hall of the facility. The facility's Daily Census dated 12/9/22 document R1, R3, R22, and R29-R39 reside on the South Hall of the facility. On 12/22/22 at 10:43 AM V3 Infection Preventionist stated resident COVID-19 testing is documented in the progress notes and residents who are newly or readmitted are tested on admission and on days 3 and 5. On 12/27/22 at 8:30 AM V3 stated the facility's policy is to test staff and residents every 3 to 7 days during a COVID-19 outbreak. On 12/27/22 at 10:26 AM V1 Administrator stated V1 has no additional documented COVID-19 tests for V25. V1 stated V1 has no additional documentation to provide for R3's, R4's, and R5's COVID-19 tests.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent the spread of COVID-19 (Human Coronavirus Infection) during an outbreak by failing to involve the Infection Preventionist in the surveillance/monitoring of resident/employee COVID-19 infections, perform contact tracing of employees to identify high risk exposures, move positive residents away from asymptomatic/negative room mates, monitor vital signs, implement transmission based precautions, properly wear/remove/discard/disinfect Personal Protective Equipment (PPE) upon leaving COVID-19 positive rooms, educate visitors on PPE use, keep COVID-19 positive resident room doors closed, and restrict a symptomatic employee from work. These failures have the potential to affect all 73 residents residing in the facility. Findings include: 1.) The facility's Resident COVID-19 Monitoring logs dated 12/6/22-12/19/22 document 45 residents have tested positive for COVID-19 and the outbreak has affected all units within the facility. This log does not identify the locations where the positive residents reside, if they have room mates, or the symptom onset date. The facility's Employee COVID-19 Monitoring logs dated 12/5/22-12/20/22 document 25 employees have tested positive for COVID-19. This log does not identify the location where the positive employees worked prior to testing positive. The Infection Prevention & Control Monthly Log dated December 2022 documents two resident infections and does not include the COVID-19 infections. The facility's Resident Roster dated 12/21/22 documents 73 residents reside in the facility, and the facility does not have a designated COVID-19 unit. On 12/22/22 at 9:20 AM V3 Infection Preventionist stated V3 has been the facility's Infection Preventionist since mid October 2022. V3 stated V3 records and monitors resident infections on the Infection Prevention & Control Log. V3 confirmed these logs do not document COVID-19 infections. V3 stated the COVID-19 infections are logged by V1 Administrator. V3 confirmed V3 has not been assisting V1 with the surveillance/monitoring of the COVID-19 logs during the outbreak. On 12/22/22 at 7:54 AM V1 Administrator stated the facility's COVID-19 outbreak began on 12/6/22, and the resident and employee COVID-19 positive logs are the facility's infection control logs for COVID-19. On 12/22/22 at 11:03 AM V1's office contained a white board with handwritten notes documenting a timeline of the outbreak and included the list of COVID-19 positive staff and residents. This board did not identify the location the positive employees worked. V1 confirmed the COVID-19 logs do not document the location where the employees worked to identify exposures. V1 stated We do have consistent staffing so I know where they work. V1 stated the facility takes the COVID-19 logs to the Quality Assurance meeting after the outbreak to determine what could have been done differently since it is difficult to track/identify trends in the middle of an outbreak. V1 confirmed V1 does not talk to positive staff to determine if there was any possible exposures to staff/residents. V1 confirmed V1 has been maintaining the COVID-19 logs without V3's assistance. V1 stated V1 is going to start having V3 assist with the COVID-19 logs/monitoring, and that V3 was new to the Infection Preventionist position. The facility's Infection Preventionist Job Description dated May 28, 2018 documents: The Infection Preventionist's duties include the following Completes on-going monitoring of infections. Assesses infection prevention & control concerns and makes recommendations for corrective action. Monitors infection prevention & control practices and employee compliance. Serves as a resource for all departments, staff, residents, family members, visitors, consultants, contractors, volunteers, and care givers who provide care and services to residents on behalf of the facility (e.g. Hospice staff), and students in the facility nurse aide training programs or from affiliated academic institutions. Conducts outbreak investigation and initiates control measures. Initiates follow-up on employee/resident exposures to communicable diseases. 2.) The facility's Resident Roster dated 12/21/22 documents: R4 tested positive on 12/19/22 and resides with R10 (COVID-19 negative). R11 tested positive on 12/19/22 and resides with R12 (COVID-19 negative). R13 tested positive on 12/22/22 and resides with R14 (COVID-19 negative). R2 tested positive on 12/11/22 and resides with R15 (COVID-19 negative). R16 tested positive on 12/12/22 and resides with R17 (COVID-19 negative). R19 tested positive on 12/12/22 and resides with R18 (COVID-19 negative). The facility has 6 semiprivate beds open to allow for cohorting COVID-19 positive residents together, away from negative residents. R10's Diagnosis List dated 12/22/22 documents R10's diagnoses include Asthma, Chronic Obstructive Pulmonary Disease, and Atrial Fibrillation. R12's Diagnosis List dated 12/22/22 includes Acute Diastolic Congestive Heart Failure. R12's Census dated 12/22/22 documents R12 receives hospice care. R14's Diagnosis List dated 12/22/22 documents R14's diagnoses include Chronic Obstructive Pulmonary Disease, and Centrilobular Emphysema. R17's Diagnosis List dated 12/22/22 documents R17's diagnoses include history of pulmonary embolism and venous thrombosis. R18's Diagnosis List dated 12/22/22 documents R18's diagnoses include Chronic Diastolic Congestive Heart Failure and Atrial Fibrillation. On 12/21/22 at 1:37 PM R18 and R19 were in the same room and contact/droplet isolation signage was posted on the door. On 12/21/22 at 1:45 PM R4 and R10 resided in the same room and contact/droplet isolation signage was posted on the door. On 12/22/22 at 8:48 AM R16 and R17 were sharing a room, and there was a sign on th door indicating contact/droplet precautions. On 12/22/22 at 9:20 AM V3 Infection Preventionist stated: In the beginning of the COVID-19 outbreak we moved negative/exposed residents into a private room away from the positive room mate. We did this for 3 or 4 residents, but then we ran out of rooms and began leaving negative residents to reside with their positive room mates. On 12/27/22 at 8:50 AM V3 reviewed the Resident Roster dated 12/21/22 and confirmed there were 6 semiprivate beds open/available to cohort positive residents together and away from negative room mates. V3 confirmed R4 resided with R10, R11 resided with R12, R13 resided with R14, R2 resided with R15, R16 resided with R17, and R18 resided with R19. 3.) R4's Census dated 12/27/22 documents R4 admitted to the facility on [DATE]. R4's nursing notes document R4 tested positive for COVID-19 on 12/19/22. R4's medical record does not document a temperature and pulse oximetry on 12/13, 12/16, 12/17, or that temperature and pulse oximetry were routinely monitored every 4 hours after R4 tested positive on 12/19/22. R3's Nursing Notes document on 12/11/22 R3 was transferred to another room due to R3's room mate testing positive for COVID-19. R3's medical record does not document temperature and pulse oximetry were monitored/recorded after 12/7/22. R5's Census dated 12/27/22 documents R5 readmitted to the facility on [DATE]. R5's Diagnosis List dated 12/22/22 documents R5 has a diagnosis of Chronic Myeloid Leukemia. R5's medical record does not document temperature and pulse oximetry on 12/16, 12/17, and 12/20/22. On 12/22/22 at 9:20 AM V3 stated temperature and pulse oximetry are monitored daily and documented in the vitals or nursing note sections of the residents' electronic medical records. On 12/27/22 at 8:50 AM V3 confirmed positive residents should have temperature and pulse oximetry completed every 4 hours. V3 stated If it (vital sign monitoring) isn't documented then I (V3) don't know how we can prove it (vital sign monitoring) was done. On 12/22/22 at 9:40 AM V1 stated V1 had no additional documentation to provide for temperature and pulse oximetry monitoring for R3, R4, and R5. 4.) R4's Census documents R4 admitted to the facility on [DATE]. There is no documentation in R4's medical record that R4 was placed on transmission based precautions prior to testing positive for COVID-19 on 12/19/22. On 12/22/22 at 9:20 AM V3 Infection Preventionist stated for newly admitted /readmitted residents they are no longer placed on Transmission Based Precautions (TBP). On 12/22/22 at 10:43 AM V3 stated R4 was not placed on TBP upon admission. V3 confirmed the facility was in outbreak status with positive cases on the South and North sections of the facility on 12/9/22, including R4's hallway. 5.) R5's Census documents R5 readmitted to the facility on [DATE]. There is no documentation in R5's medical record that R5 was placed on transmission based precautions upon readmission. R5's Care Plan dated 11/7/22 documents R5 has Chronic Myeloid Leukemia and is at risk for infections due to chemotherapy. This care plan includes interventions for contact isolation precautions, and wear gown and gloves during care if exposure to body fluids. On 12/21/22 at 3:14 PM, 4:04 PM, and on 12/22/22 at 5:12 AM and 8:13 AM R5's doorway did not contain isolation signage and there was no PPE container outside of R5's doorway. On 12/21/22 at 2:54 PM V1 Administrator stated R5 is on Transmission Based Precautions due to receiving chemotherapy and being immunocompromised. On 12/21/22 at 3:35 PM V12 Licensed Practical Nurse stated R5 is not on isolation. N95 mask and eye protection need to be worn in R5's room. On 12/27/22 at 9:40 AM V1 reviewed the facility's COVID-19 policy. V1 confirmed R5 should be on Transmission Based Precautions due to R5 being immunocompromised. V1 stated signage should be posted if a resident is on TBP. 6.) The Resident Roster dated 12/21/22 documents the following residents tested positive for COVID-19: R20 on 12/17, R21 on 12/14/22, R22 on 12/11/22, R23 on 12/19/22, R24 on 12/11/22, R26 on 12/11/22, and R27 on 12/19/22. On 12/21/22 at 1:45 PM The sign posted on R4's doorway indicated R4 (COVID-19 positive) was on contact/droplet precautions. R4's door was open. V5 (R4's Power of Attorney) was in R4's room wearing a surgical mask. V5 was not wearing a gown, gloves, or eye protection. V5 was within three feet of R4, who was not wearing a face covering. V5 touched items in R4's room including clothing. V5 stated No one provided me any information or instructions on what to do during my visits. I walked in and came straight to (R4's) room. No one greeted me. V5 stated R4 tested positive for COVID-19 on Monday (12/19/22). V5 left R4's room and walked down the hallway wearing the same surgical mask that was worn in R4's room. On 12/22/22 at 6:03 AM R4's door was open. On 12/21/22 at 1:58 PM The sign posted on R11's/R12's doorway indicated contact/droplet precautions. V6 Hospice Registered Nurse was in R11's room (COVID-19 positive) wearing a surgical mask, and V6 was not an N95 mask, eye protection, gown, and gloves. V6 left R11's/R12's room and did not change V6's mask. V6 stated V6 was not sure why the isolation sign was posted, because neither R11 nor R12 had tested positive for COVID-19. V6 confirmed V6 assessed both R11 and R12 during V6's visit. V6 stated hospice hasn't been notified that either R11 or R12 had tested positive. V6 stated for COVID-19 positive rooms, V6 would wear an N95 mask, eye protection, gown and gloves. On 12/21/22 at 2:15 PM V10 Maintenance was in R20/R21's room (COVID-19 positive) wearing an N95 mask, gown, gloves, and eye protection. V10 left R20's/R21's room without removing V10's PPE worn in the room, carried a mattress out of the room and out the exit door near R11's/R12's room. V10 then returned to R20's/R21's room and removed V10's gown and gloves. V10 did not change V10's mask or disinfect/change V10's eye protection. V10 stated contact/droplet signage is posted to indicate which residents are COVID-19 positive. V10 stated V10 changes V10's N95 mask at least daily and cleans V10's eye protection with alcohol wipes daily. On 12/21/22 at 3:09 PM R22's room door was open and the doorway contained a sign for contact/droplet precautions. R22's nebulizer treatment was administering while R22's door was open. On 12/21/22 at 3:27 PM V13 Certified Nursing Assistant (CNA) left R23's/R24's room (COVID-19 positive), removed V13's N95 mask that was worn in the room and placed the contaminated mask into V13's pants pocket. V13 did no disinfect or change V13's eye protection upon leaving the room. On 12/21/22 at 3:28 PM V13 confirmed V13 did not change or disinfect V13's eye protection upon leaving R23's/R24's room. V13 stated eye protection is disinfected once per shift. On 12/21/22 at 3:47 PM V14 CNA stated: Signs are posted to indicate the resident has COVID-19. N95 mask, eye protection, gown, gloves are worn for care of COVID-19 positive resident, and we change the N95 mask, gown, gloves before going into COVID-19 negative rooms. Eye protection is not changed and V14 disinfects V14's eye protection about every 2 hours with alcohol. On 12/21/22 at 4:10 PM V15 CNA stated N95 masks are changed and eye protection is disinfected with an alcohol lens cloth upon leaving COVID-19 positive rooms. On 12/21/22 at 4:26 PM V16 CNA stated: We were separating residents and doing room changes, but we had some negative residents rooming with positive residents. I didn't change PPE between caring for negative/positive room mates. Eye protection is disinfected a couple times per shift. On 12/22/22 at 5:27 AM V24 CNA was working on the North Hall of the facility, and V24 was not wearing eye protection. V24 stated V24 worked night shift on the North Hall and North Pod of the facility, cared for positive and negative residents, and did not wear eye protection during V24's shift. V24 stated the eye protection is located on the other side of the facility. At 5:33 AM V23 and V24 CNAs entered R25's room and provided incontinence care. V24 was not wearing eye protection. On 12/22/22 at 8:48 AM V26 CNA R16's/R17's room wearing an N95 mask and eye protection and delivered a meal tray. The sign on the room door indicated contact/droplet precautions. V26 did not apply gown or gloves upon entering. At 8:53 AM V26 left the room and without performing hand hygiene poured drinks from pitchers on the drink cart. V26 applied gloves, delivered the drinks into R16's/R17's room, and touched the overbed table in the room. V26 was not wearing a gown while in the room, and R16 was coughing. V26 left the room wearing the same gloves worn into R16's/R17's room. V26 touched the ice scoop, cups, and pitchers on the drink cart and pushed the cart to R26's/R27's room (COVID-19 positive). At 9:02 AM V26 applied gown and gloves and delivered R26's/R27's meal room. At 9:07 AM V26 left the room without removing/discarding V26's gown and gloves. V26 went to the drink cart and poured coffee into disposable cups while wearing the same gloves and gown worn in R26's/R27's room. V26 returned to the room and touched the overbed table and light switch. At 9:10 AM V26 left the room wearing the same gown and gloves and grabbed a milk carton from the drink cart. V26 left the room and removed V26's gown and gloves and changed V26's N95 mask. V26 did not disinfect or change V26's eye protection. At 9:12 AM V26 stated gown, gloves and N95 mask are changed when leaving a COVID-19 positive room, and V26 does not change or disinfect V26's eye protection. V26 confirmed V26 did not change V26's gown and gloves while going in and out of R16's/R17's and R26's/R27's rooms. On 12/22/22 at 9:20 AM V3 Infection Preventionist stated staff are to wear full PPE - N95 mask with a surgical mask applied over top of the N95, eye protection, gown, gloves into positive rooms. We strongly request residents and families/visitors wear PPE and education is provided. We offer a mask at the front entrance and have isolation signage that includes what PPE to wear posted on the resident room door. Hopefully the visitors adhere to the sign. Visitors are typically greeted by the staff and provided instructions on PPE use. The external mask, gown, and gloves are to be removed upon leaving the positive room, PPE discarded, and hand hygiene performed. Staff should change gown and gloves between caring for positive and negative room mates. Eye protection is worn throughout the building and the only time it is disinfected is when it is soiled at the end of shift. Staff should be using (disinfectant) to wipe down eye protection and not alcohol. V3 confirmed V3 would not expect staff to disinfect or change eye protection upon leaving a positive room before going to a negative room. V3 stated V3 would expect hospice staff to follow COVID-19 guidance and wear appropriate PPE. Hospice was notified of residents testing positive. V3 stated V3 saw that the nurse (V6) was wearing only a surgical mask and V3 spoke to V6. V3 stated positive room doors should be closed if they are safe to be closed, and confirmed R4's and R22's room doors should be closed. V3 confirmed eye protection and N95 mask to be worn in resident care areas. V3 confirmed V13's contaminated N95 mask worn into a COVID-19 positive room should be discarded and not placed into V13's pocket. On 12/27/22 at 8:50 AM V3 confirmed the facility utilizes the Centers for Disease Control and Prevention (CDC) guidance and the facility has not had a shortage of eye protection. 7.) On 12/22/22 at 5:44 AM V24 CNA stated: I (V24) tested positive the Friday before last (12/9/22). I (V24) had worked with a scratchy throat for 4 hours on the North Pod. I then decided to check my temperature. V24's temperature was 102 Degrees Fahrenheit, V24 tested positive for COVID-19 and went home. V24 reported V24's temperature and test to the floor nurse. V24 did not report V24's scratchy throat since V24 attributed it to allergies. V24's Time Card documents V24 worked on 12/9/22 from 5:54 PM until 9:54 PM. The facility's Daily Staffing Schedule dated 12/9/22 documents V24 worked on the North Pod of the Facility. The facility's Employee COVID-19 Monitoring testing logs document V24 tested positive for COVID-19 on 12/9/22, and R46 and R47 tested positive on 12/10/22. The facility's Daily Census dated 12/9/22 documents R8, R11, R12, R20, R21 and R40-R53 resided on the North Pod of the facility. On 12/22/22 at 9:20 AM V3 Infection Preventionist stated if staff develop COVID-19 symptoms then they are to immediately report to V1 Administrator or V2 Director of Nursing, and they are tested immediately and sent home. If the employee is symptomatic and test negative they are sent home until symptoms improve. On 12/27/22 at 8:30 AM V3 stated V24 would have been sent home and tested for COVID-19 if V24 had reported V24's symptom of scratchy throat. The facility's COVID-19 Testing and Response Plan dated as revised 11/21/22 documents: Residents who are COVID-19 positive should be placed in a single room with the door closed. If limited single rooms are available or if numerous residents are simultaneously identified to have COVID-19, residents can remain in their current location with appropriate signage and PPE use. Cohorting may occur with other positive COVID-19 residents. Staff must wear full PPE (N95 respirator, gown, gloves, eye protection) when providing care (for COVID-19 positive residents). Facilities should provide instruction, before visitors enter the resident's room, on hand hygiene, limiting surfaces touched, and use of PPE according to current facility policy. Visitors who choose to visit a COVID-19 positive resident need to wear appropriate PPE while visiting. Visitors who are closer than 6 feet for a cumulative total of 15 minutes or more over a 24 hour period without wearing PPE are considered EXPOSED or a close contact to a positive case. Visitors who are considered to be exposed to a positive case (even if the positive case is the resident they were visiting) should quarantine per community guidance and not visit a long-term care facility for 10 full days from the last exposure (with the date of the last visit being day 0). During an outbreak, Residents should be assessed at least daily for signs and symptoms of COVID-19, including temperature and pulse oximetry. Monitor COVID-19 positive residents every 4 hours for clinical worsening including symptom assessment, vital signs, pulse oximetry, and respiratory exam. Empiric use of Transmission-Based Precautions is generally not necessary for admissions unless they meet criteria described below. Examples of when empiric Transmission-Based Precautions may be considered include: Resident unable to wear source control as recommended for the 10 days. Resident is moderately to severely immunocompromised. Resident is placed on a unit with others who are moderately to severely immunocompromised. Resident is placed on a unit experiencing ongoing SARS-CoV-2 (COVID-19) transmission that is uncontrolled with initial interventions. COVID-19 symptoms may include runny nose, sore throat, cough, worsening cough, fever, shortness of breath, chills, muscle pain, headache, loss of smell/taste, fatigue, nausea, vomiting, and diarrhea. Health care personnel, even if fully vaccinated or up to date, should report any symptoms. Symptomatic healthcare personnel should be restricted from work until they have been evaluated per guidelines. The CDC's Strategy for Optimizing the Supply of Eye Protection updated on September 13, 2021 documents: Disposable eye protection should be removed and discarded after use. Reusable eye protection should be cleaned and disinfected after each patient encounter.