**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, Physician, and the Consultant Pharmacist interviews the facility failed to prevent significant medication errors by administering Resident #223 the incorrect dose of a blood pressure medication, Losartan 50 milligrams (an antihypertensive), and administering blood pressure medications without following the physician's ordered parameters to hold the medication (Residents #223 and #47). This resulted in Resident #223 experiencing hypotension (low blood pressure) and symptoms of head pressure, neck pain, and nausea. There was no significant outcome for Resident #47. This deficient practice occurred for 2 of 2 residents reviewed for medication administration. Findings Included. 1.) Resident #223 was admitted to the facility on [DATE] with diagnoses including hypertension. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #223 was cognitively intact. A physician's order dated 07/23/24 for Resident #223 revealed Losartan 50 milligram tablets. Give via PEG (percutaneous endoscopic gastrostomy) tube at bedtime for hypertension. Hold if systolic blood pressure is less than 140 mmHg (millimeters of mercury). A nursing progress note dated 08/22/24 at 03:19 AM revealed Resident #223 requested to speak with the nurse at approximately 2:30 AM due to complaints of burning sensation, head pressure, neck pain, and nausea. Resident #223's blood pressure was 62/40 mmHg with a manual cuff, and 59/36 mmHg obtained by second nurse with an automatic cuff. His blood pressure was obtained again manually and was 62/40 mmHg and the second nurse obtained a reading of 65/45 mmHg manually. Resident #223's oxygen saturation was maintained around 95% and dropped as low as 82% with pulse oximetry. The physician was called and gave orders to have the resident sent out to the hospital for evaluation for low blood pressure. Resident #223 stated he didn't want to go to the hospital, but the physician insisted on calling the ambulance for further evaluation. Emergency Medical Services (EMS) arrived, and his blood pressure was 95/60 mmHg and pulse oximetry at 95%. His heart rate and temperature were within normal limits. EMS staff asked if the resident wanted to go to the hospital for further evaluation and Resident #223 declined. The Physician was made aware. During a phone interview on 01/09/25 at 10:33 AM Nurse #6 stated she was new to the facility at the time of the incident and was still in training. Nurse #6 stated she did give Resident #223 Losartan instead of holding the medication. She stated the blood pressure medication had hold parameters, but no box popped up in his electronic medical record to check the residents blood pressure. She stated that she administered the medication from the card that was in the medication cart. Later Resident #223 became lethargic, complained of headache, and nausea. His blood pressure was low, so they called the physician who instructed them to call 911. EMS arrived soon after. EMS asked if he wanted to go to the hospital, but the resident refused to go. She reported he did not go to the hospital, but they continued to do frequent blood pressure checks with no further complaints of headache or nausea and his blood pressure was trending up. She stated he was discharged home two days later. She stated the nurse that was orienting her questioned the dose after the resident became symptomatic when she told the nurse that she had administered it to him. She indicated she didn't realize she had given 100 milligrams instead of 50 milligrams, but she should have held the medication anyway according to the prescribed parameters. She indicated she received training on medication administration following the incident. A progress note dated 08/22/24 at 2:59 PM documented by Unit Manager #2 revealed Resident #223 was administered the right medication, but the wrong dose and the parameters were not followed per the Medication Administration Record. Resident #223's blood pressure dropped. The physician was notified, and actions were taken to improve his blood pressure. He refused to go to the hospital. Resident #223 was examined by the Physician at 8:00 this morning with this nurse present. No further adverse effects were noted. Resident #223 participated in physical therapy this morning and was up in his wheelchair. He and his family member were aware. During an interview on 01/08/25 at 1:30 PM Unit Manager #2 stated she was made aware of the incident the morning it occurred. Resident #223 was admitted for short term rehab therapy. They discovered that Nurse #6 gave the right medication but the wrong dose during the 9:00 PM medication pass. The order in Resident #223's electronic medical record revealed to administer 50 milligrams of Losartan, but the medication card read to give 100 milligrams. The order was changed from 100 milligrams to 50 milligrams, but the medication card was not updated because the new order was not sent to the pharmacy. She stated they also discovered that Resident #223's blood pressure recorded during the 9:00 PM medication pass was 117/69 mmHg so the resident should not have received the medication according to the parameters to hold the medication of the systolic blood pressure was less than 140 mmHg. She stated a few hours after receiving the medication around 2:30 AM the resident had complaints of headache and nausea, and his blood pressure was low. Resident #223 refused to go to the hospital, but EMS was called anyway. The resident continued to refuse to be sent out. The physician evaluated him later that morning and the assessment was within normal limits, and he had no further complaints. Resident #223 participated in physical therapy that morning and discharged home within a couple of days. A progress noted dated 08/24/24 at 3:19 PM Resident #223 discharged home with his family. During an interview on 01/08/24 at 1:00 PM the Director of Nursing (DON) stated on 08/21/24 Nurse #6 who was completing new hire orientation was working on the Rehab Hall on the night of the incident. Resident #223 was alert and oriented and called Nurse #6 to the room with complaints of nausea and other symptoms. His blood pressure was checked, and it was low. The physician was notified and ordered Resident #223 to be sent to the hospital for evaluation, but the resident refused to be sent out. EMS was notified to come evaluate and transport him but Resident #223 continued to refuse to go out. EMS also asked the resident if he wanted to go to the hospital, but he continued to refuse. She stated she was notified that morning, and they reviewed the Losartan medication card. She stated upon investigation they discovered that the Losartan order was changed on 07/23/24 from 100 milligrams to 50 milligrams. Nurse #6 gave 100 milligrams instead of the prescribed 50 milligram tablet. The order was updated in the electronic medical record, but the new order was not sent to the pharmacy. The nurses were still working from the old medication card that had the 100 milligram tablets. She stated the order should have been discontinued altogether and a new order entered for the 50 milligrams and the order sent to the pharmacy. The pharmacy would have sent a new card with the correct dosage and instructions. She stated they also discovered that the medication should have been held due to his systolic blood pressure being less than 140 mmHg, but Nurse #6 administered the medication. During an interview on 01/08/24 at 2:15 PM the Physician stated he was made aware of the medication error when it occurred. He indicated he evaluated Resident #223 following the incident. He stated Resident #223 was on long term antihypertensive therapy. Receiving the extra 50 milligrams would not have any severe outcome and there was no significant outcome regarding Resident #223 receiving Losartan 100 milligrams. He agreed that it was a medication error and stated he expected the nurses to follow the orders and the blood pressure parameters. During a phone interview on 01/09/25 at 1:38 PM the Consultant Pharmacist stated receiving a blood pressure medication when not indicated could cause symptoms such as low blood pressure, dizziness, nausea, and headache. 2.) Resident #47 was admitted on [DATE] with diagnoses including hypotension. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #47 was cognitively intact. A physician's order dated 12/05/24 for Resident #47 revealed Midodrine (prescribed to treat low blood pressure) 2.5 milligrams. Give 1 tablet by mouth three times a day for hypotension. Hold for systolic blood pressure greater than 95 mmHg (millimeters of mercury). Review of the Medication Administration Record (MAR) for Resident #47 dated January 2025 revealed on 01/02/25 Midodrine 2.5 milligrams was administered by Nurse #7 at the following times with blood pressure readings as follows: 01/02/25 a 6:00 AM with a blood pressure reading of 120/56 mmHg. (systolic/diastolic) 01/02/25 at 12:00 PM with a blood pressure reading of 120/62 mmHg. 01/02/25 at 5:00 PM with a blood pressure reading of 118/60 mmHg. During an interview on 01/08/25 at 1:00 PM the Director of Nursing (DON) stated there had been ongoing issues with staff not following medication parameters ordered by the physician. She indicated that according to the MAR, Nurse #7 signed off that the Midodrine was administered to Resident #47 although her blood pressure was outside of the prescribed parameters. She stated Nurse #7, who administered the Midodrine outside of parameters on 01/02/25, was out on medical leave and was unavailable for interview. During an interview on 01/08/25 at 2:15 PM the Physician stated he was made aware by Unit Manager #2 of Midodrine being administered outside of parameters to Resident #47 on 01/02/25. He reported that the medication was discontinued today as it was no longer indicated for her. He stated Resident #47 did not have any symptoms or outcome from receiving the medication. During an interview on 01/09/25 at 1:38 PM the Consultant Pharmacist stated she had identified not following blood pressure parameters in her monthly medication reviews. She reported this in her monthly reports that were sent to the DON. She stated she would work with the DON to help ensure parameters were being followed. She indicated taking Midodrine when not needed would increase the blood pressure unnecessarily, or cause side effects such as dizziness and headaches. During a follow up interview on 01/09/25 at 1:00 PM, the Director of Nursing stated they had provided education regarding not following physician orders to hold medications according to the prescribed parameters to all nursing staff beginning in August 2024. Education had also been provided verbally to individual staff members between August through December 2024. She stated she had been providing education and conducting audits regarding following medication parameters, but the problem continued. She reported further education and medication audits would be conducted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and resident interviews the facility failed to notify the nurse when a resident refused to be transferred with a mechanical lift and two nurse aides decided to transfer the resident (Resident #2) by manually lifting the resident from the bed to the shower bed causing her to fracture her tibia for 1 of 4 residents reviewed for accidents. Findings included: Resident #2 was admitted to the facility on [DATE]. Diagnoses included cerebral palsy (spastic paralysis causing impaired muscle coordination), osteoporosis (brittle and fragile bones), anxiety, vitamin D deficiency, contractures to left elbow and left wrist, and fracture of shaft of right tibia. A review of Resident #2's care plan updated 11/03/22 revealed a plan of care for at risk for falls related to resistance to getting out of bed and refusal of care of the mechanical lift. Requires a mechanical lift for all transfers out of bed with a goal that resident would not sustain serious injury over the next 90 days with interventions to include, in part, use mechanical lift with two staff to get in and out of bed. A plan of care for receiving pain medication therapy related to cerebral palsy with joint restrictions and muscle spasms with interventions to include, in part, reposition in bed for comfort and encourage to get out of bed, and a plan of care for osteoporosis with risk for injuries and fractures and pain related to hypocalcemia and vitamin deficiency. Goal to remain free of injuries or complications related to osteoporosis with interventions to include observe for and document/report to the physician any signs or symptoms of complications related to osteoporosis, acute fractures, compression fractures, and pain. The Minimum Data Set (MDS) annual assessment dated [DATE] revealed Resident #2 was cognitively intact. She demonstrated no behaviors and required extensive assistance with two staff physical assistance with bed mobility and transfers. Resident #2 was not coded as having any falls during this assessment. A review of the physician's orders revealed Resident #2 was receiving the following medications: Tylenol 325 milligrams (mg) one tablet three times a day and 2 tablets every 4 hours as needed for pain/fever written on 04/22/22. Evista 60 mg give one tablet by mouth one time a day for osteoporosis written on 04/22/22. Norco (opioid pain medication) tablet 5-325 mg give one tablet three times daily for pain written on 04/23/21. Flexeril (muscle relaxing medication) 10 mg one tablet twice daily for muscle spasms written on 07/25/11. Pain assessment every shift - ask patient if in pain according to pain scale and document response written on 04/23/21. A review of the incident report dated 11/02/22 at 10:42 AM by Unit Manager revealed Resident #2 complained of pain in right leg, hip, and knee. Resident #2 was able to move right leg and toes and slightly bend her right knee. Resident #2 was offered Tylenol for pain but declined stating the medication she took routinely for pain was enough at this time. The Nurse Practitioner was in the building and made aware. A Nurse Practitioner (NP) progress note written on 11/02/22 AM revealed Resident #2 was seen on 11/02/22 resting in bed. Resident #2 reported pain to her right knee that radiated to right hip with onset after shower on 10/30/22. She had continuous sharp pain rating 8 out of 10 and was worse with moving or touching knee. Resident #2's right knee had mild edema (swelling) and no redness. Resident #2 stated when she was lying still it reduced the pain but did not alleviate the pain. There was no pain on palpation of right hip and an x-ray was ordered for the right knee and hip. A physician's order written on 11/02/22 revealed an x-ray to right knee and hip 2 views related to pain. A review of the x-ray results of the right knee dated 11/02/22 revealed Resident #2 had an acute obliquely oriented (broken at an angle) incomplete fracture at the proximal (near) tibial (shinbone) metaphysis (neck of bone where tibia starts to narrow) medially (middle), a new finding when compared to prior examination dated 01/18/19 and mild osteoarthritis predominantly involving the knee. A record review revealed on 11/03/22, Resident #2 was transferred via mechanical lift to a wheelchair for an appointment to a walk in clinic at nearby orthopedic center where resident was seen and a right leg immobilizer placed and resident returned to facility with orders. A review of a physician's order written on 11/03/22 from the orthopedic center revealed an order for a right knee immobilizer to be worn at all times for 6 to 8 weeks. A review of the Medication Administration Record from 10/30/22 through 11/02/22 revealed Resident #2 received her scheduled Norco 5-325 mg as ordered (three times daily). The Medication Administration Record from 10/30/22 through 11/02/22 revealed Resident #2's pain was assessed on 10/30/22 and 10/31/22, and 11/01/2 and was recorded as 0 for day, evening, and night shift pain assessments. Resident #2's pain was assessed on 11/02/22 and was recorded at 8 for the day shift. Review of an investigation conducted by the facility revealed on 11/02/22 Unit Manager was made aware by Resident #2 that her right leg was hurting. The Unit Manager completed a physical assessment on Resident #2 and reported findings to the Nurse Practitioner. The Nurse Practitioner assessed Resident #2 and ordered an x-ray of her right leg. On 11/03/22, Resident #2 was transferred via a mechanical lift to a wheelchair for an appointment at a walk-in orthopedic clinic where resident was seen and right leg immobilizer was placed. Resident returned to the facility with orders. On 11/04/22, Resident #2 reported she had no new pain from 10/30/22 to 11/02/22. Resident had a diagnoses of osteopenia, cerebral palsy and refused to use the mechanical lift. The root cause of the fractured leg was noted that Nursing Assistants demonstrated lack of knowledge about who to report residents' refusal of using the mechanical lift and did not follow the [NAME] (care guide specific to resident's needs) in Resident #2's care plan. The MDS annual assessment dated [DATE] revealed Resident #2 was cognitively aware and required extensive assistance with two person physical assistance with bed mobility, total dependence with two staff physical assistance with transfers. An interview was conducted with Resident #2 on 10/30/23 at 1:10 PM. Resident #2 revealed she did not get out of bed and that was her choice. Resident #2 stated she had a fall and fractured her right leg because she fell off a mechanical lift. Resident #2 stated she could not recall what had happened when she fell off the lift or when she fell off the lift. Resident #2 stated she no longer had that pain in her right leg. An observation of Resident #2 on 10/30/23 at 1:10 PM revealed an alert and oriented resident lying in bed with head of the bed elevated. Resident #2 did not demonstrate any signs or symptoms of pain. Resident was watching TV and waiting for her lunch to arrive. An interview was conducted via phone with Nurse Aide (NA) #2 on 11/02/23 at 12:37 PM. NA #2 stated Resident #2 refused to use the mechanical lift so we transferred her with two person assistance. NA #2 stated that on 10/30/23 at around 7:00 PM she and NA #1 were putting Resident #2 in the shower bed using a two person technique with her at the head of the bed to move Resident #2's shoulders and NA #1 at the bottom of bed to move Resident #2's legs. NA #2 stated we had the shower bed beside Resident #2's bed and NA #1 placed bath blankets on the shower bed, a pillow for her head, a pillow for under her legs and a pillow for under her feet for cushioning. NA #2 reported NA #1 was holding Resident #2 from her legs and she was at the top holding the resident's arms and we shifted Resident #2 over to the shower bed. NA #2 stated Resident #2 had no complaints of new pain during the transfer, during her shower, or during the transfer from the shower bed back to her bed. NA #2 stated Resident #2 was always complaining of aches and pains, but she did not say she had new pain. NA #2 stated we have used the mechanical lift with her, but that particular time she refused. NA #2 stated she believed NA #1 (who was assigned to Resident #2) let the nurse know, but she could not remember because it was over a year ago. NA #2 stated Resident #2 complained of pain to her knees and legs all the time and that was why we kept pillows under her legs while in her bed and in the shower bed. A follow up interview was conducted with Resident #2 on 11/02/23 at 10:00 AM. Resident #2 revealed she recalled that NA #1 and NA #2 were getting her ready for her shower and they transferred her from the bed to the shower bed. Resident #2 confirmed she did not fall off the mechanical lift but that she refused to use the mechanical lift so the nurse aides transferred her with one of the aides holding her shoulders and one of the aides holding her legs and slid her on to the shower bed. She stated at the time she did not have any new pain to her right leg. She stated she took her shower and they transferred her back to bed the same way and she did not have any new pain to her right leg. Resident #2 stated she could not remember when her knee started to hurt or when she reported the new pain to the nurse. Resident #2 added, she did not like to be transferred on the mechanical lift but knew that it was for her safety. A phone interview was conducted with Nurse #2 on 11/02/23 at 12:48 PM. Nurse #2 stated she had no recollection of any nurse aides reporting to her that Resident #2 was refusing to use the mechanical lift to be transferred. Nurse #2 stated she did not recall being informed that Resident #2 had any complaints of new pain on 10/30/23. Nurse #2 added, Resident #2 had chronic pain and received routine pain medications. Nurse #2 added, if she had been told by the NA that Resident #2 was refusing to be transferred with the mechanical lift, she would have explained to Resident #2 that it was for her safety to use the mechanical lift whenever she was being transferred. A phone interview was conducted with Medication Aide (MA) #3 on 11/02/23 at 2:18 PM. MA #3 confirmed he was assigned to Resident #2 from 7:00 PM to 7:00 AM on 10/30/22 and 10/31/22. MA #3 stated he could not recall if any nurse aides reported to him that Resident #2 refused to be transferred with a mechanical lift on 10/30/22. He also stated Resident #2 had chronic pain but he was not made aware of any new pain from Resident #2. An interview was conducted with MA #2 on 11/02/23 at 9:50 AM. MA #2 reported she was assigned to Resident #2 on 10/31/23 from 7:00 AM to 7:00 PM. She stated she was not made aware of any new pain Resident #2 had nor was she made aware that Resident #2 had her shower on Sunday 10/30/23. She stated she usually had a shower on Mondays and Thursdays. MA #2 stated Resident #2 had chronic pain and she received scheduled pain medicine which she administered on 10/31/23, but Resident #2 never indicated she had new knee pain. An interview was conducted with the Unit Manager (UM) on 11/01/23 at 3:10 PM. The UM reported on 11/02/22 she was called to Resident #2's room because she was complaining of pain. She stated she offered Resident #2 Tylenol, but she refused and added she asked Resident #2 where she was hurting and she stated her right knee. The UM stated she told the Nurse Practitioner (NP) #1 and she ordered an x-ray. The UM stated when she assessed Resident #2 she was able to move her right leg and toes and slightly bend her right knee. The UM stated Resident #2 told her that she got hurt when she was transferred from her bed to the shower bed by NA #1 and NA #2 on Sunday 10/30/22. The UM reported Resident #2 refused to use the mechanical lift and the nurse aides decided to transfer her without using the mechanical lift. Attempted a phone interview with NA #1 on 11/01/23 at 7:30 PM, on 11/02/23 at 10:30 AM, and a text message at on 11/02/23 at 11:58 AM. NA #1 no longer worked at the facility and did not return any calls. Attempted a phone interview with the Nurse Practitioner (NP) #1 via phone on 11/02/23 at 2:20 PM. NP #1 no longer worked at facility and did not return call. Attempted a phone interview with the Director of Nursing (DON) on 11/02/23 at 3:10 PM. The DON no longer worked at the facility and did not return call. An interview was conducted with the Administrator on 11/02/23 at 3:15 PM. He reported it was determined that the nurse aides should have followed Resident #2's [NAME] and transferred her with the mechanical lift for her safety. The Administrator added, the nurse aides should have informed the nurse that she refused to be transferred with the mechanical lift and they should not have transferred her without the lift. The Administrator stated once she complained of new pain, an x-ray was done and determined that she had a fracture to her tibia and she was sent to the orthopedic clinic for a brace. He stated he initiated a plan of correction as a result of her injury and the nurse aides not following the [NAME]. Failure to provide supervision to prevent accidents: The facility initiated the following plan of correction. 1. On 11/02/22, the Unit Manager (UM) completed a head to toe assessment on Resident #2. The results included increase pain and edema to right knee. The UM reported the finding to NP #1 who then assessed Resident #2 and ordered an x-ray of the right leg. The x-ray was completed and resulted in fracture to right tibia on 11/03/22. Resident #2 was taken to the outpatient orthopedic clinic on 11/03/22 and was assessed by a provider who ordered a leg brace for 6-8 weeks. There were no changes to medications due to resident having scheduled Norco that was currently effective. Skin checks were ordered every shift to assess for any skin breakdown under the brace. 2. On 11/03/22, the Director of Nursing (DON) identified residents that were potentially impacted by this practice by completing a review of all interviewable residents for the last 14 days for any similar incidents of residents declining interventions for their transfer status. This was completed on 11/03/22. The results included: no other incidents identified. On 11/03/22, the DON and MDS Nurse audited all resident care plans to assure the transfer status was up to date. All care plans were up to date. On 11/03/22, the DON and Staff Development Coordinator (SDC) Nurse audited all NAs and nurses, including agency NAs and nurses, to assure they could access the [NAME] and knew how to find the transfer status of the resident. The results included: All NAs and nurses, including agency NAs and nurses, were competent with using the [NAME]. On 11/03/22, the DON interviewed NAs and nurses for incidents of refusal to follow the designated transfer status indicated on the [NAME]/care plan. The results included: Resident #2 was the only resident refusing to use the mechanical lift and the resident's [NAME]/care plan was updated to reflect resident's refusal of the mechanical lift. 3. On 11/03/22, the DON began in services on all NAs and nurses, including agency NAs and nurses, on following the resident care plan/intervention process. This training will include all current above staff including agency. This training included: accessing the [NAME] prior to initiating care of transferring a resident, resident refusal to follow the identified transfer status and notification of the nurse before transferring the resident and how to access the [NAME]. 4. As of 11/08/22, 100% staff members have attended the in-service. The DON will ensure that any of the above identified staff who did not complete the in service training by 11/08/22 will not be allowed to work until training was completed. The DON/designee will observe 5 resident transfers on various shifts/days of the week to include weekends, weekly for 2 weeks and monthly for 3 months or until resolved for compliance with following the [NAME]/care plan. Reports will be presented to the weekly Quality Assurance (QA) Committee by the Administrator or DON to ensure corrective action initiated as appropriate. Compliance will be monitored and ongoing auditing program reviewed at the weekly QA meeting. The weekly QA meeting was attended by the Administrator, DON , MDS Coordinator, Therapy, and the Dietary manager. Validation of the corrective action was completed on 11/02/23. This included staff interviews regarding transferring residents according to their [NAME]/care plan and to report to nurse if a resident refused to be transferred according to their [NAME]/care plan to ensure understanding and knowledge of the training provided. An interview with Resident #2 revealed she understood the use of the mechanical lift for her transfers was for her safety, and Resident #2's care plan was updated to reflect refusal of mechanical lift for transfers. The audits were verified and there were no concerns identified. The facility's alleged compliance with the corrective action plan on 11/08/22 was validated.

Based on record review, observation, and interviews with resident representative and staff, the facility failed to provide effective leadership and oversight to ensure systems and policies were implemented related to COVID-19 staff vaccinations for 3 of 3 dietary staff (Dietary Aide #1, Dietary Aide #2, and Dietary Aide #3), resident vaccinations for 1 of 5 residents (Resident #39), and staff testing for 3 of 3 unvaccinated staff (Nurse #3, Nurse Aide #3 and Housekeeper #1). The facility was in COVID-19 outbreak status and had 18 residents test positive for COVID-19 since 6/15/22 (Resident #31, Resident #64, Resident #21, Resident#1, Resident #17, Resident #40, Resident #35, Resident #270, Resident #5, Resident #38, Resident #24, Resident #54, Resident #3, Resident #36, Resident #39, Resident #42, Resident #101, and Resident #102). Findings included: This tag is cross reference to: F888: Based on observation, record review and interviews, the facility failed to implement their policy on COVID-19 vaccinations and to meet the requirement for staff vaccination when Dietary Aide (DA) #1, DA #2, and DA #3 worked without being fully vaccinated and without an exemption. This was for 3 of 3 kitchen staff reviewed for vaccinations. The facility was in COVID-19 outbreak status and had 18 residents test positive for COVID-19 since 6/15/22 (Resident #31, Resident #64, Resident #21, Resident#1, Resident #17, Resident #40, Resident #35, Resident #270, Resident #5, Resident #38, Resident #24, Resident #54, Resident #3, Resident #36, Resident #39, Resident #42, Resident #101, Resident #102). F887: Based on record review, resident representative interview and staff interviews, the facility failed to ensure residents not up to date with COVID-19 vaccinations were offered the COVID-19 vaccine prior to scheduled COVID-19 clinics and failed to maintain a record of refusal for the COVID-19 vaccine for 1 of 5 residents (Resident #39) reviewed for COVID-19 immunizations. This occurred during a COVID-19 pandemic, and the facility was in outbreak status for COVID-19. F-886: Based on record review and staff interviews, the facility which was located in a county with a high community transmission level and was in an outbreak status for COVID-19 failed to conduct COVID-19 testing per Centers for Medicare and Medicaid guidelines every three days and track documentation of COVID-19 testing twice a week for 3 of 3 COVID-19 unvaccinated staff members (Nurse #3, NA #3 and Housekeeper #1) reviewed for COVID-19 testing. Eighteen residents and eleven staff members tested COVID-19 positive since the outbreak. This occurred during a COVID-19 pandemic. In an interview with the Administrator on 7/15/2022 at 12:25 p.m., he stated the facility used broad based measures in response to the COVID-19 outbreak that began on 6/10/2022. He stated the last positive COVID case was on 6/30/2022 and the facility would remain in outbreak status until fourteen days without new positive cases. In an follow-up interview with Administrator on 7/15/202 at 5:16 p.m., he stated he had not explored into how residents were offered COVID-19 vaccination or the process when residents refused the COVID-19 vaccine and stated all staff were COVID-19 tested because of county's high community transmission level.

Based on observation, record review and interviews, the facility failed to implement their policy on COVID-19 vaccinations and to meet the requirement for staff vaccination when Dietary Aide (DA) #1, DA #2, and DA #3 worked without being fully vaccinated and without an exemption. This was for 3 of 3 kitchen staff reviewed for vaccinations. The facility was in COVID-19 outbreak status and had 18 residents test positive for COVID-19 since 6/15/22 (Resident #31, Resident #64, Resident #21, Resident#1, Resident #17, Resident #40, Resident #35, Resident #270, Resident #5, Resident #38, Resident #24, Resident #54, Resident #3, Resident #36, Resident #39, Resident #42, Resident #101, Resident #102). Findings included: The facility ' s Covid-19 Staff Vaccination Policy revised 2/2/22 read in part Staff must have the necessary vaccines to be fully vaccinated by February 26, 2022 and newly hired employees and other new staff will also be required to comply with this policy. In order for a person to be hired or eligible to provide services at the facility after 2/26/22, all such individuals must be fully vaccinated or request a medical/religious exception. Proof of vaccination will be required. Under the heading New Hires, the policy stated, Employees will not be allowed to work with residents unless they have either one vaccine or an approved exception. A review of the National Healthcare Safety Network (NHSH) data reported the week of 6/26/2022 indicated 84% of the staff had completed COVID-19 vaccinations and 84% of the staff had completed or was partially COVID-19 vaccinated. A review of the facility ' s surveillance COVID-19 log revealed 18 residents (Resident #31, Resident #64, Resident #21, Resident#1, Resident #17, Resident #40, Resident #35, Resident #270, Resident #5, Resident #38, Resident #24, Resident #54, Resident #3, Resident #36, Resident #39, Resident #42, Resident #101, Resident #102) residing in the facility tested positive for COVID-19 since 6/15/2022. a. A review of the facility ' s COVID-19 Staff Vaccination Status for Providers spreadsheet revealed DA #1 was partially vaccinated and DA #1 received the first dose of a two dose vaccination series on 7/5/2022. The kitchen schedule for dietary employees revealed DA#1 was scheduled to work on 7/9/22, 7/10/22 and 7/12/22 through 7/14/22. An observation and interview were conducted on 7/13/22 at 3:08 PM with DA #1. DA #1 was observed working in the facility ' s kitchen. He stated he started last week and started training after orientation. He stated he worked in the kitchen and had delivered meal carts to resident halls. An interview was conducted with the Corporate Nurse Consultant on 7/13/22 at 3:30 PM and she stated the facility was following their policy for new hires. She stated she thought new employees could work in the facility if they had their first dose of a vaccine as long as they followed personal protective equipment and testing protocols for exempt employees. b. A review of the facility ' s COVID-19 Staff Vaccination Status for Providers spreadsheet revealed DA #3 was partially vaccinated and received the first dose of a two dose vaccination series on 5/23/22. She was scheduled to work 7/7/22, 7/8/22, 7/10/22 and 7/12/22. An interview was conducted with DA #3 on 7/14/22 at 4:00 PM, and she stated she had been working at the facility for approximately 2 weeks. She also stated she received her second shot on 7/14/2022. An interview was conducted with the Corporate Nurse Consultant on 7/13/22 at 3:30 PM and she stated the facility was following their policy for new hires. She stated she thought new employees could work in the facility if they had their first dose of a vaccine as long as they followed personal protective equipment and testing protocols for exempt employees. c. A review of the facility ' s COVID-19 Staff Vaccination Status for Providers spreadsheet revealed DA #2 was partially vaccinated and received the first dose of a two dose vaccination series on 6/28/22. Dietary work schedules revealed DA #2 was scheduled to work 7/7/22, 7/8/22, 7/11/22, and 7/15/22. An interview was conducted with the Corporate Nurse Consultant on 7/13/22 at 3:30 PM and she stated the facility was following their policy for new hires. She stated she thought new employees could work in the facility if they had their first dose of a vaccine as long as they followed personal protective equipment and testing protocols for exempt employees.