Based on observation, staff interview, and facility policy review, the facility failed to safely store and lock hazardous cleaning chemicals in one (1) of four (4) shower rooms observed during the annual survey. Findings Include: A review of the facility policy titled Hazardous Materials/Chemicals and Waste-Storage, revised on 11/7/23, revealed, Purpose: To provide a policy whereby hazardous materials/chemicals and waste can be stored in a safe manner to prevent injury to patients, personnel, or visitors. Policy: It is the policy of this facility that all hazardous materials are received into the department by appropriate personnel and stored in a supply closet suitable for chemicals . Storage areas are kept locked and secured from the public at all times to prevent injury to patients, personnel, or visitors . Hazardous waste storage and processing areas will be free of clutter and effectively separated from patient care . All Hazardous Waste is to be kept in a locked and secure area inaccessible to the general public . An observation of the south shower room on 8/26/24 at 10:30 AM revealed two (2) spray plastic containers of Clorox cleaner and one (1) spray plastic container of Medco Rinse Agent sitting on the top of a shelf, unattended and not secured. A second observation of the south shower room on 8/26/24 at 11:40 AM revealed the same two (2) spray plastic containers of Clorox cleaner and one (1) spray plastic container of Medco Rinse Agent sitting on top of a shelf, still unattended and unsecured. On 8/26/24 at 4:00 PM, during an observation and interview the Director of Nursing (DON) confirmed that the chemicals were sitting on top of a shelf in the shower room, unattended. The DON stated that both the Clorox cleaner and Medco Rinse Agent should have been locked inside a cart, as they are biohazard chemicals. She confirmed that there were no wandering residents in the facility and that there had been no incidents involving chemicals in the last 12 months. During an interview on 8/26/24 at 4:20 PM, the Administrator confirmed that chemicals should not be left unattended anywhere in the facility and should always be securely locked. The Administrator acknowledged that the chemicals could be harmful if residents accessed them. A review of the Medco Rinse Agent Material Safety Data Sheet (MSDS), prepared on 2/2/09, revealed that exposure to the eyes, skin, respiratory tract, or gastrointestinal tract could be irritating. A review of the Clorox Germicidal Bleach Safety Data Sheet (SDS), revised on 12/11/20, revealed that in case of eye or skin contact, inhalation, or ingestion, immediate medical attention is required.

Based on observations, interviews, and facility policy review, the facility failed to ensure proper sanitation procedures were utilized during dishwashing, as evidenced by, the minimum water temperature of the low-temperature dishwasher machine was not reached during two dishwasher observations for two (2) of four (4) dietary tours. Findings Include: A review of the facility's policy titled Machine Warewashing, revised on 09/12/11, revealed, Chemical Sanitizing Machines use a low temperature to clean and sanitize. Follow the dishwasher manufacturer's guidelines. Suggested temperature = 120 degrees. If the dish machine cannot be used, dishes should be washed according to the procedures for washing pots and pans in the three-compartment sink. During an observation on 08/28/24 at 12:01 PM, Dietary [NAME] #2 demonstrated how the low-temperature dishwasher worked. It was noted that the chemical sanitizer was within the recommended manufacturer's guidelines, however, the thermometer of the machine only measured 60 degrees Fahrenheit (F). At that time, the Dietary Supervisor ran the machine three (3) more times, but the temperature remained at 60 degrees F. Dietary Worker #3, who normally checked the dishwasher temperature, used an analog thermometer to manually check the water temperature. The temperature was 110.6 degrees F. On 08/28/24 at 12:43 PM, the Administrator observed the rinse cycle of the dishwasher and confirmed the dishwashing thermometer was not working. On 08/29/24 at 9:09 AM, the Dietary Supervisor was observed running the dishwasher. She stated that they continued to use the dishwasher as the temperature, manually checked that morning, revealed it reached 114 degrees F. She added that chemicals were also used in the dishwasher. The Dietary Supervisor stated that she was also pre-rinsing the dishes with hot water and dishwashing liquid. The policy was reviewed with the Dietary Supervisor, and it stated that if the dishwasher could not be used, dishes should be washed according to the procedure used for washing pots and pans in the three-compartment sink. The Dietary Supervisor confirmed that she had not been following this procedure. On 08/29/24 at 9:45 AM, Dietary [NAME] #2 was observed testing the three-compartment sink with test strips and demonstrated that the chemical levels were within the manufacturer's recommended guidelines. On 08/29/24 at 9:57 AM, during an interview, the Maintenance Supervisor stated that the dishwasher servicing company had arrived the previous afternoon around 4:00 PM and informed the facility that the part for the dishwasher had to be obtained from a nearby town, and they should be back later that day. On 08/29/24 at 11:10 AM, the Administrator confirmed that the dishwasher servicing company had been in the building earlier that morning and was in the process of obtaining a part to ensure that the dishwasher's temperature reached and recorded the recommended temperature. On 08/29/24 at 12:27 PM, the kitchen staff were observed washing dishes in the three-compartment sink.

Based on interviews, record review, and facility policy review, the facility failed to implement its protocol for antibiotic use and thereby failed to prevent the unnecessary and inappropriate antibiotic use for one (1) of five (5) residents reviewed for unnecessary medications. Resident #78. Findings Include: Review of the facility's, Antibiotic Stewardship Policy revised 9/9/22, revealed, It is the policy of this facility to observe the practice of Antibiotic Stewardship to monitor antibiotic use in the care and treatment of our residents. It is our goal to promote appropriate selection and use of antibiotics . Monitoring for accountability of provider and staff for following acceptable criteria (McGreer criteria) for initiation and continued treatment with an antibiotic . As part of the Antibiotic Stewardship Program, all clinical infections treated with antibiotics will undergo review by the infection preventionist (IP) . Review of the facility's, ESBL (Extended-Spectrum Beta-Lactamases) or VRE (Vancomycin Resistant Enterococci) in Urine Protocol, updated 3/28/22, revealed, In the event a urinalysis is positive for ESBL or VRE the facility will follow the steps of this protocol. Implement contact precautions and complete antibiotic treatment as ordered by the provider. Communicate current or recent treatment to provider and no follow-up urinalysis . Record review of the Physicians Orders for Resident #78, revealed a physician's order dated 12/20/22, for Macrobid 100 mg (milligrams) by mouth twice a day for ten days related to urinary tract infection (UTI). Record review of the result of the facility's, Urine Culture, dated 12/22/22, revealed Escherichia Coli (ESBL). Record review of the Resident # 78's Physicians Orders dated 12/22/22, revealed the Nurse Practitioner ordered Augmentin 500-125 mg by mouth twice a day for seven (7) days related to UTI. Record review of the facility's, December 2022 Medication Administration Record (MAR) confirmed Resident #78 received Macrobid 100 mg twice a day for 10 days for UTI and Augmentin 500-125 mg twice a day for seven (7) days for UTI. Record review of the Departmental Notes, revealed a nurses note dated 12/20/22, at 10:18 AM, of a monthly telemedicine visit with the Medical Doctor, in which a Licensed Practical Nurse (LPN) reviewed the U/A (Urinalysis) results for Resident #78 and received a new order for Macrobid 100 mg to be given twice a day for 10 days for UTI. Record review of the Departmental Notes, revealed a nurses note dated 12/23/22, at 2:31 PM, of documentation by a LPN that Resident #78 continued to receive both Augmentin 500-125 mg and Macrobid 100 mg orally twice a day. Record review of the facility's, Revised McGeer Criteria for Infection Surveillance Checklist, dated 12/29/22, revealed Resident #78 met UTI criteria. Registered Nurse (RN) #2 reviewed the checklist nine (9) days after Resident #78 began taking antibiotics. During an interview on 1/11/23, at 10:00 AM with RN #2, she confirmed she is the Infection Preventionist (IP) for the facility. The IP revealed that she was off during the time Resident #78 was on antibiotic therapy. The IP said she is responsible for initiating the McGee's tool when a resident is placed on an antibiotic. She stated the Director of Nursing (DON) monitors the antibiotics when she's off. The IP confirmed she initiated the tool when she returned. She stated she thought the Macrobid was discontinued, and the Augmentin was started. During an interview on 1/11/23, at 10:20 AM, with the Director of Nurses (DON), she confirmed she was responsible for covering for the IP when she's on vacation. The DON confirmed she failed to follow the facility's antibiotic protocol while the IP was on vacation. During an interview on 1/11/2023, at 11:00 AM, the Nurse Practitioner (NP) confirmed on 12/22/22, he ordered Augmentin 500-125 mg po (by mouth) twice a day times seven (7) days related to UTI for Resident #78. The NP revealed he unaware the physician had ordered Macrobid on 12/20/22. The NP said the nurse called him with the culture results. He was not told the resident was receiving Macrobid. The NP confirmed receiving both antibiotics at the same time was unnecessary, as the Macrobid could have managed the infection. The NP also confirmed any time several antibiotics are given, it could result in the resident developing a Multi Dose Resistant Organism (MDRO). During an interview on 1/11/23, at 2:00 PM, RN #1 confirmed she received the order for Augmentin 500-125 mg. RN #1 said she doesn't know why she didn't tell the NP about the Macrobid. The nurse stated she normally checks the residents' medications for allergies and other medications. RN #1 confirmed she is familiar with the facility's antibiotic stewardship protocol and normally looks at the resident's medication and the culture for sensitivity. Record review of the Face Sheet, revealed the facility admitted Resident #78 on 1/13/22. The resident's diagnoses included Urinary Tract Infection, Dysuria, Urine Retention, and Depression. The Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 10/14/22, revealed Resident # 78 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure resident rights were honored by prohibiting residents from group activities and restricting resident use of common areas of the facility without clinical justification for three (3) of 18 sampled residents, with the potential to affect 62 residents. Residents # 3, #4, and #45 Findings include: Record review of the facility's policy, Resident Rights Policy, updated 9/5/15, revealed, It is the policy of this facility that resident rights will be addressed as follows: .Exercise rights .Each resident will be able to exercise his/her rights as follows: As a resident in this facility . 2. To voice grievances to: .State Department of Health . Resident #3 On 1/08/23 at 11:25 AM, during an observation and interview with Resident #3, he was dressed and sitting in his room with the door open. Resident #3 revealed that because his unit of the facility has COVID-19 positive residents, the facility has prohibited the COVID-19 negative residents from having group activities by restricting the use of common areas. A record review of the Face Sheet of Resident #3 revealed the resident was admitted by the facility on 5/27/22 with diagnoses including Rheumatoid Arthritis, Heart Disease, and Type 2 Diabetes Mellitus. A record review of Resident #3's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/21/22, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. Resident #4 On 1/08/23 at 11:45 AM, during an interview with Resident #4, the State Agency (SA) observed Resident #4 dressed and sitting in her room. She confirmed that since her unit has COVID-19-positive residents, the facility has restricted the COVID-19 negative residents from entering the common areas in the facility. A record review of the Face Sheet revealed the facility admitted Resident #4 on 3/22/19, with diagnoses including, Acute kidney Failure, Type 2 Diabetes Mellitus, and Heart Failure. A record review of Resident #4's Quarterly MDS with an ARD of 11/21/22, revealed a BIMS score of 15, which indicated she was cognitively intact. Resident #45 On 1/08/23 at 11:55 AM, during an interview with Resident #45, she revealed that the facility has required that she remain on her unit and not enter the common areas in the facility, because there are COVID-19 positive residents on her hall. A record review of the Face Sheet revealed the facility admitted Resident #45 on 11/19/17 with diagnoses including Essential hypertension, Chronic Kidney Disease, and Type 2 Diabetes Mellitus. A record review of Resident #45's Quarterly MDS with an ARD of 10/10/22, revealed she had a BIMS score of 15, which indicated she was cognitively intact. On 1/08/23 at 12:05 PM, an interview with Certified Nurse Assistant (CNA) #1, working on the south unit of the facility, confirmed the facility had restricted both COVID-19 positive and negative residents from exiting the unit and going to any common areas in the facility. On 1/09/23 at 9:25 AM, during an interview with License Practical Nurse (LPN) #1 confirmed the south unit has several residents that are COVID-19-positive. LPN #1 revealed she was informed by the Director of Nursing (DON) and Infection Preventionist (IP) that the residents that are COVID-19 negative, as well as the COVID-19 positive residents were to remain on the unit and not allowed to exit to common areas in the facility. On 1/09/23 at 12:15 PM, an interview with the IP confirmed there were both COVID-19-positive and negative residents on the south unit. The IP revealed to keep COVID-19 from spreading throughout the facility, she felt it would be best to prevent the negative residents on that unit from entering the common areas. On 1/09/23 at 12:25 PM, an interview with the DON revealed she had requested the residents in the south unit, who are COVID-19 negative to remain within the unit, to avoid the spread of COVID-19 to other areas of the facility. The DON confirmed she informed her staff that COVID-19 negative residents should avoid the common areas within the facility. On 1/09/23 at 12:30 PM, an interview with the Administrator revealed his expectation is that COVID-19 negative residents are allowed to enter the common areas in the facility.

Based on resident interviews, staff interviews, record reviews, and facility policy review, the facility failed to ensure the resident funds were free from misappropriation, for one (1) of four (4) Resident Trust Funds reviewed. Resident #61. Findings include: A review of the facility's Abuse and Neglect-Consumer Information Sheet, undated, revealed, according to the Nursing Home Reform Act of 1987, all residents in nursing homes are entitled to receive quality care and live in an environment that improves or maintains the quality of their physical and mental health. This entitlement includes freedom from abuse and misappropriation of funds. Review of the facility's policy titled, Abuse, Neglect, or Exploitation Policy, no date, revealed: Definition: Misappropriation of Resident Property- The deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident's belongings or money without the resident's consent. Reporting: The complaint must be reported as soon as possible to the Administrator, Director of Nurses, and Facility Contact Person. Investigation: Any report of abuse, neglect or exploitation will be investigated by the Administrator, Director of Nurses, Social Services, Quality Assurance Committee, and Facility Security. Action: Any employee suspected of abuse, neglect or exploitation will be investigated and actions taken will at the discretion of administration. On 8/15/19 at 11:00 AM, an interview with Administrator #1, revealed nothing had been reported to him. On 8/15/19 at 11:01 AM, an interview with Administrator #2, revealed nothing had been reported to her. On 8/15/19 at 11:05 AM, an interview with the Assistant Administrator (AA), revealed she was not aware of anyone handling the resident roughly, but rather it was Certified Nursing Assistant (CNA) #5 (CNA #5 was also Resident #61's relative) taking the resident to the bathroom. The AA stated the resident had stated CNA #5 had not been talking to her. The AA also stated she asked CNA #5 to take someone with her when she went in to care for Resident #61. The AA stated Resident #61 reported to her that CNA #5 did not want to work with her (Resident #61) and that CNA #5 was acting like her daddy. The AA stated Resident #61 and CNA #5 just did not get along. The AA stated CNA #5 had started swapping out when she had to care for Resident #61. She also stated she had talked with the Resident #61's Resident Representative (RR) and the RR stated she gets along with her cousin, CNA #5. The AA stated Resident #61 thinks transferring on the sit to stand lift is handling her rough because she is unable to hold onto one side of the lift, and she thinks the staff is doing something to her. She stated Resident #61 feels she can do more than what she is able to do for herself. She also stated she does know it was the sit to stand lift that Resident #61 was referring to. The AA stated Resident #61 never reported to her that CNA #5 was handling her roughly. She stated she did not do an investigation because she did not feel there was anything to investigate because this happened before the last survey. She also stated Resident #61 stated she had some money missing but Resident #61 had found her money. The AA stated, Resident #61 had $105.00 or $106.00. She stated she was off from work the next day. She also stated, Resident #61 had given the Licensed Social Worker (LSW) $100.00 and had gotten $50.00 of it the other day from the LSW. She stated Resident #61 signed off on it in her (AA) office and she (AA) had the money in a little locked box. The AA stated that was the day Resident #61's son had come to the facility. She also stated Resident #61 has $50.00 left. The AA stated she usually does not hold money. She stated the resident had money missing last month and had brought some money to the office to the LSW and Front Office Worker #1 which was $100.00. She stated Wednesday morning when she returned to work, the LSW gave her $100.00 for Resident #61 and this was last week, but her days are kind of running together. The AA also stated when the resident's son was at the facility, Resident #61 had gotten $50.00 of her money. She stated she rolled the camera back, and she did not see anyone go in or out of Resident #61's room. She also stated the next day Resident #61 brought the money to her office because she did not want to hold that amount of money. She stated she does not know the policy on when a resident has missing money. She also stated she generally handles it by telling the residents if they have any problems to let her know about it and she will roll the camera back. She stated she did not tell Administrator #1. She also stated she told the Director of Nursing (DON), but at that time, the money came back. She stated to her, the situation was over with because she (Resident #61) brought money to the office. She also stated, she asked the resident when she has that kind of large sums of money, she needs to have it locked up. She stated Resident #61 had not had that type of money before. The AA also stated she did not write anything down regarding the CNA situation or the money situation. She stated it is the facility's policy to investigate the resident's concerns, but she did not investigate because it was an issue that was resolved. She also stated other than the nurse that was standing in the hallway, no one knew about the situation. She stated she does not remember who that nurse was. She stated she should have gone to the Director of Nurses (DON) and the DON should take the next step, but she kind of handled it herself. She stated she thought everything was okay. She stated Resident #61 wants to go home tonight if she could. She also stated the resident was here previously, had gone to a facility in another town, and eventually returned to this facility. She stated the resident was wanting to go home before all of this occurred. She also stated if she failed to do something it was because of the relationship that she and Resident #61 has. This interview was conducted by speaker phone in the presence of another surveyor. On 8/15/19 at 11:35 AM, an interview with the Licensed Social Worker (LSW) revealed, Resident #61 had not reported anything to her about being unhappy with a CNA. She also stated the resident had not personally reported to her that she had some money missing. The LSW stated she had witnessed the AA giving the resident some money ($50.00) this week out of $100.00. She stated the rest of the $50.00 is in the AA's office. The LSW stated Resident #61 always goes to the AA and does not open up to her (LSW). She stated the resident had not mentioned anything to her. She stated if a resident came to her with a concern regarding how a CNA for example, is caring for them, she would go through the chain of command. She stated she would go to Licensed Practical Nurse (LPN) #5. On 8/15/19 at 11:50 AM, an interview with the DON, revealed the resident had not mentioned anything to her regarding any CNA. She also stated the resident had not told her about any missing money. On 8/15/19 at 12:00 PM, an interview with Resident #61, revealed she had gone to the AA because CNA #5 had stopped speaking to her. She stated she had not had a chance to talk to the AA about CNA #5 handling her roughly. She stated she had not told anyone about that. She also stated the AA came to her and gave her $50.00, and she had $50.00 left in the office. Resident #61 stated she wanted to draw half of the $100.00 out. She stated the $100.00 she had missing was about one month ago. She also stated a staff member brought her $50.00 of the $100.00 that was missing a month ago. Resident #61 also stated she told the AA and the AA said she would roll the camera back. Resident #61 stated she had another $100.00 after the first $100.00 went missing. She stated she had $100.00 twice, but not at the same time. She stated she had the first $100.00 about a month ago. Resident #61 stated the whole $100.00 came up missing. She stated she had nine $10.00 bills and two $5.00 bills. She stated she had another $5.00 and $1.00 bill. She stated she did not tell anyone until one of the workers came into her room. Resident #61 told this worker that $100.00 was taken out of her purse and her purse was taken from underneath her pillow. Resident #61 does not want to state the worker's name. She stated the first person she told was Resident #23, and then she told the AA and the AA told her (Resident #61) she was going to roll the camera back. She stated the AA told her that a woman was coming to talk to her and would want to know where the money came from. She stated the woman never came. She stated the AA stated she would have to get someone else to come. She stated that same worker (the worker that Resident did not want to give her name) came into her room that night and put $50.00 in the envelope. She stated the worker was going through her things and she saw the worker lift her hand and handed the envelope to her which had the $50.00 in it. She stated the worker told her it was not $100.00 but it was $50.00. The resident stated she asked the worker where was her other $50.00 at. She stated she never heard anymore from the AA. On 8/15/19 at 12:30 PM, an interview with Administrator #1 revealed, he would expect the Assistant Administrator to handle issues and does not expect her to bring everything to him. He stated the policy on misappropriation is to go through the proper chain of command. He stated anyone in the facility can go to Quality Assurance (QA). He also stated he would expect the staff to report abuse to the administrator. He stated if someone reported to him that a resident had money missing, he would conduct an investigation. A review of the facility's Face Sheet revealed, the facility admitted Resident #61, on 7/20/18, with diagnoses including Myoneural Disorder and Gastroesophageal Reflux Disease (GERD). A review of the most recent Yearly comprehensive Minimum Data Set (MDS) reveaintact.led, Resident #61 had a Brief Mental Status (BIMS) score of 15, which indicated she was cognitively intact.

Based on record review, staff interviews, resident interviews, and facility policy review, the facility failed to initiate an investigation regarding an allegation of misappropriation of the Resident #61's Trust Fund, for one (1) of four (4) Resident Trust Funds reviewed. Findings include: A review of the facility's policy titled, Abuse, Neglect, or Exploitation Policy, undated, revealed any report of abuse, neglect, or exploitation will be investigated by the Administrator, Director of Nursing, Social Services, Quality Assurance Committee, and Facility Security. Investigation shall include but is not limited to, questioning of the resident involved when appropriate. Questioning all staff members working in that area at the time of the incident suspected of abuse, neglect, or exploitation, who might have knowledge of the reported complaint. Questioning any family or visitors who might have knowledge of the incident. Written statements by all staff questioned and signed by staff member. The resident's statement may be written by facility staff. Written statements by family questioned and by visitors questioned. An interview, on 8/15/19 at 11:00, revealed Administrator #1 stated nothing had been reported to him. An interview, on 8/15/19 at 11:01 AM, revealed Administrator #2 stated nothing had been reported to her. On 8/15/19 at 11:05 AM, an interview with the Assistant Administrator (AA), revealed she was not aware of anyone handling the resident roughly, but rather it was Certified Nursing Assistant (CNA) #5 (CNA #5 was also Resident #61's relative) taking the resident to the bathroom. The AA stated the resident had stated CNA #5 had not been talking to her. The AA also stated she asked CNA #5 to take someone with her when she went in to care for Resident #61. The AA stated Resident #61 reported to her that CNA #5 did not want to work with her (Resident #61) and that CNA #5 was acting like her daddy. The AA stated Resident #61 and CNA #5 just did not get along. The AA stated CNA #5 had started swapping out when she had to care for Resident #61. She also stated she had talked with the Resident #61's Resident Representative (RR) and the RR stated she gets along with her cousin, CNA #5. The AA stated Resident #61 thinks transferring on the sit to stand lift is handling her rough because she is unable to hold onto one side of the lift, and she thinks the staff is doing something to her. She stated Resident #61 feels she can do more than what she is able to do for herself. She also stated she does know it was the sit to stand lift that Resident #61 was referring to. The AA stated Resident #61 never reported to her that CNA #5 was handling her roughly. She stated she did not do an investigation because she did not feel there was anything to investigate because this happened before the last survey. She also stated Resident #61 stated she had some money missing but Resident #61 had found her money. The AA stated, Resident #61 had $105.00 or $106.00. She stated she was off from work the next day. She also stated, Resident #61 had given the Licensed Social Worker (LSW) $100.00 and had gotten $50.00 of it the other day from the LSW. She stated Resident #61 signed off on it in her (AA) office and she (AA) had the money in a little locked box. The AA stated that was the day Resident #61's son had come to the facility. She also stated Resident #61 has $50.00 left. The AA stated she usually does not hold money. She stated the resident had money missing last month and had brought some money to the office to the LSW and Front Office Worker #1 which was $100.00. She stated Wednesday morning when she returned to work, the LSW gave her $100.00 for Resident #61 and this was last week, but her days are kind of running together. The AA also stated when the resident's son was at the facility, Resident #61 had gotten $50.00 of her money. She stated she rolled the camera back, and she did not see anyone go in or out of Resident #61's room. She also stated the next day Resident #61 brought the money to her office because she did not want to hold that amount of money. She stated she does not know the policy on when a resident has missing money. She also stated she generally handles it by telling the residents if they have any problems to let her know about it and she will roll the camera back. She stated she did not tell Administrator #1. She also stated she told the Director of Nursing (DON), but at that time, the money came back. She stated to her, the situation was over with because she (Resident #61) brought money to the office. She also stated, she asked the resident when she has that kind of large sums of money, she needs to have it locked up. She stated Resident #61 had not had that type of money before. The AA also stated she did not write anything down regarding the CNA situation or the money situation. She stated it is the facility's policy to investigate the resident's concerns, but she did not investigate because it was an issue that was resolved. She also stated other than the nurse that was standing in the hallway, no one knew about the situation. She stated she does not remember who that nurse was. She stated she should have gone to the Director of Nurses (DON) and the DON should take the next step, but she kind of handled it herself. She stated she thought everything was okay. She stated Resident #61 wants to go home tonight if she could. She also stated the resident was here previously, had gone to a facility in another town, and eventually returned to this facility. She stated the resident was wanting to go home before all of this occurred. She also stated if she failed to do something it was because of the relationship that she and Resident #61 has. This interview was conducted by speaker phone in the presence of another surveyor. On 8/15/19 at 11:35 AM, an interview with the Licensed Social Worker (LSW) revealed, Resident #61 had not reported anything to her about being unhappy with a CNA. She also stated the resident had not personally reported to her that she had some money missing. The LSW stated she had witnessed the AA giving the resident some money ($50.00) this week out of $100.00. She stated the rest of the $50.00 is in the AA's office. The LSW stated Resident #61 always goes to the AA and does not open up to her (LSW). She stated the resident had not mentioned anything to her. She stated if a resident came to her with a concern regarding how a CNA for example, is caring for them, she would go through the chain of command. She stated she would go to Licensed Practical Nurse (LPN) #5. On 8/15/19 at 11:50 AM, an interview with the DON, revealed the resident had not mentioned anything to her regarding any CNA. She also stated the resident had not told her about any missing money. On 8/15/19 at 12:00 PM, an interview with Resident #61, revealed she had gone to the AA because CNA #5 had stopped speaking to her. She stated she had not had a chance to talk to the AA about CNA #5 handling her roughly. She stated she had not told anyone about that. She also stated the AA came to her and gave her $50.00, and she had $50.00 left in the office. Resident #61 stated she wanted to draw half of the $100.00 out. She stated the $100.00 she had missing was about one month ago. She also stated a staff member brought her $50.00 of the $100.00 that was missing a month ago. Resident #61 also stated she told the AA and the AA said she would roll the camera back. Resident #61 stated she had another $100.00 after the first $100.00 went missing. She stated she had $100.00 twice, but not at the same time. She stated she had the first $100.00 about a month ago. Resident #61 stated the whole $100.00 came up missing. She stated she had nine $10.00 bills and two $5.00 bills. She stated she had another $5.00 and $1.00 bill. She stated she did not tell anyone until one of the workers came into her room. Resident #61 told this worker that $100.00 was taken out of her purse and her purse was taken from underneath her pillow. Resident #61 does not want to state the worker's name. She stated the first person she told was Resident #23, and then she told the AA and the AA told her (Resident #61) she was going to roll the camera back. She stated the AA told her that a woman was coming to talk to her and would want to know where the money came from. She stated the woman never came. She stated the AA stated she would have to get someone else to come. She stated that same worker (the worker that Resident did not want to give her name) came into her room that night and put $50.00 in the envelope. She stated the worker was going through her things and she saw the worker lift her hand and handed the envelope to her which had the $50.00 in it. She stated the worker told her it was not $100.00 but it was $50.00. The resident stated she asked the worker where was her other $50.00 at. She stated she never heard anymore from the AA. On 8/15/19 at 12:30 PM, an interview with Administrator #1 revealed, he would expect the Assistant Administrator to handle issues and does not expect her to bring everything to him. He stated the policy on misappropriation is to go through the proper chain of command. He stated anyone in the facility can go to Quality Assurance (QA). He also stated he would expect the staff to report abuse to the administrator. He stated if someone reported to him that a resident had money missing, he would conduct an investigation. A review of the facility's Face Sheet revealed, the facility admitted Resident #61, on 7/20/18, with diagnoses including Myoneural Disorder and Gastroesophageal Reflux Disease (GERD). A review of the most recent Yearly comprehensive Minimum Data Set (MDS) revealed, Resident #61 had a Brief Mental Status (BIMS) score of 15, which indicated she was cognitively intact.

Based on record review, staff interview, and facility policy review, the facility failed to make a Level II referral related to Resident #49's change in status for one (1) of four (4) residents reviewed for Preadmission Screening Resident Reviews (PASRR). Findings include: Review of a typed statement provided by the facility, on the facility's letterhead, no date or signature, revealed the facility followed the policies and procedures of (Name of Management Company) to complete PASRRs. A review of the (Name of the Management Company), Provider Manual, revised 7/3/13, revealed when a resident experienced a significant status change, a PASRR Level II Change in Status Request form must be completed by the provider and faxed to (Name of Management Company). Significant changes included a resident who exhibits behavioral, psychiatric, or mood-related symptoms suggesting the presence of a diagnosis of mental illness . A review of the Diagnosis/History List, for Resident #49, revealed a diagnosis of Major Depressive Disorder, recurrent severe with psych symptoms dated 2/15/18, Major Depressive Disorder, recurrent 2/8/19, and Hallucinations 9/11/15. A review of Resident #49's Department of Mental Health Level II letter, dated 2/11/16, indicated the resident did not require specialized services because the resident was ruled out due to there was not sufficient evidence of serious mental illness. An interview, on 8/14/19 at 12:04 PM, revealed Social Services (SS) #1 said the referral for the Level II for Resident #49 had not been submitted, and she was unaware a referral was to be sent for residents with added mental disorder or diagnosis after admission. She also said she was not at this job when the diagnoses were added last year. SS #1 said she had a training planned about the PASSRs next week. She also said they use (Name of Management Company) for their policy to complete the PASSRs. Because the facility had no Level II designated as a major mental illness, no trigger was in place when the resident had a significant change. Therefore, the facility failed to notify (Name of Management Company) when Resident #49 had added diagnoses. A review of Resident #49's Pre-admission Screening (PAS), provided by the facility, revealed the PAS was dated 2/2/16 with No indicated for a diagnosis of major mental illness or recent history resident had a significant change. Therefore, the facility failed to notify (Name of Management Company) of the mental illness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record reviews, and facility policy review, the facility failed to accurately complete the Preadmission Screen (PAS) for one (1) of four (4) resident PASs reviewed. Resident #44. Findings include: A review of the facility's policy titled, Preadmission Screening Resident Review (PASRR) Policy, undated, revealed it is the policy of this facility that the PASRR will be completed as follows: Completed on Long Term care residents only for admission, according to the guidelines from Medicaid, and faxed to Medicaid once completed following admission (long term care residents only). A review of the Resident Assessment Manual, dated October 2018, revealed all individuals who are admitted to a Medicaid certified nursing facility, regardless of the individual's payment source, must have a Level 1 Preadmission Screening Resident Review (PASRR) completed to screen for possible mental illness (MI), intellectual disability (ID), (mental retardation/MR) in federal regulation)/developmental disability (DD), or related condition. Individuals who have or are suspected to have MI or ID/DD or related conditions may not be admitted to a Medicaid-certified nursing facility unless approved through Level II PASRR determination. A record review of the most recent comprehensive admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 3/26/19, revealed the MDS was coded to indicate Resident #44 had not been evaluated by a Level II PASRR. The most recent admission comprehensive MDS assessment was also coded to include a diagnosis of Psychotic Disorder. Review of the Comprehensive Care Plan revealed a Focus for Psychotropic Drug - Risperdal for Psychosis and Delusional Disorder. At risk for side effects. The Onset Date was 3/19/19. Review of the PAS dated, 3/20/19, indicated the resident did not have a diagnosis of a major mental illness, recent history of a major mental illness, and did not take, or have a history of taking psychotropic medication. A review of the Diagnosis and History List revealed the resident had a diagnosis of Psychosis, dated 3/19/19. On 8/15/19 at 10:30 AM, an interview with the Director of Nursing (DON), revealed the resident had a diagnosis of Psychosis upon admission. On 8/15/19 at 3:31 PM, an interview with the Licensed Social Worker (LSW) #1, revealed, the resident was admitted on [DATE] and a Level II referral should have been done. She also stated the PAS was not completed accurately. A review of the facility's Face Sheet revealed, the facility admitted Resident #44 on 3/19/19 with a diagnosis of Psychosis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy the facility failed to follow the Resident #15's Comprehensive Care Plan related to falls, and Resident #33's Comprehensive Care Plan for Foley catheter care, for two (2) of 23 resident care plans reviewed for one (1) of 23 resident care plans reviewed. Findings include: A review of the facility's policy titled Total Care Plan Policy, without a date, revealed the facility would identify the problems that would affect the resident and his/her care needs. The Care Plan would identify problems that affect the resident and his/her care needs, and address areas identified on the Minimum Data Set MDS, and the Care Area Trigger (CAT)s. Resident #15 A review of the Resident #15's Comprehensive Care Plan revealed the Problem/Need, dated 10/23/12, for the risk of falls due to an unsteady gait and a diagnosis of Parkinson's Disease. Interventions included staff to stay in the bathroom with the resident while being toileted related to fall risk. Review of Resident #15's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/22/19, revealed in section J1900B the resident fell two or more times since the prior assessment with injury (not major). A review of Resident 15's, Resident Incident Report, dated 6/11/19, revealed Resident #15 was assisted by Certified Nursing Assistant (CNA) #1 to the bathroom. CNA #1 removed the resident's walker from the bathroom. While Resident #15 was standing in front of the commode pulling her down pants and brief, Resident #15 started to fall, but CNA #1 was not able to break the fall. Resident #15 fell to the floor hitting her face and forehead and knee. The incident report noted an abrasion to the forehead and right side of neck and lip. Resident #15 was sent to emergency room (ER) for evaluation without any orders on return for treatment on her medical record. Review of a handwritten statement, dated 6/11/19, by CNA #1, on the facility's Written Statement on Accident/incident was attached to Resident #15's incident report. CNA #1 stated, she turned her back to Resident #15 to move the walker out of the way of the resident, and when she turned around the resident was falling. A review of Resident 15's Resident Incident Report, dated 4/11/19, revealed the resident was found in front of bathroom door by Licensed Practical Nurse (LPN) #1 with a laceration to the right brow, and was sent to to the ER for evaluation. The documentation noted on the incident report revealed the fall was not witnessed. A review of Resident 15's Resident Incident Report, dated 2/11/19, revealed the resident was in the bathroom and stood up by herself, and lost her balance, leaned against the wall and then slid to the floor. LPN #4 documented the CNAs were reminded that Resident #15 cannot be left alone in the bathroom and discussed with the Director of Nursing (DON). No injuries were reported on the incident report. The incident was documented as non-witnessed. An interview, on 8/14/19 at 2:43 PM, with LPN #1 revealed Resident #15 had a history of not calling for help when she would go to the bathroom, but that had improved now. LPN #1 said she did help when Resident #15 fell, on 4/11/19, but was not her nurse and couldn't recall who the aide was that day. An interview, on 8/14/19 at 3:28 PM, with LPN #4, revealed she was present when Resident #15 fell on 2/11/19. She said she completed the incident report and said CNA #2 assisted Resident #15 to the bathroom, but left Resident #15 in the bathroom to answer another call light. LPN #4 said when CNA #2 came back to the bathroom, the resident was on the floor. LPN #4 said Resident #15 had no injuries. LPN #4 also said she was aware the resident's care plan said to stay with the resident while in the bathroom. LPN #4 said the expectation for nurses and aides was to follow the care plan. An interview, on 8/14/19 at 2.51 PM, with CNA #2, revealed she said she was Resident #15's CNA when she fell on 2/11/19. CNA #2 said she helped Resident #15 to the toilet in the bathroom and had heard a call light that had been going off for about 5 minutes and went to answer it. CNA #2 said she asked Resident # 15 to not get up and that she would return. CNA #2 said when she got back, Resident #15, was leaning on the wall by the hand rail on the floor. CNA #2 said she was aware Resident #15's care plan said the resident needed to have someone to stay with her in the bathroom, but she knew the other staff members were busy with other residents and wanted to answer the light. CNA #2 said she had received education and had not left the resident by herself anymore. An interview, on 8/15/19 at 8:36 AM, with Resident # 15 revealed she always was helped and that no one has left her alone in the bathroom. Resident #15 said this place was a good home. She also said she was getting in her recliner this [NAME] from her wheelchair, and a nurse walked by and reminded her not to get up without calling for help. An interview, on 8/15/19 at 9:31 AM, revealed the DON said the expectation was to follow the care plan specific to Resident #15. An interview, on 8/15/19 at 2:13 PM, with LPN # 2/MDS Nurse revealed the expectation of the staff was to follow the care plan specific to each resident. She confirmed Resident #15's care plan stated to stay with the resident while in the bathroom. Resident #33 Review of Resident #33's Comprehensive Care Plan, revealed the Problem/Need, dated 2/15/2014, for a history of Urinary Retention and inability to void. At risk for Urinary Tract Infections, and the presence of a Foley catheter. Interventions included Foley catheter care every shift. On 8/14/19 at 9:35 AM, an observation revealed, CNA #6 assisted by CNA #7 performed Resident #33's catheter care. CNA #6 had already set up her barrier and supplies. Both CNA #6 and CNA #7 washed their hands and applied clean gloves. CNA #6 set up two (2) basins, one was to wash Resident #33, and one was to rinse the resident. When CNA #6 was cleaning Resident #33's penis she wiped the resident's penis three times (x3) without rotating her washcloth, then placed that washcloth in the soiled linen bag. CNA #6 retrieved another washcloth and wiped the resident's penis again twice (x2). When CNA #6 rinsed the resident's penis area she wiped two times (x2) without rotating the washcloth and placed that washcloth in the soiled linen bag. CNA #6 retrieved another washcloth and wiped the resident's penis area three time (x3) without rotating the washcloth. CNA #6 then dried the resident's penis area, and while drying the area she used a patting motion times five (x5 ) without rotating the towel, then patted the area dry again three times (x3 ) and again four times (x4) without rotating the towel. On 8/14/19 at 3:00 PM, an interview with CNA #6 revealed she stated she, wiped too many times. CNA #6 stated she should have wiped one time and folded her washcloth before she wiped again. She also stated wiping too many times causes germs to spread. On 8/15/19 at 2:13 PM, an interview with Licensed Practical Nurse (LPN) #2/MDS Nurse, revealed she would expect the staff to follow the comprehensive care plan. Review of the Physician's Orders revealed an order, dated 4/29/19, to change the Foley catheter (18 French (FR) with a 10 cubic centimeter (cc) bulb every 30 days and as needed) for the diagnosis of Neurogenic Bladder. A record review of the most recent Quarterly Minimum Data set (MDS) assessment, with an Assessment Reference Date (ARD) of 6/3/19, revealed Resident #33 was coded for an indwelling catheter.

Based on resident interview, staff interview, record review, and facility policy review, the facility failed to prevent falls for one (1) of three (3) residents reviewed for falls. Resident #15. Findings include: A review of the facility's policy titled, Fall Protocol Policy, without a date, revealed the facility would evaluate possible alternative interventions to help prevent falls. A review of the Resident #15's Comprehensive Care Plan revealed staff was to stay in the bathroom with the resident while being toileted related to her fall risk. Review of Resident #15's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/22/19, revealed in section J1900B the resident fell two or more times since the prior assessment with injury (not major). A review of Resident 15's, Resident Incident Report, dated 6/11/19, revealed Resident #15 was assisted by Certified Nursing Assistant (CNA) #1 to the bathroom. CNA #1 removed the resident's walker from the bathroom. While Resident #15 was standing in front of the commode pulling her down pants and brief, Resident #15 started to fall, but CNA #1 was not able to break the fall. Resident #15 fell to the floor hitting her face and forehead and knee. The incident report noted an abrasion to the forehead and right side of neck and lip. Resident #15 was sent to emergency room (ER) for evaluation without any orders on return for treatment on her medical record. Review of a handwritten statement, dated 6/11/19, by CNA #1, on the facility's Written Statement on Accident/incident was attached to Resident #15's incident report. CNA #1 stated, she turned her back to Resident #15 to move the walker out of the way of the resident, and when she turned around the resident was falling. A review of Resident 15's Resident Incident Report, dated 4/11/19, revealed the resident was found in front of bathroom door by Licensed Practical Nurse (LPN) #1 with a laceration to the right brow, and was sent to to the ER for evaluation. The documentation noted on the incident report revealed the fall was not witnessed. A review of Resident 15's Resident Incident Report, dated 2/11/19, revealed the resident was in the bathroom and stood up by herself, and lost her balance, leaned against the wall and then slid to the floor. LPN #4 documented the CNAs were reminded that Resident #15 cannot be left alone in the bathroom and discussed with the Director of Nursing (DON). No injuries were reported on the incident report. The incident was documented as non-witnessed. An interview, on 8/14/19 at 2:43 PM, with LPN #1 revealed Resident #15 had a history of not calling for help when she would go to the bathroom, but that had improved now. LPN #1 said she did help when Resident #15 fell, on 4/11/19, but was not her nurse and couldn't recall who the aide was that day. An interview, on 8/14/19 at 3:28 PM, with LPN #4, revealed she was present when Resident #15 fell on 2/11/19. She said she completed the incident report and said CNA #2 assisted Resident #15 to the bathroom, but left Resident #15 in the bathroom to answer another call light. LPN #4 said when CNA #2 came back to the bathroom, the resident was on the floor. LPN #4 said Resident #15 had no injuries. LPN #4 also said she was aware the resident's care plan said to stay with the resident while in the bathroom. LPN #4 said the expectation for nurses and aides was to follow the care plan. An interview, on 8/14/19 at 2.51 PM, with CNA #2, revealed she said she was Resident #15's CNA when she fell on 2/11/19. CNA #2 said she helped Resident #15 to the toilet in the bathroom and had heard a call light that had been going off for about 5 minutes and went to answer it. CNA #2 said she asked Resident # 15 to not get up and that she would return. CNA #2 said when she got back, Resident #15, was leaning on the wall by the hand rail on the floor. CNA #2 said she was aware Resident #15's care plan said the resident needed to have someone to stay with her in the bathroom, but she knew the other staff members were busy with other residents and wanted to answer the light. CNA #2 said she had received education and had not left the resident by herself anymore. A review of a facility's In-Service Meeting, dated 2/6/19, revealed CNA #2 attended the education related to fall prevention safety. An interview, on 8/15/19 at 8:36 AM, with Resident #15, revealed she stated she was helped and that no one has left her alone in the bathroom. Resident #15 said this place was a good home. She also said she was getting in her recliner this morning from her wheelchair, and a nurse walked by and reminded her not to get up without calling for help. An interview, on 8/15/19 at 9:31 AM, revealed the DON said CNA #2 was instructed and educated after the fact with a write up in her file for not following the care plan resulting in a fall. Review of the Face Sheet revealed Resident #15 was admitted by the facility, on 10/23/12, with diagnoses that included Parkinson's Disease and Tremors. Review of Resident #15's Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/4/19, revealed a Basic Interview for Mental Status (BIMS) was coded a 15, which indicated no cognitive impairment.

Based on observation, staff interviews, record reviews, and facility policy review, the facility failed to provide catheter care in a manner to prevent possible cross contamination for one (1) four (4) resident catheter care observations. Resident #33. Findings include: A review of the facility's policy titled, Incontinent care Policy, undated, revealed: Wipe area only once with same cloth, change cloth or fold cloth to clean side and clean from front to back. A review of the facility's policy titled, Catheter Care Policy, undated, revealed it is the policy of this facility that catheter care will be done as follows: Wiping buttock from the anal area upward and cleanse the catheter from the body to the end of the catheter, never from the end of the catheter toward the body. On 8/14/19 at 9:35 AM, an observation revealed CNA #6 assisted by CNA #7 performed Resident #33's catheter care. CNA #6 had already set up her barrier and supplies. Both CNA #6 and CNA #7 washed their hands and applied clean gloves. CNA #6 set up two (2) basins, one was to wash Resident #33, and one was to rinse the resident. When CNA #6 was cleaning Resident #33's penis she wiped the resident's penis three times (x3) without rotating her washcloth, then placed that washcloth in the soiled linen bag. CNA #6 retrieved another washcloth and wiped the resident's penis again twice (x2). When CNA #6 rinsed the resident's penis area she wiped two times (x2) without rotating the washcloth and placed that washcloth in the soiled linen bag. CNA #6 retrieved another washcloth and wiped the resident's penis area three time (x3) without rotating the washcloth. CNA #6 then dried the resident's penis area, and while drying the area she used a patting motion times five (x5 ) without rotating the towel, then patted the area dry again three times (x3 ) and again four times (x4) without rotating the towel. On 8/14/19 at 3:00 PM, an interview with CNA #6 revealed she stated she, wiped too many times. CNA #6 stated she should have wiped one time and folded her washcloth before she wiped again. She also stated wiping too many times causes germs to spread. An interview, on 8/14/19 at 3:17 PM, with Registered Nurse (RN) #1, revealed when CNA #6 wiped more than once without rotating her washcloth that caused cross contamination and infection control issues. Review of the Physician's Orders revealed an order, dated 4/29/19, to change the Foley catheter (18 French (FR) with a 10 cubic centimeter (cc) bulb every 30 days and as needed) for the diagnosis of Neurogenic Bladder. A record review of the most recent Quarterly Minimum Data set (MDS) assessment, with an Assessment Reference Date (ARD) of 6/3/19, revealed Resident #33 was coded for an indwelling catheter.

Based on observations, staff interview, record review, and facility policy review, the facility failed to ensure the prevention for possible cross contamination and spread of infection for one of five days (1 of 5) days of the survey as evidenced by staff's failure to wear gloves during resident contact (Resident #79) and to wash hands after the resident contact. Findings include: A review of the facility's policy titled, Hand Washing Policy, without a date, revealed hand washing would be done after any direct contact with another person. Review of the facility's policy titled, Infection Control - Isolation Policy, no date, revealed it is the policy of the facility that isolation will be used as follows: In order to prevent spread of infection. In the least restrictive form possible. Isolation form to be determined by the physician, or facility Infection Control Nurse. A sign will be placed on the outside of the door to indicate that visitors should see the nurse before entering the room. Notify family of isolation precautions. Technique: Isolation techinques utilized by this facility included 2. Wound and skin isolation such as Shingles. Resident equipment should be placed in the room for individual use. Resident specific equipment must be disinfected prior to removing from isolation room, which includes thermometer, blood pressure cuff, stethoscope, and any other equipment that actually touches the resident. Personal proctective equipment will be used when indicated. Review of the facility's policy titled, Occupational Exposure Policy, no date, revealed that in the case occupational exposure these steps will be taken, which included clean and disinfect the exposed area. An observation, on 8/12/19 at 11:03 AM, revealed Resident #79 was propelling his wheelchair and positioned his oxygen tubing on his face. Resident #79 had wounds that were noted on top of his scalp that were red and open to air, but no drainage noted. Resident #79 was observed touching the hallway rails by the dayroom across from the [NAME] Wing nurse's desk. Licensed Practical Nurse (LPN) #3 was at the desk and assisted Resident #79 in his wheelchair, and then pushed the resident away from the rail without using gloves. Resident # 79 scratched the top of his head and wheeled himself down the hallway to the other nurse's desk. LPN #3 went back to her medication cart and did not perform hand hygiene, typed on her computer keyboard, and used the mouse. LPN #3 then put on gloves and set up mediations for another resident. An interview, on 8/12/19 at 11:10 AM, revealed LPN #3 said Resident #79 had Shingles, but rarely complains. She said he will scratch at it late in evenings. LPN #3 also said Resident #79 won't stay in his room because of mental status. A review of Resident # 79's Physician's Orders, dated 8/7/19, revealed he was on valacyclovir 1000 milligrams (mg) one (1) three times a day for seven days for Varicella Zoster (Shingles) of the scalp. Further review of Resident #79's Physician's Orders revealed no order for any type isolation. A review of the Care Plan, for Resident #79, revealed the Problem/Need, dated 7/16/19, for risk for skin problems related to a history of shingles prior to admission, and possible reoccurrence. The Approaches included the administration of the valacyclovir. An interview, on 8/13/19 at 11:20 AM, revealed Certified Nurse Assistant (CNA) #4 said she was not aware of any infection precautions with Resident #79. She said he was in Physical Therapy at present time. An interview, on 8/14/19 at 7:33 PM, revealed the Director of Nursing (DON) said the medication for Varicella Zoster was ordered because Resident #79 had been complaining of pain without any open wounds. The DON also stated the resident would pick at them and open the scabs back up. The DON said Resident #79 usually wore a cap to cover his head. The DON stated the policy was to keep the blisters covered on his head because the wounds were open. The DON confirmed LPN #3 should have performed hand hygiene after assisting the resident. The DON also said the concern was the cross contamination from the resident scratching and touching his hands then other areas of the facility that could spread the infection.

Based on staff interview, record review, and facility policy review, the facility failed to notify the resident/Resident Representative in writing of the reason for transfer to the hospital for two (2) of three (3) hospital transfers reviewed. Residents #20 and #37. Findings include: A review of the facility's policy titled, Family Notification Policy, without a date, revealed the facility would notify the family with any transfer to another health care setting such as a hospital. The policy did not specify as to how the family would be notified. A review of Resident #20 Physician's Orders revealed an order, dated 4/28/19, to transfer on 4/28/19 related to a fall. A review of Resident #20's medical record did not reveal a letter notifying the Resident's Representative of a transfer to the hospital. An interview on 08/15/19 at 10:02 AM, with Social Services (SS) #1 revealed she was responsible for notifying the family and the Ombudsmen of facility initiated transfers/discharges. SS #1 said the nurses notified the family only by telephone at the time of Resident #20's transfer. Review of the Face Sheet revealed Resident #20 was admitted by the facility, on 9/29/11, with the included diagnosis of Hemiplegia. Resident #37 A review of Resident #37's Physician's Orders revealed an order, dated 7/28/19, to transfer to evaluation of confusion and congestion. Review of Resident #37's medical record revealed no documentation was provided to the resident or the Resident's Representative regarding the hospital transfer on 7/28/19. An interview, on 08/15/19 at 10:02 AM, with SS #1 revealed she said she was responsible for notifying family and the ombudsmen of the facility initiated transfers/discharges. SS #1 said she started emailing the notifications of bed hold to the Resident Representatives, but it did not include the written notification of the reason for transfer. She said the nurses notified the family by telephone at the time of Resident #37's transfer. Review of the Face Sheet revealed Resident was admitted by the facility, on 11/13/15, with the included diagnoses of History of Falling and Asthma.