**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to identify, assess, monitor, and follow physicians' orders for signs and symptoms of hypoglycemia (low blood sugar) for 1 of 3 residents (R1) who had diagnosis of diabetes. This resulted in an immediate jeopardy (IJ) situation for R1 who had continuous low blood sugars without treatment that resulted in hospitalization with hypoglycemia. The IJ began on 8/29/25 at 4:00 p.m., when interventions were not implemented to prevent hypoglycemia. The facility did not notify the provider and R1's blood sugars continued to drop until he was sent to the ED on 8/30/25 at 1:20 a.m. The administrator, director of nursing (DON), assistant director of nursing ADON), regional nurse consultant (RNC), activity director (D), health unit coordinator (HUC), and licensed social worker (LSW) were notified of the IJ on 9/4/25 at 5:14 p.m. The immediacy was removed on 9/5/25, but noncompliance remained at the lower scope and severity level 2 (D), which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy.Findings include:According to the American Diabetes Association (ADA) the recommendations for target blood sugar levels are: Before a meal (pre-prandial): Typically, between 80 and 130 mg (milligrams/deciliter); Two hours after starting a meal (postprandial): Less than 180 mg/dL According to the ADA, hypoglycemia is defined as a blood glucose level below 70 mg/dL (3.9 mmol/L). Hypoglycemia is further categorized into three levels: Level 1 is below 70 mg/dL but above or equal to 54 mg/dL (3.9-3.0 mmol/L), Level 2 is below 54 mg/dL (<3.0 mmol/L), and Level 3 is a severe event requiring assistance, regardless of the glucose level. R1's admission minimum data set (MDS) dated [DATE], identified R1 was admitted on [DATE] and discharged to a hospital on 8/30/25. Further identified R1's cognition was intact and had diagnoses of diabetes mellitus, rhabdomyolysis (A breakdown of muscle tissue that releases a damaging protein into the blood that can cause damage to the kidneys).R1's order summary dated 8/27/25, included the following orders for diabetic management:-Metformin (oral medication given to reduce blood sugar levels) 1000 milligrams (mg) twice daily for diabetes (start date 8/27/25).-Glimepiride (medication used to increase insulin secretion resulting in lowered blood sugar levels) 2 mg twice daily for diabetes (start date 8/27/25). -Accu-Chek (blood glucose monitoring system) every morning and evening and PRN (as needed) -(start date 8/27/25).-If Blood Sugar (BS) <70 and resident is symptomatic and not alert, give 1 mg Glucagon (an injectable medication used to counter the effects of insulin to raise blood glucose levels) intramuscular/subcutaneous (IM/SQ). Recheck blood glucose in 15 minutes. Repeat if resident is not alert and symptomatic. If resident is now alert, BS <70 and symptomatic, give orange juice or tube of Glucose gel (medication used hypoglycemia to raise blood glucose when it becomes dangerously low). Recheck blood sugar in 15 min. If BS >70 and not symptomatic, do not treat. If BS <70 and resident is alert, symptomatic or asymptomatic, give orange juice or tube of Glucose Gel followed by a complex carbohydrate. Recheck blood sugar in 15 minutes as needed for monitoring (Start date 8/28/25)-8/28/25 Glucagon Emergency Kit 1mg, inject 1 dose IM as needed for blood sugar <60, use if resident is unresponsive. Notify MD (Start date 8/28/25) . -8/28/25 Glucose Gel 40 %, give 1 dose by mouth as needed for hypoglycemia- blood glucose of <70, symptomatic and alert, notify MD recheck blood sugar in 15 minutes (Start date 8/28/25).R1's care plan identified a focus, the resident has Diabetes Mellitus, dated 8/28/25, with interventions dated 8/28/25 to Monitor/document/report as needed any sign/symptoms of hypoglycemia: Sweating, Tremor, Increased heart rate (Tachycardia), Pallor, Nervousness, Confusion, slurred speech, lack of coordination, Staggering gait and Fasting Serum Blood Sugar as ordered by doctor. R1's Blood glucose vital summary document identified blood sugar at 7:59 a.m. on 8/29/25 was 81. R1's plan of care response form identified on 8/29/25, R1 ate 75%-100% for breakfast. R1's medication administration record (MAR) for 8/29/25, identified Metformin1000 mg and Glimepiride 2 mg was signed as given on 8/29/25 at 8:00 a.m. when R1's blood sugar was 81.According to FDA Glimepiride starts working within about an hour, peak concentration is 2 to 3 hours after dose taken and the glucose-lowering effect is maintained for 24 hours after a single dose.R1's plan of care response form identified on 8/29/25, R1 ate 75%-100% for lunch. R1's record did not identify a blood sugar recording between 7:59 a.m. and 4:49 p.m. R1's blood glucose vital summary document identified blood sugar documented at 4:50 p.m. R1's blood sugar was 54 and R1's plan of care response form identified on 8/29/25, R1 ate 50% of his meal. In review of R1's record on 8/29/25 identified there was no indication R1 was assessed for signs/symptoms of hypoglycemia nor physician orders followed that directed intervention if the blood sugars were less than 70 that included administration of medications and/or give carbohydrates to raise the blood sugar and notify the physician. Further no indication R1's blood sugar was rechecked after R1 completed his meal.R1's MAR on 8/29/25, at 8:00 p.m. identified R1 was administered both Metformin1000 mg and Glimepiride 2 mg even though there was no indication R1's blood sugar was checked prior to the administration of the medications that would lower blood sugar. On 8/29/25 R1's Blood glucose vital summary document identified blood sugar at 9:05 p.m. R1's blood sugar was 39. In review of R1's record there was no indication the physician was notified after R1's blood sugar was 39 nor was there evidence R1 was continuously monitored and assessed for signs and symptoms of hypoglycemia. R1's Situation, Background, Assessment, and Recommendation (SBAR) note dated 8/29/25 at 9:45 p.m., identified R1 had Diabetes type 2, blood sugar during daytime was 81, blood glucose at 4:00 p.m. (which was inconsistent with the documentation in the vital summary), was 54, had eaten a half sandwich for dinner, now is 39. R1 was alert and oriented and not exhibiting signs and symptoms of hypoglycemia, R1 got IM glucagon 1 mg injection from emergency kit and blood sugar will be checked again in 15 minutes. Review of R1's record MAR indicated the glucagon was not documented as given. R1's blood glucose vital summary document identified blood sugar on 8/29/25 at 10:05 p.m. was 86. According to the Food Drug Administration (FDA) the Glucagon Injection the blood glucose concentration rises within 10 minutes of injection and maximal concentrations are attained at approximately 30 minutes after injection. The duration of hyperglycemic action after intravenous or intramuscular injection is 60 - 90 minutes.R1's blood glucose vital summary document identified blood sugar on 8/30/25 at 12:20 a.m. was 51. R1's late entry progress note for 8/30/25 identified R1 was transferred to the emergency department at 1:30 a.m. R1's ED to hospital admission notes dated 8/30/25 to 9/5/25, identified R1was admitted to the ED at 1:31 a.m. for hypoglycemia with a history of diabetes where he was receiving oral medications. R1 was recently hospitalized for rhabdomyolysis and discharged to Edenbrook Rochester [NAME] on 8/30/25. R1 presented to the ED from skilled nursing facility (SNF) for hypoglycemia and lethargy, endorsing symptoms of weakness, lightheadedness and dizziness. R1's glucose was 29 upon arrival prompting administration of intravenous (IV) dextrose (a sterile solution of glucose and water, administered directly into a patient's vein to restore blood glucose levels) 25 grams. R1 was admitted for continued evaluation and management. Upon admission to the hospital R1 continued to be persistently hypoglycemic requiring frequent dextrose injections and continuous D10 infusion (an IV solution containing 10% dextrose (D-glucose) in water, used to increase blood glucose levels). Per R1 history it was believed to be driven by Glimepiride. R1 returned to normal glycemic state on D10 infusion around 24 hours following his last Glimepiride dose. During a phone interview on 9/4/25 at 2:12 p.m., hospital registered nurse (HRN)-A stated R1 was admitted early morning of 8/30/25, and his primary diagnosis was hypoglycemia. When R1 arrived at the ED his blood glucose was 29. HRN-A stated regulating R1's blood glucose levels to normal ranges took about 16 hours and R1 was still in the hospital.During a phone interview on 9/8/25 at 11:22 a.m., R1 stated he has no recollection of the day at the facility when he was sent to the hospital for hypoglycemia. During an interview on 9/4/25 at 4:30 p.m., registered nurse (RN)-B stated she was the nurse that was responsible for R1 on 8/29/25 from 2:00 p.m. until 10:30 p.m. R1 was a new resident, and it was the first time she worked with him. RN-B checked R1's blood sugar at 4:00 p.m. At 4:50 and it was 54, she gave him orange juice. R1 questioned why he had to drink the juice, RN-B stated she explained to R1 it was very risky to have a blood sugar that low and if we don't do something he could die from it. RN-B stated she never called the provider for further direction for the blood sugar of 54. Then R1 had supper between 5:00-6:00 p.m.; he ate about a half white bread sandwich, ham, mayonnaise, and cheese. RN-B explained R1 told her he only ate half the sandwich because he did not like it, and she did not offer him any other food. RN-B stated at 8:00 p.m., she did give R1 1000 mg of Metformin and 2 mg of Glimepiride and stated she did not think to call the provider to see if it would be safe to give the medications. When she checked his blood sugar at 9:30 p.m., (which was inconsistent vital summary indicating 9:05) he was down to 39, that's when she gave him the glucagon injection. RN-B could not recall if she documented giving the glucagon and stated she did not call the on-call provider to get further instruction rather faxed an SBAR to the provider. RN-B stated she did work two days later after the event and typically worked at this facility three times a week. RN-B stated she had not received any education regarding diabetic monitoring or when to notify the provider with a change in condition.During a phone interview on 9/9/25 at 9:31 a.m., RN-C stated she worked the night shift on 8/29/25, she got to the facility at about 9:50 p.m. RN-C explained she received report from RN-B that R1 had low blood sugars, had some orange juice, a half a sandwich and required glucagon. RN-B was not told the times R1 was given orange juice/sandwich, what time the glucagon was administered, and R1 was still in the facility. RN-C indicated she had not immediately gone to evaluate R1, and some time had passed (could not recall how long) by the time she got to R1's room to check his blood sugar. When RN-C did check the sugar (documented at 12:20 a.m.) it was 51 and at that time R1 was kind of groggy. RN-C left R1's room, consulted with RN-A and it was decided to give orange juice and call the physician. RN-C brought R1 orange juice then left the room again to call the physician. RN-C explained she was on the on the phone for quite a while (did not know how long) trying to get through to an on-call provider and the person on the phone finally told her he would have a provider call her back. RN-C then went back to R1's room, she did not recheck the blood sugar because R1 was sleeping had 1/2 glass of orange juice in his hand that was tipped, and there was no point because the blood sugar would not have gone up in the time she was gone. RN-C then left the room again to talk to RN-A, decided to just call 911 and get R1 sent to the hospital. R1 was transferred out on 8/30/25 at 1:20 a.m. RN-A had only taken R1's blood sugar one time between 10:50 p.m. and 1:20 a.m. RN-C stated the nurse at the hospital called and reported R1's blood sugar was 29 when he got to the hospital. That was so dangerous to have a blood sugar that low. During an interview on 9/4/25 at 1:42 p.m., RN-A stated she was the charge nurse on 8/29/25. RN-A indicated at 9:30 p.m. RN-B came running down the hallway with glucagon injection in one hand and a glucometer in the other reporting R1's blood sugar was 39. RN-A stated she had not been aware of the blood sugar of 54 at supper time. RN-A directed RN-B to give Glucagon, check blood sugars every 15 minutes, and notify the provider. RN-A went to R1's room, his mentation was not great, woozy could not complete sentences and only could answer yes/no questions. She would not have considered R1 to have the ability to speak for himself because of the way he was speaking/acting because of his low blood sugars. R1 was sent to the hospital for further evaluation. However, RN-A reported her concerns to the director of nursing (DON). RN-A stated R1 had elevated risk of death from hypoglycemia with the predisposing diagnosis of rhabdomyolysis if he had not been sent the ED. During an interview on 9/4/25 at 1:28 p.m., DON stated she expected nurses to follow the hypoglycemic protocols with assessment and monitoring, providing emergency medications, and notify the provider. She expected for blood glucose under 50 the nurse would give emergency med, notify the provider and recheck every 15 minutes. DON verified the protocols were not followed and should have been. DON confirmed RN-B had not been provided any education nor had any other staff. The DON identified RN-B last worked on 8/31/25 and remained on the current schedule.During an interview on 9/4/25 at 1:22 p.m., medical doctor (MD)-A stated R1's low blood sugars may have been low related to the rhabdomyolysis and stated she would have expected to be notified if a resident's blood glucose was under 70 and after giving the glucagon, especially since R1 was a newer admit and the facility was unaware of his baseline. After glucagon was administered blood glucose needed to be checked every 15 minutes until they are within normal range. MD-A indicated failing to identify and treat hypoglycemia would result in further decreasing blood sugars and decline in mental status.Facility policy, Care of the Diabetic Resident, revised 6/30/25, identified a purpose to assist the resident to establish a balance between diet, exercise, and insulin; prevent recurrence of hyperglycemia/hypoglycemia; recognize, assist, and document the treatment of complications commonly associated with diabetes; and individualize teaching according to carefully assessed resident and family needs. Diabetes Mellitus is a chronic, hereditary, or developmental disorder in which there is relative or absolute lack of insulin characterized by glucose intolerance. It is defined as Type I (Insulin-Dependent Diabetes Mellitus) and Type II (Non-Insulin-Dependent Diabetes Mellitus) .2.Hypoglycemia a. Signs and symptoms of hypoglycemia (low blood sugar), usually have a sudden onset and may include the following: i. polyphagia (excessive eating/hunger); ii. weakness, dizziness, or faintness; iii. nervousness and/or muscle twitching; iv. tachycardia (increased heart rate); v. pale, cool, moist skin; vi. excessive perspiration; vii. dilated pupils; viii. irritability or bizarre changes in behavior; ix. blurred or impaired vision; x. headaches; xi. numbness in the tongue and lips/thick speech; xii. trembling and/or restlessness; xiii. paralysis with tonic or clonic spasms; xiv. incontinent of urine; xv. awkward body movement; xvi. stupor, unconsciousness and/or convulsions; and xvii. coma. b. Upon presentation of symptoms, the licensed nurse should check the blood glucose level via an Accu-Chek. I. If an Accu-Chek reveals a blood glucose level below 70 mg/dl or level identified per individual physician orders, hypoglycemia should be suspected. 1. Should evidence of severe, or life-threatening signs/symptoms exist, contact the physician immediately or call 911. ii. If any of the above signs or symptoms, or other abnormal condition, are identified, report the diabetic resident's condition to the physician immediately. c. Follow the resident's individual hypoglycemic protocol, if ordered by a physician. If no individual protocol is ordered, update the physician based on clinical assessment and current blood sugar. d. Hypoglycemic Treatment Protocol i. Treat hypoglycemia promptly with 15 to 20 g of fast-acting (simple) carbohydrates for blood sugar less than 70 mg/dl. ii. Half cup (4oz) juice OR 1 cup (8 oz) skim milk OR glucose gel/tablets OR four sugar packets. iii. Glucagon 1 mg (subcutaneously or I.M.) is given by a licensed staff if the patient cannot ingest a sugar treatment, per physician orders. iv. Repeat the Accu-Chek and report findings to the physician v. Repeat the protocol only once if the blood glucose level remains less than 70mg/dl and report findings to the physician. 3. If any of the above signs or symptoms, or other abnormal condition, are identified, report the diabetic resident's condition to the nurse and/or physician immediately.The immediate jeopardy that began on 8/29/25, was removed on 9/5/25, when it was verified, the facility implemented the following corrective actions:-Educated licensed nursing staff and agency staff about diabetic management of hypoglycemia and hyperglycemia monitoring, assessing, treatments, physician notification and standards of documentation with competency testing.-Reviewed all current residents with diagnosis of diabetes to ensure blood glucose levels were within range, had diabetic protocols in place, care plans were accurate and provider orders were followed.-Reviewed facility Diabetic Monitoring and Change of Condition policies for accuracy

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review the facility failed to administer the right prescribed medications to right residents for 1 of 3 residents (R1). R1 had developed hypotension (low blood pressure) and bradycardia (low heart rate) that required emergency medical treatment and admitted to the hospital ICU (intensive care unit) to stabilize R1's condition which resulted in an immediate jeopardy (IJ). The immediate jeopardy (IJ) began on 10/9/23, when registered nurse (RN)-A failed to identity R1 prior to the administration of prescribed medications. The director of nursing (DON) and vice president of success (VPOS) were notified of the IJ on 10/24/23, at 6:30 p.m. The facility immediately implemented corrective action on 10/9/23, the deficient practice was corrected on 10/9/23, prior to the start of the survey and was therefore issued at Past Noncompliance. Findings include: Facility reported incident (FRI) dated 10/9/23, indicated registered nurse (RN)-A (who was in training as new employee) was orienting with RN-B working together on the cart to dish up medications. RN-A stated to R1 is your name (R2's name), R1 stated yes. RN-A went to the med cart and told RN-B that R1 did not want the nasal spray. RN-B went to check in the bathroom and realized RN-A had accidentally given R2's medications to R1. Vitals signs were checked, provider called, R1 was visually monitored throughout the shift, and R1 was sent to the ED. Education provided to RN-A and RN-B on medication competency checklist, review of cardiac medications, side effects and policies of medication administration and errors. All trained medication assistants (TMAs) and licensed staff will be educated prior to the start of their next shift. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1's cognition to be moderately impaired and included diagnoses of multiple sclerosis (a neurological disease that results in nerve damage that disrupts communication between the brain and the body), hypertension (high blood pressure), and dementia. Further, the MDS identified R1 had adequate hearing without hearing aides. R1's medication administration record (MAR) dated 10/9/23, at 9:08 a.m. indicated R1 received the following scheduled medications per physician orders: amlodipine besylate 10 milligrams (mg) (a calcium channel blocker that helps to lower blood pressure), lisinopril 20 mg (relaxes blood vessels to help lower blood pressure), lactase 9,000 units (an enzyme that helps break down milk), acetaminophen 1,000 mg (pain reliever), and cholecalciferol (vitamin D),1000 units. R1's progress note dated 10/9/23, at 9:35 a.m. indicated R1 was given the wrong medications this morning, and received her own scheduled medications. R1 received in error, diltiazem (blood pressure medication)120 milligrams (mg), furosemide 20 mg (diuretic medication), metoprolol 20 mg (blood pressure medication), quetiapine fumarate 20 mg (antipsychotic medication), senna (stimulant laxative) and Tylenol 1000 mg (pain medication). Provider team notified, family notified. Blood pressure-151/51, pulse-66, O2 sats 94% on room air and temperature was 97.3, no pain noted. R1's med error report, dated 10/9/23, at 9:30 a.m. identified RN-B was mentoring RN-A had medications dished up and gave them to the wrong resident (R1). RN-B administered crushed medications to R1 instead of R2. R1 was aware she was given the wrong medications and vital signs are stable, no signs and symptoms of overdose at this time. Nursing at this time will continue to monitor. RN-B educated orientee RN-A about importance of following the medication administration rights. Also discussed not to go by what the resident says, some may not be able to answer accurately. There were no progress notes or vital signs records from 9:35 a.m. until 1:15 pm, to identify staff were monitoring R1's condition as a result of the medication error which she received medications diltiazem, furosemide, metoprolol, and quetiapine that could potential to lower blood pressure and/or heart rate. R1's progress note dated 10/9/23 at 1:15 p.m., indicated R1's vital signs were rechecked, blood pressure 55/32, pulse 32, respirations-12, and oxygen saturations were 96% on room air. R1 appeared pale cool, very lethargic, was able to respond to verbal commands. 911 was called, emergency medical services (EMS) arrived at 1:20 p.m. Intravenous (IV) started, fluids started IVP Atropine (used to treat slow heart rate) was given by EMS at 1:30 p.m. EMS obtained blood sugar 192 mg/dl (normal 80-120 mg/dl). Blood pressure 55/23 and pulse 26. Family member (FM)-A was called and wanted all action to be taken at this time. EMS took R1 via ambulance at 1:35 p.m. According to the American Heart Association a normal blood pressure for an adult is a systolic (top number) reading that is below 120 and a diastolic (bottom number) reading that is below 80. A blood pressure would be considered low if under 90/60. A normal pulse is 60 - 100. R1's nurse practitioner note, dated 10/9/23, at 1:25 p.m. identified Chief Complaint was medication overdose incident; R1 was administered another resident's medications. R1's heart rate recorded 36 bpm (beats per minute) and she was getting symptomatic. Nursing is sending R1 in for immediate evaluation and intervention. EMS has been called and is currently at the facility. R1's ambulance report dated 10/9/23, at 1:45 p.m. indicated upon arrival R1 was slumped over in her wheelchair and alert to painful stimuli. Staff reported shortly before arrival, R1 reported not feeling well with more sluggish behavior and weak pulses. Staff reported pulses between 30's -40's. R1 was not able to answer questions well, unknown if this was due to dementia or shock. R1's skin was pale and dry; speech was slurred and not able to follow commands appropriately and had noted hypotension and bradycardia. R1 transferred patient care to receiving team at Saint Mary's Hospital. R1's ED to hospital note, dated 10/9/23, indicated reason for visit was a drug overdose with a primary diagnosis as bradycardia. Hospital course: R1 presented with bradycardia and hypotension in the setting of iatrogenic (illness caused by medical treatment) medication administration, generally takes amlodipine 10 mg and lisinopril 20 mg daily while at Rochester West. R1 received diltiazem XL and metoprolol instead of her usual medications. R1 was then transferred to intensive care unit (ICU) where R1 weaned off of the vasopressor (a group of medicines that constrict (tighten) blood vessels and raise blood pressure) medications within hours. During an observation and interview on 10/24/23 at 8:40 a.m., R1 was seated in a wheelchair up to the table in the dining room. R1 stated I did have to go to the hospital recently, that's why I have bruises all over my arms from where they shot me up. R1 indicated not remembering why she was hospitalized . During a phone interview on 10/24/23 at 4:13 p.m., registered nurse (RN)-A indicated it was her first day of orientation at the facility on 10/10/23, and RN-B was training her in. RN-A indicated she mistakenly gave R1, R2's medications. RN-B told her R1 would be on the toilet. RN-A had asked R1 if she was R2 and R2 indicated she was R1, so she gave R1 the pills. R1's vital signs were checked right away and they were normal. We tried calling the provider three different times with no call back. We finally called 911 because R1's pulse was in the 30's and R1 was sent out to the hospital. RN-A indicated it was not known when R1's blood pressure and heart rate started to drop because no one was monitoring vital signs and did not identify why monitoring was not in place. RN-A stated R1's vital signs should have been frequently monitored after the error. During a phone interview on 10/24/23 at 10:33 a.m., RN-B stated on 10/9/23, she was mentoring RN-A who was a new nurse to the facility. Around 9:30 a.m. RN-B stated RN-A had dished up R2's medications and went to the bathroom and gave the medications to R1 in error. RN-B indicated R1 had received her morning meds around 7:30 a.m. and then received R2's morning meds around 9:30 am. RN-B stated she took R1's vital signs right away and they were within normal limits, attempted to call the on-call physician, but was unable to get a return call timely. RN-A indicated R1's vital signs had not been monitored after the medication error and before the physician returned the call at 1:15 p.m. RN-A was unable to articulate why there was no monitoring in place. When the provider called back at 1:15 p.m., R1 was lethargic, cool to the touch, and had a pulse of 32. The on-call provider gave the order to send to the hospital. She stayed with R1 trying to keep her awake until the ambulance arrived; they immediately started an IV and gave R1 some Atropine (a medication that increases heart rate) and sent to the hospital. During an interview on 10/24/23 at 3:02 p.m., director of nursing (DON), indicated that on 10/9/23, RN-A should not have been passing medications because it was her first day of orientation. RN-A should have just observed, that was the reason access to the electronic health record was not immediately given to new staff. RN-A gave R1, R2's medications in addition to her own mistakenly. DON indicated she informed RN-B to check vital signs and call the provider. DON was not aware there was difficulty with contacting the provider until after lunch time and not aware R1's vital signs were not being monitored or assessed. R1 was transferred from the ER to the ICU for cardiac treatment; her diagnoses were a drug overdose and bradycardia. DON immediately educated RN-A and RN-B on the five rights of medication administration, triple checking medications, cardiac med side effects, the monitoring and assessing of a change in condition, and education on how to contact the on-call medical provider. Additionally she educated all trained medication assistants (TMAs) and licensed staff prior to their next shift. During an interview on 10/25/23, at 11:00 a.m. medical director (MD) indicated he was aware of the medication error had occurred however was not aware of the details that led up to the error, did not realize R1's vital signs were not monitored from 9:09 a.m. until R1 was sent by ambulance at 1:15 p.m., and unsure why their was a delay with the on-call physician services. At a minimum MD expected frequent monitoring of R1's vital signs for changes and when R1's pulse dropped to 32 and blood pressure dropped to 55/32 with signs and symptoms of lethargy became an emergent situation requiring emergency services. MD further indicated medications R1 received in the hospital increased and stabilized her blood pressure and heart rate. Facility policy Medication Administration General Guidelines dated 01/21, identified .10. Residents are identified before medication is administered using at least two resident identifiers. Methods of identification include a. check identification band, b. check photograph attached to medical record, C. verifies resident identification with other nursing care center personnel. Note: the residents room number or physical location is not used as an identifier. Facility policy Medication Error Reporting and Adverse Reaction Prevention and Detection dated 9/2010, identified 3. Medication errors and adverse drug reactions are considered significant if they: a. require discontinuing a medication or modifying a dose, b. require hospitalization .require treatment with a prescription medication .F. are life threatening 6. In the event of a significant medication error or adverse drug reaction, immediate action is taken, as necessary, to protect the residents safety and welfare. A. The prescriber is notified promptly of any significant error or adverse medication reaction, b. Any new prescriber's orders are implemented, and the resident is monitored closely for 24 to 72 hours or as directed. Facility policy Change in Condition of the Resident, dated 9/20/22, identified A facility should immediately .consult with the resident's physician .when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); or a need to alter treatment significantly. Facility policy, Physician Visits, dated 6/17/19, identified a facility must provide or arrange for the provision of physician services 24 hours a day, in case of emergency. Lacked a procedure. The past noncompliance immediate jeopardy that began on 10/9/23, was removed on 10/9/23, after the facility implemented a systemic plan which included training of all staff responsible for medication administration to include: the right patient, right medication, right dose, right time, right route, and documentation. Assessing for a change in condition and monitoring the residents condition along with provider notification. A plan was made for medication competency checks and audits to ensure compliance, which was verified through interview and document review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to thoroughly investigate allegations of abuse and neglect made by 4 residents (R9, R24, R5, and R17) about 1 nursing assistant (NA-A) and an unidentified NA. This resulted in an immediate jeopardy for R9, R24, R5 and R17 who expressed distress and psychosocial harm as they had not been protected from NA-A being verbally abusive towards them and rough with them. The IJ began on 4/20/22, when it was identified NA-A had multiple accusations of rough and verbally abusive behavior and neglectful behaviors made against her and the facility had not thoroughly investigated or protected residents during an investigation. The administrator and director of nursing (DON) of the facility were notified of the IJ on 4/20/22, at 2:13 p.m. The IJ was removed on 4/21/22 at 5:00 p.m., but noncompliance remained at the lower scope and severity level of D - no actual harm with potential for more than minimal harm. Findings include: R9's quarterly Minimum Data Set (MDS) dated [DATE], included cognitively intact with diagnoses including cerebral palsy and recurrent major depressive disorder. No behaviors or rejection of cares were noted. R9's care plan revised 8/3/21, indicated R9 was a vulnerable adult and at risk for potential abuse related to being a long term resident that utilized adaptive equipment and required staff assistance for activities of daily living (ADL's). R9's care plan indicated facility staff would be educated on reporting abuse and would redirect from potentially dangerous situations. R19 should remain free of retaliation if alleged abuse was reported. Facility staff would observe for changes in mood, behavior, psychosocial needs and cognition. R9's care plan also included, Has verbalized specific staff that she prefers not to provide care to her. The only interventions for this included, it would be reviewed at care conferences how it was going and, Staff have been made aware of resident preferences. During an observation and interview on 4/18/22, at 3:41 p.m. R9 stated nursing assistant (NA)-A was, such a smartass and does not listen to her residents. R9 stated NA-A told her, don't tell me what to do! R9 stated NA-A is two faced; stating one minute she is really sweet and the next time she will turn a cheek on you. R9 disclosed NA-A and activities aide (ACT)-B were family members. R9 had asked ACT-B to assist her with elevating legs from floor to bed. NA-A entered R9's room on 4/11/22, and yelled at ACT-B for assisting resident's legs into bed, stating you can't do that, you don't know what you're doing, and you're not doing it right. R9 stated NA-A, threw, her legs into bed and it hurt her legs and hurt her pride. R9 stated she felt NA-A treated her legs roughly on purpose. R9 stated she did not report the incident to management, but thought ACT-B would have notified them. R9 stated NA-A would often make her feel, less than human and as someone without a brain, when providing cares to her. NA-A would often tell R9 she did not know what she was doing when it came to her own cares, well-being, and knowing her own body. R9 was observed teary eyed and saddened when speaking to surveyor about the incident. R9 stated she felt NA-A verbally abused her and physically hurt her legs. R9 stated she knew her own body, she has full cognition, and has to tell NA's how to do their jobs as most of them are improperly trained at facility. When interviewed on 4/19/22, at 8:24 a.m. R9 stated NA-A is, just a thorn in my side. R9 stated she wished NA-A wasn't even at the facility as she gets very nervous when NA-A is around her. R9 stated she has told facility staff about NA-A's, psychosocial mistreatment, verbal abuse, and being rough, with her. R9 stated she had informed other NA's, activity staff, and the director of nursing (DON) but nothing was ever done about it. R9 stated she felt the DON, didn't do anything at all, to be honest. R9 stated she cringed at the sight of seeing NA-A out in the north hallway, let alone, when she comes into my room. R9 was observed shaking and teary eyed again after repeating incident. When interviewed on 4/19/22, at 8:56 a.m. activities director (AD)-A stated she was unaware of the situation involving R9, NA-A, and ACT-B as ACT-B did not mention it to her. AD-A stated ACT-B should not have been completing activities of daily living (ADL's) such as assisting legs into bed for R9. ACT-B was not available for interview. When interviewed on 4/19/22, at 9:25 a.m. the director of nursing (DON) stated she was unaware of an incident involving R9, NA-A, and ACT-B where R9 made an accusation NA-A had verbally abused her and provided rough treatment by throwing her legs into bed roughly. DON stated numerous times the facility was immediately suspending NA-A pending an internal investigation. DON stated she was going to notify the facility management team and start an investigations right away. DON stated R9 and NA-A had a concern approximately one year ago, but there were no recent concerns noted. The DON was notified R9 was very tearful when talking about NA-A and R9 stated she cringes at the sight of NA-A. DON confirmed again NA-A would be suspended. A facility reported incident dated 8/19/21, identified R9 had reported NA-A and another NA had transferred her roughly, this was found to be unsubstantiated by the facility investigation. When interviewed on 4/20/22, at 7:56 a.m. licensed practical nurse (LPN)-A stated she had no knowledge of R9 making any allegations against NA-A. When interviewed on 4/20/22, at 8:19 a.m. environmental services manager (EVS)-A stated R9 shared with her an incident that occurred sometime in the past month but was uncertain of exact date. EVS-A brought laundry to R9'S room the following morning. R9 informed EVS-A an incident happened the evening prior when NA-A was working. NA-A yelled at R9 telling her, No we are going to do it my way, not your way. EVS-A stated R9 was visibly upset about this, raised her voice, and shook as she spoke about it. EVS-A immediately reported it to the DON, but did not know if anything had been done about it. EVS-A reported DON has bimonthly nursing staff meetings so EVS-A assumed it was addressed. EVS-A stated she has heard, through the grapevine, that NA-A can be rough with residents at the facility, but had not witnessed this herself. When interviewed on 4/20/22, at 9:30 a.m. SW stated she had witnessed NA-A, rushing, resident cares and has told NA-A to slow down. Once in December 2021, NA-A was putting on R9's shoes, so quick it hurt her. SW had told NA-A to slow down and NA-A got defensive. SW had stayed in R9's room afterwards and R9 told her, I was so thankful you stayed in the room and were here. SW stated R9 had confided in her that she was, terrified, of NA-A. SW stated she had reported the episode to registered nurse (RN)-D, however, RN-D told NA-A and then NA-A came back to her and NA-A became upset and told SW, this is none of your business. When interviewed on 4/20/22, at 10:20 a.m. the DON stated R9 and NA-A had, prior encounters and had gone back and forth many times. R9 did not like NA-A because she was, loud, brassy, and a know it all. NA-A had been moved to the other hallway (south) at one time as R9 did not want NA-A on her hallway (north) nor providing cares for her. The DON stated R9 was, strong-minded, needs to be in control, and tells staff how she likes things done and does not like to it if anyone gives their own opinion. The DON stated NA-A, clashes with any resident who required delicate care. The DON stated there were residents on the other hall that would be considered delicate too and NA-A was eventually moved back to the hall where R9 resides. When interviewed on 4/20/22, at 1:40 p.m. the administrator stated she was unaware of incident involving R9, ACT-B, and NA-A. The DON typically does the initial report to the state agency, but stated she kept a full paper copy of all incidences reported. The administrator had not allegations of abuse from R9. When interviewed on 4/21/22, at 8:51 a.m. R9 stated she cringed every single time NA-A was working and especially if she was assigned to the north hall. R9 stated NA-A caused her a great deal of pain when she, grabbed, her legs and no other staff has ever done this to her before. R9 stated she found out today that NA-A was not coming back and she was happy she would not be abused again. R9 stated she was about at the end of her rope with the cares she received from NA-A. R9 stated she was treated with much disrespect and this made her feel mad. When interviewed on 4/25/22, at 9:25 a.m. R9 stated knowing NA-A was gone that it took a big load off of her shoulders. R9 stated she cried many times behind closed doors from the treatment she received from NA-A. R9 stated facility staff were aware NA-A was not welcome inside her resident room, but for some reason NA-A consistently worked on north hall. R9 stated NA-A was rough and would, just yank my legs which caused severe pain in my back and legs. R9 stated she almost slipped off the edge of her bed once as NA-A, yanked on me so hard and fast. R9 stated she told multiple facility staff which included NA's, SW, and DON that she preferred NA-A to not be in her room, but this never happened as R9 felt she was never heard by facility staff. R9 stated she kept quiet for a long time until she could not take it anymore as the treatment only got worse. R9 stated she felt NA-A verbally and physically abused her at facility. R24's significant change MDS dated [DATE], included cognitively intact with diagnoses including schizoaffective disorder, anxiety disorder, fibromyalgia, rheumatoid arthritis, and chronic pain syndrome. No behaviors or rejection of cares were noted. R24's care plan dated 4/16/21, indicated R24 was a vulnerable adult at risk for potential abuse due to requiring assistance for all activities of daily living (ADL's) and some assistance for decision making. R24's care plan indicated the facility staff were educated on reporting abuse and would redirect from potentially dangerous situations. R19 should remain free of retaliation if alleged abuse was reported. Facility staff would observe for changes in mood, behavior, psychosocial needs and cognition. When interviewed on 4/18/21, at 6:05 p.m. R24 stated some of the nursing assistants (NA) were, rough and tough. R24 stated she told them to be more gentle as it really hurt her. R24 stated an unnamed NA recently refused to get her a bedpan to have a bowel movement. NA instructed R24 to just go in her depends and they would change her afterwards. R24 stated the NA told her the bedpan was not big enough for her and the facility does not utilize bedpans. R24 stated she did not want to go in her pants and this was not okay with her. R24 would not provide specific information on who this NA was. R24 was observed to be teary eyed during interview and appeared to be hesitant in providing information specific to NA. When interviewed on 4/19/22, at 3:27 p.m. R24 stated she spoke to SW earlier today and informed her of the NA's name but was unwilling to share information as her roommate was in the room. R24 informed surveyor NA was a female. When interviewed on 4/19/22, at 4:43 p.m. SW stated R24 informed her the alleged perpetrator was NA-A and was very focused on this NA. When interviewed on 4/21/22, at 1:36 p.m. R24 stated the NA she had concerns with was NA-A. R24 stated NA-A on multiple occasions would grab her arm so hard it would hurt. Once she grabbed her arm so hard it lifted her right off the bed. R24 also stated NA-A would scrub so hard on her, private parts, that she felt like, a scrubbing board. R24 stated NA-A had left bruises on her arms and legs at times. R24 stated having to be cared for by NA-A had, taken a toll, on her mental health and she was depressed over it. Once R24 requested to be boosted up in bed by NA-A and NA-A told her to do it herself. When R24 told NA-A she was unable to do that, NA-A told her if she didn't stay in bed all the time, she would be able to do it. At that point R24 tried to explain her medical condition to NA-A and NA-A just walked out of the room while she was speaking. R24 stated she didn't know why NA-A was so rough and mean to her. I feel like a big fat nobody. R24 had tears in her eyes. R24 had not reported it, stating every time she would say something, NA-A would be take it out on her. R24 stated she felt she had been physically and verbally abused by NA-A on multiple occasions. When interviewed on 4/22/22, at 8:45 a.m. NA-B stated R24 had no behavioral concerns other than refusing cares at times. NA-A stated R24 could be, needy at times and demanding on staff. R5's annual MDS dated [DATE], identified R5 had had a slight decline in his cognitive score from being fully cognitively intact in January, to being moderately impaired, and also exhibited mild depression. The MDS indicated R5 did require assistance with his activities of daily living skills (ADLs). R5's care plan had a focus problem area dated 4/16/20: ADL self-care deficit related to: physical limitations. Associated interventions prompted NAs to provide assistance with his daily cares including bathing and hygiene, but did not indicate how many persons were required to assist with his care. Additionally, R5's care plan indicated: Resident was at risk for potential abuse due to requiring assistance with mobility and ADL's. The goal indicated he would be safe and free from abuse during his stay. Associated interventions indicated staff would be educated and R5 would be encouraged to verbalize concerns of problems. When interviewed on 4/19/22, 9:30 a.m. R5 stated there was a nursing assistant, that he was only able to describe as a black woman (her name possibly starting with a T) who would not respond to his request for assistance to clean up after a bowel movement. R5 stated, she will say, 'I need to find someone to help me', but then she will leave and it will be an hour or so. R5 stated the NA might come back and say she had not found anyone to help and would leave again. R5 felt he had waited up to four hours for help. R5 stated he was able to turn himself in bed so cares could be provided, and his ability to turn was observed during the interview. R5 stated he had asked for someone in leadership to come talk with him, but felt they did not respond to his requests. R5 also reported that he had complained to a NA about his care, feeling it was rough and caused him pain. R5 further reported, the NA responded to him in a mocking tone and said, why don't you call the ombudsman or your caseworker? R5 was unable to recall the name of the NA. R5 stated he had called his personal representative to report his concerns since he felt no-one was responding to his request to talk. R5 felt he had been treated roughly and rudely on multiple occasions by this NA. On 4/19/22, 4:31 p.m. the administrator brought in evidence of a past investigation related to R5, and also the nursing schedule for 4/7/22 through 4/10/22 that had been reviewed in response to R5's allegations. The administrator stated the only person with a name starting with T had worked on 4/7/22 prior to R5's stated concerns, and stated that individual did not fit the description, so they had no one they could suspend while they investigated. Administrator and DON were both present and stated they had not yet spoken with R5 since receiving the reported concern at 10:47 a.m. because the facility worked with R5's representative, a case worker-advocate (CW) instead, saying that was what he [R5] was comfortable with. The administrator was unaware R5 had requested management speak with him, but no one ever came. A review of a Grievance/Complaint form dated 4/13/22 indicated the facility had received a concern from R5's CW. It indicated the complaint was provided to the administrator and social worker (SW). The grievance outlined R5's concerns with the NA (a person of color, name starting with T) turning off the call-light after he had requested assistance, and included a statement that NA had indicated lack of knowledge of how to change a bed with a resident in it [standard of care for NA]. Grievance indicated NA did not return for four hours. Also, the form included a grievance that the same NA took two hours to bring a glass of ice, and also the same NA had told R5 to hurry up as NA was scheduled to leave soon as it was almost 10 p.m. A subsequent review of the nursing schedule for 4/8/22 and 4/9/22 did not show any nursing assistants with a name starting with the letter T. When interviewed on, 4/20/22, 8:54 a.m. CW, providing support to R5, stated R5 had had similar concerns in the past. In the last week or so, R5 had stated a similar complaint of a person not providing care when he had turned his light on for assistance after he had a BM. R5 had reported rude, mocking and disrespectful behavior by a nursing assistant to CW. CW stated, Last week we talked to SW and administrator to file a grievance. I didn't know another way to file a complaint. CW said R5 had requested to talk to anyone in leadership, the administrator, DON, but said no-one had responded to his request. CW stated she assisted R5 by calling the facility to file a grievance on 4/12/22. In response to that call, CW said the facility indicated they would investigate his concerns, pull a call-light report and try to talk with the staff person to address R5's concerns. CW also said R5 could not recall the name of the NA, but it might have started with a T, and the incident had occurred possibly Friday 4/8/22 or Saturday 4/9/22 during the evening shift. CW stated she attempted to advocate for R5, but felt it was difficult as the facility did not often reach out to her and she felt there was little change in response to any concerns brought forward. When interviewed on 4/20/22, at 9:30 a.m. SW stated she had spoken to R5's CW on 4/12/22, CW had been concerned because an aide had turned off his call light, was not attentive, would not give him ice and made him wait 4 hours in soiled undergarment before changing him. SW stated the CW was reporting neglect and this should have been reported to the state agency and investigated. When interviewed on, 4/25/22, 8:20 a.m. NA-F stated she usually took care of R5 in the morning and R5 would require a total change of bed linen almost every morning due to accidents with his urinal use. NA-F stated R5 did not get out of bed at that time because it was too painful for him to use the Hoyer lift, but his arms were strong. NA-F stated R5 only required a boost on his back or bottom to fully turn in bed. NA-F stated she could easily change the linens and provide personal cares to R5 independently without assistance. NA-F stated that R5 sometimes had refused to have cares completed, but one person could provide those cares when he was accepting of them. When interviewed on 4/25/22, 9:33 a.m. R5 again expressed distress about being left in BM unattended, and being talked to in a mocking tone of voice and stated it made him feel, so, so .I felt uncared for, like you're, like you're not good enough. R5 had difficulty speaking this, turned away and had tears in his eyes. R17's significant change MDS dated [DATE], identified cognitively intact and had no behavior problems. R17 required extensive staff assistance for most activities of daily living (ADL's) except could feed self with set up. R17 diagnosis included heart, kidney and respiratory failure. R17's care plan dated 9/23/21, included paranoia/suspiciousness related to life experiences history of unhealthy relationships. R17's goal was to feel safe and secure in the environment. Staff were directed to, use consistent daily routine and caregivers, praise for acceptable behavior and explain procedures. Another care plan area was, ruminating and catastophizing behavior. Staff were directed to keep details to a minimum, remain positive, and ask if would like to be left alone for a while. In addition, the care plan identified R17 as a vulnerable adult and was at risk for abuse. Staff were to be educated on abuse reporting and R17 would be encouraged to verbalize concerns or problems. When interviewed on 4/18/22, at 2:31 p.m. R17 stated she was unsure of the date, but there was an incident which occurred possibly in August or September 2021 with NA-A. R17 stated she was unsure of the date, but she had been stronger and had been able to get up to the toilet. R17 said she had not been able to get fully seated on the toilet stool and had dribbled on it, so asked NA-A for paper towels to clean it. Then R17 said she realized she had not finished urinating and asked NA-A to wait. R17 reported that NA-A had said, Jesus Christ [R17's name]. R17 stated there had been another incident with NA-A where NA-A had come to collect her meal tray while R17 was on the toilet, and R17 had told her she was not yet done with the tray, and heard NA-A say, that figures. R17 stated she still had her beverages to drink, a dish of sweet potatoes and dessert left. R17 said, sweet potatoes are my favorite thing. When R17 returned to her room she found NA-A had removed the tray but left her beverages and dessert. R17 said she told NA-A that she was not done with the sweet potatoes and NA-A left the room, cursing under her breath, saying, Fuck you, and slammed the door. R17 said she had tried to talk with NA-A about her treatment and told NA-A she could not talk to her like that. R17 said NA-A had replied, look at the way you talk to me! R17 said she did report NA-A's behavior to the DON. R17 said the DON sat on the foot of the bed with her head in her hands and said, I'm just so short [staffing]. R17 said she had replied, are you going to have someone so abusive work here? A facility reported incident dated 6/14/21, identified, Today the resident stated to facility interim Administrator that on Monday night around 6 pm, she was abused. The resident stated the evening aide came into the room, took her dinner tray, walked out of her room and slammed the door. The resident stated she repeatedly asked/told the aide she wasn't done eating yet. The alleged staff member, identified as NA-A, had been suspended pending investigation. The investigative report dated 6/23/21, identified NA-A had claimed she had been polite to R17. The facility assigned NA-A to a different group of residents and assigend R17 to, Cares in Pairs. When interviewed on 4/20/22, 2:53 PM R17 reported the DON and social worker (SW) had come to talk to her. R17 said the DON had asked if NA-A had left any bruises, R5 said, I said, 'no, it was verbal abuse,' I don't know why she can't remember it! When interviewed on 4/22/22, 11:07 a.m. R17 voiced frustrated on her interactions with NA-A in the past, stating how angry she felt about it, and that she felt it was abusive behavior and the facility did not protect her from being cared for by NA-A. On 4/25/22, 9:40 a.m. R17 stated she wanted to talk about her experience with NA-A again. R17 repeated that she had reported the incident, and described her feelings about how she had been treated. R17 said, I felt like I was going to throw up. I didn't feel safe. Each time she came in, I thought she would say nasty things to me. It pissed me off, and made me feel angry. When I tried to talk to her in the past, it was like a power play. She [NA-A] said, 'oh, [R17] get real! R17 shrugged her shoulders. An anonymous staff member had filed a complaint on 3/8/22, on behalf of all residents indicating NA-A was providing, rough treatment to residents and would often refuse to assist them. Another separate complaint from a staff member was also filed on 3/8/22, identified NA-A was, rough and rude to residents and would refuse to assist them with cares. It was unknown if either of these staff members had reported their concerns to the DON or administrator as required in the facility policy as they did not leave contact information. When interviewed on 4/20/22, at 8:00 a.m. RN-A stated she had witnessed NA-A treat residents poorly. RN-A stated NA-A was short with the residents and would not listen to their needs. A couple months ago two residents, R99 and R5 had complained about NA-A and had reported the concerns to the DON. NA-A was then not allowed in R5's, R17's, or R9's room, because they did not like how NA-A treated them. However, because of scheduling NA-A was actually still caring for those residents. RN-A had witnessed sometime in December of 2021, NA-A was talking in harsh tones to residents, she did not remember who, and RN-A had confronted NA-A, but NA-A told her the residents had behaviors. RN-A did not send NA-A home or provide continuous supervision. RN-A stated the executive director had a conversation with NA-A. NA-A then confronted RN-A. cornering her in a room and slamming the door and yelled at her, if you have a problem with me, we don't need to get leadership involved. In the past couple weeks RN-A had witnessed NA-A tell R18, You don't have to use the bathroom, you can wait until it is the right time. RN-A stated there had been multiple times NA-A had been reported to the DON. When interviewed on 4/20/22, at 8:53 a.m. NA-A stated the facility had called her yesterday and made her aware of allegations pertaining to R9, but they were not specific. NA-A stated back in December 2021, the executive director told her she had a poor bedside manner and talked to her about communication and not rushing residents. NA-A denied being rough with, abusing or neglecting any resident. NA-A stated, if we are honest, I feel it's a racist thing. NA-A stated she was not supposed to care for R9 or R17, but sometimes she was the only one available to care for them, so she did. NA-A stated she felt multiple residents were alleging neglect of care, being rough/physically abuse or verbally abusive towards them because she, speaks loud, is efficient with her work and dictative. NA-A stated she has never refused to take residents to the bathroom, but reminds them when they had just been there or it wasn't time to go yet. The administrator and director of nursing (DON) of the facility were notified of the IJ on 4/20/22, at 2:13 p.m. On 4/21/22, Between 8:30 a.m. and 10:00 a.m. LPN-A, NA-B, MAINT, HSK-A, EVS-A had been interviewed and had not recieved education on the abuse policy and abuse reporting prior to starting their shift. However, by noon all staff working had been educated. The immediate jeopardy that began on 4/20/22, was removed on 4/21/22, when the facility removed NA-A from working with residents and she subsequently resigned; psychosocial assessments were completed with affected residents, investigations into the allegations were started to include interviews with staff and other residents, staff were educated prior to working their next shift to include reporting of allegations of abuse, investigating and on their abuse policy and audits of grievances were reviewed to ensure none met the definition of abuse for reporting. However, the noncompliance remained at the lower scope and severity level of a G, actual harm that is not immediate jeopardy because R9 and R24 both had expressed they had lived in fear due to the abuse not being addressed by the facility and it had affected their psychosocial wellbeing. Actions taken by the facility were verified through interview of LPN-A, NA-B, MAINT, HSK-A, EVS-A, SW, RN-A and NA-C, and review of psychosocial assessments and documentation of staff being trained on abuse. A facility policy dated March 2018, titled Abuse Prevention Program included, residents have the right to remain free from abuse and neglect. Upon receiving an allegation of abuse, the staff member receiving the allegation must immediately notify the supervisor on duty. The supervisor will immediately notify the administrator or designee. The alleged perpetrator will be asked to leave the facility immediately and be escorted out of the facility. If necessary law enforcement would be notified. If an employee, they would be suspended immediately pending investigation. The resident would have a full physical assessment and psychosocial support as needed. The administrator or designee would report the allegation to the state agency within 2 hours. All facility staff would be inserviced on the abuse prevention policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to ensure infection control procedures were implemented to reduce the risk and spread of an unknown gastrointestinal (GI) illness in the facility resulting in 10 of 28 residents (R82, R27, R1, R20, R18, R19, R26, R15, R13, and R9) developing GI symptoms and the facility lacked any investigation of causal factors and or testing for pathogen. In addition, the facility failed to implement timely isolation of symptomatic residents, and failed to perform hand hygiene following care of symptomatic residents, placing this vulnerable population of residents and health care workers at risk of serious illness. Further, the facility failed to use sanitary practices when passing ice water to residents, using bare hands and a cup inside with the ice to scoop, this had the potential to affect all 28 residents currently residing in the facility. The immediate jeopardy (IJ) began on 4/12/22 when the facility failed to ensure infection control procedures were implemented related to signs and symptoms of GI illness to reduce the risk of spread of unknown GI illness and was identified on 4/22/22. The administrator and director of nursing (DON) were notified of the IJ on 4/22/22, at 1:31 p.m. The IJ was removed on 4/27/22 at 1:07 p.m. when the facility ensured all residents with symptoms of GI illness were placed on transmission-based precautions with signage in place. All residents were screened for signs of GI illness, the physician was notified, policies and procedures were reviewed, all staff were educated, high touch areas were disinfected, tracking was started for employee call in's, and audits of handwashing were started. However, the non-compliance remained at the lower scope and severity of an E - a pattern with no actual harm with potential for more than minimal harm. Findings include: When interviewed on 4/20/22, at 2;39 p.m. the director of nursing stated they had some GI illness in the facility but it was resolved at this point. The DON stated they treated it as an outbreak and notified [NAME] County Public Health and notified the nurse practitioner and the medical director. One test had been ordered for R9, but canceled because R9 went to the hospital and they determined her symptoms were from constipation. Another specimen was ordered, but pending. Some staff had been ill with GI symptoms, but did not come back to work until all symptoms were gone. The DON had not tracked which staff had been ill. They were questioning if they had a norovirus (gastro-intestinal illness that is highly contagious), but did not have confirmation of that. The DON stated they put anyone who had one to two loose stools on precautions and anyone who had an emesis immediately. Staff were to wear gowns and gloves in any symptomatic resident room. Also, they placed the residents on, enhanced barrier protection, which meant staff were also supposed to use soap and water for washing hands after any cares rather than hand sanitizer. R82's admission Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment, with diagnosis of heart failure and dementia. R82 required extensive assistance with toileting and was frequently incontinent of stool. R82's care plan dated 4/15/22, identified a gastro-intestinal illness related to an outbreak of Clostridium Difficile Colitis, (an inflammation of the colon caused by the bacteria Cloststridium difficile, often resulting from disruption of normal healthy bacteria in the colon, often from antibiotics. C. Diff can also be transmitted from person to person by spores and spores are not killed by hand sanitizer, they can be washed off with judicious hand washing with soap and water). Staff were directed to, Maintain droplet precaution as indicated for cdiff, and monitor for signs of dehydration. The care plan did not direct staff on contact precautions or direct them to use soap and water for hand washing rather than hand sanitizer and did not give any direction on cleaning room or dedicating equipment to prevent the spread of infection. R82's medication administration record dated 4/15/22, identified enhanced barrier precautions for cdiff. R82's bowel record showed she had frequent loose stools, up to several times per day since admission on [DATE]. The facility GI illness tracking log identified R82, but did not identify the start date of loose stool, it indicated, Ongoing, only. The map of GI illness had R82 listed as being, C. Diff. During observation on 4/19/22, at 4:10 p.m. R82's door was closed and there was a sign on the door indicating, enhanced barrier precautions, and instructed to staff to clean hands and there was picture of a bottle of hand sanitizer on it, use of gloves and gown. A bottle of hand sanitizer was on top of the cart and some disinfectant wipes. During observation on 4/20/22, at 8:20 a.m. NA-B entered R82's room with a meal tray. NA-B did not put on gown or gloves. NA-B set the meal tray on R82's over-bed table and with bare hands moved the table towards R82 and arranged items on the tray table. NA-B then took the plate cover off and left the room without performing any hand hygiene. NA-B placed the plate cover on the tray cart, then proceeded to move the cart down the hall with her bare hands. When interviewed at this time, NA-B stated R82, might have C. Diff. NA-B stated she had been told to wear a gown and gloves if she was working with, body fluids, and did not wash her hands due to being in a hurry. NA-B stated she should have used hand sanitizer and was unaware C. Diff spores are not removed by using hand sanitizer and hand washing with soap and water should be used instead. When interviewed on 4/20/22, at 9:38 a.m. the environmental services supervisor (EVS)-A stated hand sanitizer should be used before going into a resident room and after leaving the room. In the case of C. dif, EVS-A stated she was not aware of any difference, stating, we typically use hand sanitizer, it is quicker. EVS-A stated infection control education had been provided at the facility, but did not recall receiving anything specific related to washing hands with soap and water in the case of C. dif. or Rotavirus. When interviewed on 4/20/22, a 9:46 a.m. licensed practical nurse (LPN)-A stated, for residents such as R82 who had C. Diff, the resident should have separate dedicated equipment, staff should use gown and gloves and hands should be washed with soap and water instead of hand sanitizer. LPN-A stated staff should be using hand washing with soap and water for any residents with vomiting or diarrhea symptoms. LPN-A was not sure why the TBP sign indicated hand sanitizer was to be used for R82. During observation on 4/21/22, at 10:50 a.m. occupational therapist (OT)-A was observed assisting R82 to the bathroom, R82 had an incontinent loose stool and OT-A wearing gown and gloves assisted R82 with cleaning up, when completed OT-A placed the soiled items in a bag. OT-A removed her gloves and gown and left the room with a tablet, OT-A set the tablet down and used hand sanitizer. When interviewed, OT-A stated R82 had an infection, but was unsure what type of infection. OT-A did not know R82 had C. Diff and hand washing should be used instead of hand sanitizer. OT-A had not sanitized her tablet after it had been in R82's room and touched by OT-A with contaminated hands. It was noted at this time, R82 shared a bathroom with R15 in an adjacent room. When interviewed on 4/21/22, 10:59 a.m. a registered nurse (RN)-C stated staff would know what type of transmission based precautions (TBP) a resident required if infectious by the sign posted on their door. RN-C also said that staff should use soap and water hand washing instead of alcohol based sanitizer when working with a person with C. dif, but was unsure it that information was posted on the door, or how staff knew that. After checking R82's door, and not finding such information, RN-C stated he was going to post a sign immediately. When interviewed on 4/21/22, 11:30 a.m. the director of nursing stated there had been some gastro-intestinal (GI) infections in the facility over the past week, but normally they did not consider it to be an outbreak until they had three or more cases of diarrhea in residents. DON said the physicians and nurse practitioners (NP) had been notified, but said they, didn't think anything of it, but DON stated in her past experience they would have been hyper-vigilant. Three residents had received orders for testing, but DON said they had been unable to gather a sample for one resident, and the orders for another had been canceled. The test for R82 had indicated R82 was positive for C. Dif. DON said in the case of a GI outbreak, residents with symptoms would be monitored, signs regarding TBP would be posted, and personal protective equipment (PPE) supplies would be placed outside the room. DON said she was unsure if there was a sign posted about using soap and water instead of hand sanitizer in the case of C. Dif. DON said she had not posted a sign, but had started educating staff between 9:30 a.m. and 10:00 a.m. and she would go post the sign right away. DON said she was going to start PPE and handwashing audits. DON said R15 and R26 had developed symptoms of GI illness, and she had placed them in enhanced barrier precautions and droplet precautions and was going to talk with the medial providers and strongly encourage testing to be done on them, and any residents who developed GI symptoms. DON said R15's FM should not use the bathroom shared with R82, but was unsure if there was a sign on the door or in the bathroom. R27's admission MDS dated [DATE], identified cognitively intact and had heart disease and diabetes. R27 required limited assistance with toileting and was continent of bowel. R27 was not shown on the facility GI illness tracking log. R27's medical record identified R27 had loose watery stools and emesis on 4/12/22, and had been placed on TBP, which were removed on 4/14/22. When interviewed on 4/22/22, at 9:00 a.m. R27 stated he had gotten ill about 10 days ago and has had loose stools off and on since then. When interviewed on 4/22/22, at 10:19 a.m. the DON stated a stool collection order was not obtained for R27 as they only had vomiting and no diarrhea. The DON was not aware R27 reported he had loose stools along with the vomiting on 4/12/22. During an observation and interview on 4/22/22, at 10:31 a.m. RN-C was observed leaving R27's room and proceeded going from room to room on south hall completing vital signs on each resident. RN-C observed using hand sanitizer outside each resident room instead of hand washing. RN-C was observed not sanitizing thermometer and pulse oximeter equipment between resident use. RN-C stated he should have disinfected the equipment between each resident and used soap and water for hand washing. R1's annual MDS dated [DATE], identified cognitively intact with diagnosis of heart disease. R1 required extensive assistance to toilet and was frequently incontinent of stool. R1's bowel record identified loose stools as early as 4/9/22, with multiple daily loose stools starting on 4/12/22. R1's care plan dated 4/22/22, identified a gastro-intestinal illness related to C. diff and Rotavirus, staff were to educate on signs and symptoms of GI outbreak, frequent handwashing and encourage to stay in room along with contact precautions, and to monitor for signs of dehydration. The care plan also directed to use soap and water for hand washing. R1 was identified on the facility map of GI infections as being in one room but moved due to GI illness symptoms to another room where she did not have a room mate and a stool specimen was sent on 4/23/22. The line listing of GI illness identified R1 as starting symptoms on 4/20/222, with the word, again. A stool specimen had been sent and was back, with no information on pathogen. R1's Clinical Communication from Mayo Clinic lab identified they had received a stool specimen on 4/23/22, and the stool contained Rotavirus and C. Diff and directed facility to place R1 on isolation and provide proper infection control processes and a report was sent to community heath. Vancomycin (antibiotic used to treat C. Diff) was ordered. R1's progress note dated 4/23/22, at 10:42 p.m. included, Call received from [physician] from clinic with lab results for resident. Stool was tested and resulted with positive results for Rotavirus and C-diff. Pharmacy notified, as [physician] gave telephone order for Vancomycin 125 mg to start within 24 hrs. Pharmacy will be sending enough med through back up pharmacy to be started tomorrow morning. When interviewed on 4/24/22, 8:17 a.m. RN-C stated R1 had developed GI symptoms the previous evening, and had to be moved to a private room. Testing had been completed immediately and returned results indicated R1 had Rotavirus and C. Diff. RN-C stated staff were to isolate the resident, wear PPE of gown, gloves and mask and wash hands with soap and water. R20's quarterly MDS dated [DATE], identified cognitively intact and diagnoses including irritable bowel syndrome with diarrhea and a stroke. R20 required extensive assistance with toileting, but was always continent of bowel. R20's bowel and bladder elimination log for April 2022 identified loose stools starting on 4/14/22, had two loose incontinent stools on 4/15/22 and again on 4/21/22. R20's progress notes identified the DON had been notified of loose stools and R20 was placed on transmission-based precautions (TBP). R20 was identified on the facility GI illness tracking log as starting symptoms on 4/21/22. The map of GI illness's identified R20 as having Rotavirus and GI symptoms. R20's Clinical Communication from Mayo Clinic identified a stool sample had been obtained by the lab on 4/22/22, and on 4/25/22 the specimen identified Rotavirus (a very contagious virus that causes diarrhea, vomiting, fever and/or abdominal pain and can lead to dehydration or even death). The communication identified public health would need to be notified of this contagious virus. A nurse practitioner note dated 4/22/22, also identified R20's stool sample was positive for Rotavirus. During observation on 4/22/22, at 9:50 a.m. nursing assistant (NA)-B was in R20's room and arranged items on the bedside stand, removed gloves and left the room without washing hands. NA-A touched R20's door handle, then went to a mechanical lift in the hallway and brought it to the communal bath hallway. NA-A then went into R3's room and went into the bathroom where she washed her hands. NA-A did not disinfect the door handle or the lift after touching with contaminated hands. During observation on 4/22/22, at 9:58 a.m. medical doctor (MD)-C was observed to have assisted R20 with toenails, when MD-C exited the room he used hand sanitizer outside of the room. According to the Center for Disease Control (CDC) updated 2021, hand washing with soap and water is most effective for removing Rotavirus from hands versus hand sanitizer. MD-C used his personal laptop, touched a backpack then used personal cell phone from shirt pocket and proceeded to R30's room. MD-C donned gloves without washing hands with soap and water and assisted R30 with toenails. When interviewed on 4/22/22, at 12:11 p.m. MD-C stated staff had instructed him to don/doff gloves at door, but did not specify the type of illness the residents who were on TBP had. If he had known, he would have used soap and water versus hand sanitizer. During observation on 4/24/22, at 9:25 a.m. R18 attempted to bring a bottle of sparkling water to R20 whose room is directly across the hall. The regional nurse consultant (RNC)-B instructed R18 she could not take items from one room to another without using a bleach wipe on it. During observation on 4/25/22, at 8:27 a.m. the health unit coordinator (HUC) knocked on R20's door, donned personal protective equipment (PPE) and entered the room with a meal tray. The HUC set the tray on the bedside table, moved R20's urinal off the bedside table, removed gloves and stepped outside the room, where she punched a code into the utility room door and used the door handle to open the door. The HUC then washed her hands, but did not disinfect the code buttons or the door handle that she had touched with potentially contaminated hands. The facility provided room tracking log identified R20 as having GI symptoms, and the GI illness tracking log identified R20 as beginning symptoms on 4/21/22, even though loose stools were noted prior to that date. R18's significant change MDS dated [DATE], identified cognitively intact with diagnosis of multiple sclerosis. R18 required extensive assistance with toileting and was frequently incontinent of stool. R18's bowel record identified loose watery stools on 4/14/22. R18's medical record identified she had been placed on TBP on 4/16/22, but was removed on 4/18/22. A progress note identified a note was sent to R18's physician on 4/22/22 indicating she had loose stools again, so isolation precautions were started again. R18 was identified on the facility GI illness log as starting symptoms on 4/22/22. During an observation on 4/24/22, at 8:08 a.m. a new isolation cart was located outside R18's room. During an observation on 4/24/22, at 8:47 a.m. R18 was observed coming outside of her isolation room and into hallway. LPN-A glanced over and asked R18, What's up? and did not provide redirection to R18 to go back into her room. Family member (FM)-A was observed leaving another resident room on north hallway and redirected R18 to go back into her room. FM-A donned PPE and assisted R18 back to room. During an observation on 4/24/22, at 8:54 a.m. R18 was observed back in hallway requesting help to get to the bathroom. LPN-A observed at medication cart; while FM-A ran down the hallway to assist. FM-A requested help from DON; however, DON told FM-A to, hold on. R18 stated she couldn't wait. R19's quarterly MDS dated [DATE], identified cognitively intact with diagnosis of diabetes and prostate cancer. R19 required extensive assistance for toileting and was always continent of bowel. When interviewed on 4/19/22, at 11:35 a.m. R19 stated he had become ill with severed diarrhea starting 4/16/22. R19 stated staff were aware of his diarrhea and had placed incontinent pads on his bedding as he was unable to control the loose stools. R19 stated he had started to feel better on 4/18/22 in the evening, but was still unable to eat much dinner. R19 stated he had never been placed on any time of precautions and he went out to eat Easter lunch on 4/19/22, but was unable to eat as he still felt ill. R19's bowel elimination record for April 2022, identified regularly formed stools until 4/16/22, then had incontinent watery/diarrhea bowel movements after 4/16/22. R19's progress notes did not show any identification of the diarrhea, nor did R19's medical record show any evidence the physician had been notified of the illness or any monitoring of R19's illness. When interviewed on 4/22/22, at 10:19 a.m. the DON stated . DON confirmed she was aware R19 had diarrhea on 4/16/22 as she worked an overnight shift. DON failed to inform medical provider of gastrointestinal symptoms. DON confirmed R19 was never placed on isolation precautions and his symptoms still existed on 4/18/22. No stool sample had been sent to the lab. A facility provided map of GI illness symptoms, undated, identified several residents who had GI illness, but R19 was not identified as having any GI illness. A line listing of residents who had been ill with a GI illness dated 4/24/22, also did not identify R19. R26's quarterly MDS dated [DATE], identified cognitively intact with diagnosis of heart failure. R26 required extensive assistance with toileting and was frequently incontinent of bowel. R26 was identified on the facility GI illness tracking log as beginning GI symptoms on 4/21/22. The map of illness showed she had GI symptoms. R26 has 2 loose stools on 4/19/22, 4/20 had one loose, one formed, 4/21 had 7 loose stools, was put on isolation the 21st. During an observation on 4/21/22, 10:29 a.m. R26 had a sign on her door indicating the need for droplet precautions, but the door was wide open and R26 was sleeping without cough or obvious symptoms of respiratory disease noted. R26's bowel record showed R26 had loose stools on a regular basis, but had an increase in frequency on 4/21/22. R26's clinical communication from Mayo clinic identified R15's stool sample had been obtained on 4/22/22, and was identified to be Rotavirus and community health was to be advised. R15's admission MDS dated [DATE], identified cognitively intact, required extensive assistance with toileting, and was frequently incontinent of bowel and had a diagnosis of ulcerative colitis, Chrohn's disease or an inflammatory bowel disease. R15's bowel record showed she had started having loose stools on 4/16/22. R15's physician orders dated 4/24/22, identified staff were to collect a stool specimen for diarrhea over 7 days. The facility GI illness tracking log identified a start date of symptoms as 4/20/22. The map of infections identified her as having a GI illness. During an observation on 4/21/22, at 10:49 a.m. it was noted R15 shared a bathroom with R82 who had been placed on precautions for GI illness. Family member (FM)-C was visiting R15, but was not wearing a gown, gloves or mask. He was overheard on the phone to not visit as R15 had a case of, stomach flu. FM-C went into the shared to the bathroom. FM-C came out of the bathroom. At 10:57 a.m. FM-C said he was aware of R15's illness and also R82's illness. FM-C said persons should not enter without wearing a gown and gloves. FM-C stated it was too far to walk all the way down the hall to dump things such as unconsumed beverages, so he had gone in the bathroom to dispose of them. He said he had been told he should not use the bathroom. He stated there was no posted information in the bathroom regarding use of the toilet or handwashing. R15's progress note dated 4/22/22, at 8:45 a.m. identified R15 had developed, GI symptoms that have been going around the facility. R13's quarterly MDS dated [DATE], identified cognitively intact with diagnosis of a stroke. R13 required extensive assistance to toilet and was frequently incontinent of stool. R13 was identified on the GI illness tracking log that he had developed symptoms and was placed on isolation on 4/21/22. R9's quarterly MDS dated [DATE], included cognitively intact with diagnoses including cerebral palsy. R9 required extensive assistance with toileting and was always continent of bowel. A progress note dated 4/12/22, at 1:29 p.m. indicated R9 had four episodes of emesis which started at 7:15 a.m. Registered nurse (RN)-A documented R9 suddenly awoke this morning and threw up without no warning. R9 had one small, hard bowel movement but has refused enema at this time. RN-A documented there were reports of other residents with symptoms on emesis at the skilled nursing facility. A progress note dated 4/13/22, at 10:08 a.m. indicated R9 requested to go to emergency room for evaluation as she was not feeling well. R9 stated she felt weak and had abdominal discomfort. R9 refused enema at this time. At 4:50 p.m., R9 returned to facility. An emergency department note dated 4/13/22, at 1:47 p.m. indicated R9 was likely to have constipation; however, abdominal pain and vomiting resolved without further intervention. A fleets enema offered to R9, but she declined since her abdominal pain resolved. A progress note dated 4/16/22, at 10:21 a.m. indicated R9 had two emesis and two loose stools which was reported to director of nursing (DON). At 10:09 p.m., R9 had three emesis and diarrhea. On 4/17/22, at 6:30 p.m. licensed practical nurse (LPN)-A indicated R9 had no emesis or loose stools on this shift and the issues were resolved. When interviewed on 4/18/22, at 4:02 p.m. R9 stated she became violently ill on 4/12/22 with gastrointestinal signs and symptoms of vomiting and diarrhea. R9 stated she was so ill that it was coming out both ends at the same time. R9 stated she requested to be transferred to the local emergency department on 4/13/22. R9 stated other resident's down the south hallway with similar gastrointestinal symptoms. R9 stated she was sick all week with nausea, vomiting, and diarrhea and could barely eat as her stomach did not feel well. R9 stated the facility placed her on isolation precautions; however, the isolation cart which was located outside R9's room was not utilized on 4/18/22 and no door signs were posted. When interviewed on 4/22/22, at 10:19 a.m. the DON stated the nurse practitioner (NP)-A had canceled a stool specimen for R9 as she had issues with constipation not diarrhea and was maybe not part of the GI illness outbreak. When interviewed on 4/21/22, at 12:27 p.m. the facility social worker (SW) stated she had not received any new infection control training today. When interviewed on 4/21/22, at 12:31 p.m. RN-E stated she had not received any recent infection control training. When interviewed on 4/22/22, at 11:18 a.m. the DON stated it was important for staff to be using a bleach based cleaning solution for surfaces, but had not switched out their standard disinfectant with bleach. The DON stated they would do that right away. When interviewed on 4/22/22, at 10:19 a.m. the DON stated no stool samples had been obtained yet, they had received orders, and sent specimens in the wrong type of specimen cup so they had been rejected by the lab on 4/21/22. When interviewed on 4/24/22, 8:39 a.m. DON stated one staff person had developed GI symptoms 4/22/22 and was sent home, and another had called in sick overnight; R1 was moved due to symptoms and confirmed GI infections The facilities GI illness outbreak log identified a dietary aide had come down with GI symptoms on 4/22/22 and a nurse had on 4/24/22. When interviewed on 4/24/22, 8:39 a.m. DON stated one staff person had developed GI symptoms 4/22/22 and was sent home, and another had called in sick overnight; R1 was moved due to symptoms and confirmed GI infections. DON also said R18 had started to develop some GI symptoms on 4/22/22 in the afternoon. DON said she had done some staff audits on PPE use and handwashing for the facility IJ removal plan that morning when arriving at the facility. DON stated a regional nurse consultant (RNC)-B had come in to help, and they had been going through their infection control policies in the last two days. When interviewed on 4/24/22, 8:59 a.m. RNC-B stated she was not sure if the correct cleaning products were out on the isolation carts for staff to use, but then brought in a container of Oxivir TB wipes containing peroxide, and said they did have the correct cleaning solution. Shortly after this, an observation revealed there were no bleach, peroxide or Oxivir TB wipes on any isolation carts or with the shared equipment in the facility such as mechanical lifts. During an observation on 4/25/22, at 8:14 a.m. NA-F walked across the north hallway carrying unbagged laundry against her clothing to the dirty clothes bin. NA-F then washed hands located near the laundry receptacle. NA-F did not change her potentially contaminated clothing. When interviewed at 8:17 a.m. NA-F stated she should have bagged the laundry and not carried it against her clothing. During an observation on 4/25/22, at 8:27 a.m. HUC knocked on R20's door, donned appropriate PPE, entered the room with R20's breakfast tray, set the breakfast tray down the bed side table, moved R20's urinal off the bedside table, removed gloves, stepped outside the threshold of R20's room, removed her gloves, walked to the utility room door, punched the code in, used the door handle to open the door, entered and washed her hands with soap and water, exited the room and walked away. HUC did not disinfect the door handle. During an interview on 4/25/22, at 8:39 a.m. RNC-C indicated she had seen the HUC contaminate the door code and handle, and indicated more infection control audits of the staff needed to be completed. When interviewed on 4/25/22, at 9:29 a.m. registered dietician (RD) indicated even though she had educated nursing staff to not return trash from isolated resident trays back to the kitchen, the practice continued. RD indicated in order to mitigate this she had made signs so that this practice was stopped. When interviewed on 4/24/22, at 10:01 a.m. RNC-B and the administrator stated they had updated all resident care plans and had ordered disinfectant that works on Rotavirus and C. Diff. They had placed spray bottles of bleach solution for staff to use on each wing. Lab results for R20 and R26 had come back and were positive for Rotavirus. When interviewed on 4/25/22, at 11:28 a.m. RD stated even with all the signs on the resident doors who are on isolation and again talking to nursing staff, nursing brought back 5 trays from isolation rooms with garbage back to the kitchen. One was tray was even set on a kitchen countertop. During an observation on 4/25/22, at 11:49 a.m. R21 wheeled down to use the communal bathroom in the hallway and then returned to her room. R21's roommate remained on TBP for GI illness. The toilet bowel in the bathroom was observed to have brown spots all over the toilet bowel. At 11:57 a.m. NA-B walked down the hallway with gloves on carrying a used mattress protector up against her chest. NA-B then walked to a mechanical lift located down the hallway and used the appropriate disinfectant to wipe it off, then washed her hands with soap and water. NA-B did not change her contaminated clothing. At 11:59 a.m. NA-B assisted R9 onto mechanical lift and put her on the toilet in the communal bathroom, even though the brown spots on the toilet seat had not been cleaned off. During an interview on 4/25/22, at 12:04 a.m. NA-B confirmed she put R9 onto the toilet in the communal bathroom and stated R10 who was on TBP and was R21's roommate. NA-B stated R21 had a formed bowel movement, stated she had wiped down the toilet seat however did not clean the toilet bowel prior. NA-B indicated the toilet bowls were not cleaned between residents, the toilet had overflowed over the weekend, the brown spots on the bowl had been there the whole weekend, and housekeeping had not cleaned it after it overflowed. NA-B stated she knew that brown stuff has been there since Saturday, that's when I noticed it During an interview on 4/25/22, at 12:13 p.m. HSK stated she had been the housekeeper on Saturday. HSK indicated she had been told to clean only the resident room bathrooms and did not clean the communal bathrooms and/or toilets on Saturday. During an observation and interview on 4/25/22, at 12:21 p.m. EVS-A completed cleaning the toilet in the communal bathroom, brown spots were not longer observed in the toilet bowl. EVS-A verified the condition of the toilet bowl prior to cleaning. EVS-A stated that was the first time she had cleaned the bathroom/toilet today. Indicated she had not cleaned it prior because the bathroom had been busy. EVS stated the toilet bowls were not disinfected after each resident and were cleaned after breakfast, after lunch, and before leaving at the end of the day. EVS-A stated she had worked on Sunday and did not notice the dirty toilet bowl. During an interview on 4/25/22 at 12:39 p.m. RNC-C was unaware why commodes were not being used until surveyor brought it to her attention. RNC-C indicated in outbreak status it would be expected to be cleaning the toilet in between each use. RNC-C indicated the facility would need more time to have an interdisciplinary team [TRUNCATED]