Every finding on record at Ahava Healthcare of Clarksville

Based on the American Council on Aging Website review, medical record review, and interview, the facility failed in their responsibility in maintaining assets under $2,000 for the 2026 Tennessee Medicaid allowance for 7 of 58 (Resident #3, #6, #19, #38, #67, #81, and #93) sampled residents. The findings include: 1. Review of the American Council on Aging Website, Tennessee Medicaid (TennCare) Income & Asset Limits for Nursing Homes & In-Home Long Term Care, dated 4/30/2026, revealed .In 2026, single Medicaid Nursing Home applicant in Tennessee must meet the following criteria.Assets under $2,000. 2. Review of the medical record revealed Resident #3 was admitted to the facility on 8/6/2023, with diagnoses including Diabetes Mellitus, Malnutrition, and Hypotension. Review of the Resident Statement Landscape, dated 4/29/2026, revealed Resident #3's balance was $18,955.25, which was $16,955.25 over the $2,000.00 limit. 3. Review of the medical record revealed Resident #6 was admitted to the facility on 5/1/2006, with diagnoses including Cerebral Infarction, Diabetes Mellitus, and Anxiety. Review of the Resident Statement Landscape, dated 4/29/2026, revealed Resident #6's balance was $4,799.11, which was $2,799.11 over the $2,000.00 limit. 4. Review of the medical record revealed Resident #19 was admitted to the facility on 5/22/2025, with diagnoses including Hemiplegia, Anxiety, and Depression. Review of the Resident Statement Landscape, dated 4/29/2026, revealed Resident #19's balance was $2,547.70, which was $547.70 over the $2,000.00 limit. 5. Review of the medical record revealed Resident #38 was admitted to the facility on 9/20/2022, with diagnoses including Chronic Obstructive Pulmonary Disease, Depression, and Dementia. Review of the Resident Statement Landscape, dated 4/29/2026, revealed Resident #38's balance was $8,119.00, which was $6,119.00 over the $2,000.00 limit. 6. Review of the medical record revealed Resident #67 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Respiratory Failure, and Diabetes Mellitus. Review of the Resident Statement Landscape, dated 4/29/2026, revealed Resident #67's balance was $12,755.29, which was $10,755.29 over the $2,000.00 limit. 7. Review of the medical record revealed Resident #81 was admitted to the facility on 6/1/2017, with diagnoses including Respiratory Failure, and Dementia. Review of the Resident Statement Landscape, dated 4/29/2026, revealed Resident #81's balance was $4,810.16, which was $2,810.16 over the $2,000.00 limit. 8. Review of the medical record revealed Resident #93 was admitted to the facility on 12/5/2012, with diagnoses including Diabetes Mellitus, Hypertension, and Anxiety. Review of the Resident Statement Landscape, dated 4/29/2026, revealed Resident #93's balance was $10,121.71, which was $8.121.71 over the $2,000.00 limit. During an interview on 4/29/2026 at 10:29 AM, the Business Office Manager (BOM) was asked the limit for the resident trust accounts. The BOM stated, $2,000.00. The BOM was asked if the resident or resident representative have been notified regarding the excessive trust balances, and documentation of notification of the risk of losing their Medicaid benefits. The BOM stated, No. The BOM was asked should you have notified the residents or representatives. The BOM stated, Yes . During an interview on 4/29/2026 at 11:03 AM, the Administrator was asked the limit for resident trust accounts. The Administrator stated, $2,000.00. The Administrator was asked should the resident or representative be informed of the risk of losing their Medicaid benefits. The Administrator stated, Yes.

Based on facility policy review, medical record review, and interview, the facility failed to ensure that all allegations of abuse/misappropriation of property were reported to all appropriate agencies for 1 of 1 (Resident #20) sampled residents reviewed for abuse. The findings include: 1. Review of the undated facility policy titled, Abuse, Neglect, and Exploitation, revealed .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .Misappropriation of Resident Property means the deliberate, misplacement , exploitation, or wrongful, temporary or permanent, use of resident's belongings or money without the resident's consent .Identifying correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property .Reporting of all alleged violations to the .state agency .and to all other required agencies as is required .Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury .The Administrator will follow up with government agencies, during business hours to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident or as required by state agencies . 2. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Heart Failure, Anxiety, Depression and Atrial Fibrillation. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #20 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was cognitively intact. During an interview on 4/27/2026 at 10:03 AM, Resident #20 confirmed that an unknown person had opened accounts in her name without her permission. Resident #20 stated, I don't know who did it, it may have been family. Resident #20 was asked if she thought it was staff. Resident #20 stated, I don't have any idea who it was. During an interview on 4/29/2026 at 7:33 AM, the Administrator was asked when did you become aware of the possible concern of accounts being opened in Resident #20's name. The Administrator stated, When the police came and asked to speak with her, maybe a couple weeks ago. The Administrator was asked did you report the possible misappropriation to the state agency. The Administrator stated, I did not, our bank accounts get hacked all the time, I didn't feel like she had anything to lose. During an interview on 04/29/2026 at 10:52 AM, the Director of Nursing (DON) was asked would you expect the suspicion of abuse (including misappropriation) to be reported to the state in a timely manner. The DON stated, Yes. The facility was unable to provide the documentation that suspected abuse was reported to all regulatory and required agencies.

Based on policy review, medical record review, and interview, the facility failed to perform an investigation for misappropriation of resident property for 1of 1 (Resident #20) sampled residents reviewed for abuse. The findings include: 1. Review of the undated facility policy titled, Abuse, Neglect, and Exploitation, revealed .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .Misappropriation of Resident Property means the deliberate, misplacement , exploitation, or wrongful, temporary or permanent, use of resident's belongings or money without the resident's consent .An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur.Identifying and interviewing all involved persons, including the alleged victim, alleged preparator, witnesses, and others who might have knowledge of the allegations.Providing complete and through documentation of the investigation. 2. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Heart Failure, and Cardiomyopathy. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #20 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was cognitively intact. During an interview on 4/27/2026 at 10:03 AM, Resident #20 was asked about the report (filed with Adult Protective Services (APS) and local law enforcement) of someone using her information to open accounts. Resident #20 stated, Someone opened up two [named] accounts using my old phone number and old address. Resident #20 was asked if she knew who may have done it. Resident #20 stated, I have no idea who it could have been . During an interview on 4/28/2026 at 10:46 AM, the Administrator was asked if she was aware of accounts being opened in Resident #20's name. The Administrator stated, Yes. APS put a referral in, the police came to facility to interview the resident, and there were concerns of accounts opened in her [Resident #20's] name . During an interview on 4/29/2026 at 7:33 AM, the Administrator was asked when she became aware of the possible concern of accounts being opened in Resident # 20's name. The Administrator stated, When the police came and asked to speak with her. Maybe a couple weeks ago. The Administrator was asked if she completed an investigation. The Administrator stated, No, I thought it was more of a case of identity theft instead of misappropriation. During an interview on 4/29/2026 at 10:52 AM, the Director of Nursing (DON) was asked if she would expect any suspicion of abuse or misappropriation to be investigated. The DON stated, Yes. The facility failed to provide any documentation that an investigation was completed related to the suspected misappropriation of resident's property.

Based on facility policy review, facility skill assessment review, medical record review, observation, and interview, the facility failed to ensure the prevention and spread of infection when 2 of 4 staff (Registered Nurse (RN) B and Licensed Practical Nurse (LPN) A) failed to use appropriate Personal Protective Equipment (PPE) and failed to follow infection control procedures during medication administration for 2 of 6 (Residents #15 and #93) sampled residents reviewed. The findings include: 1. Review of the undated facility policy titled, Enhanced Barrier Precautions, revealed .It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug -resident organisms.Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities.PPE for enhanced barrier precautions is only necessary when performing high-contact care activities. Review of the undated facility policy titled, Medication Administration, revealed Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 2. Review of the undated facility procedure skill assessment, Eye Drop or Ointment Skill Assessment, revealed .Avoid touching the tip of the bottle or tube to the resident, lid, or surface of the eye. 3. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE], with diagnoses including Cerebral Palsy Gastroparesis, Gastrostomy, and Severe Intellectual Disabilities. Review of the Physician Order dated 1/19/2026, revealed NOTHING BY MOUTH diet. Review of the Physician Order dated 2/24/2026, revealed Enteral Feed Order every shift Nutren 1.5 [a feeding supplement with a strength of 1.5] administer using pump via [by way of] enteral tube [a tube inserted through the abdominal wall used to provide fluids, nutrients and medications when a person has swallowing difficulties] @ [at] 35ml [milliliters]/hour x [times] 22 hours a day. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #15 had severe cognitive impairment. Review of the Medication Administration Record (MAR) dated 4/1/2026, revealed Enhanced Barrier Precautions due to presence of indwelling medical device. Continue precautions until device discontinued . Observation on 4/28/2026 at 3:20 PM, outside of Resident 15's room revealed LPN A donned gloves and began to prepare Resident #15's medications. LPN A poured 45 ml of Lactulose 10mg [milligrams]/ 15ml [milliliters] , 10 ml of Dicyclominesol 10mg/5ml (medication used to treat irritable bowel syndrome by relaxing stomach/intestinal muscles), and 5ml of Metoclopramide 5mg/5l [medication to reduce aspiration risk by promoting gastric emptying in PEG (percutaneous endoscopic gastrostomy) tube patients] into a medication cup. LPN A entered the resident's room, LPN A placed the pump on hold, checked the residual and administered the medication by gravity. LPA A replaced the syringe back into the plastic bag and failed to wear a gown while administered the PEG medication. During an interview on 4/28/2026 at 4:20 PM, LPN A was asked if they should have worn an isolation gown during the PEG medication administration. LPN A stated, Yes, I should have worn a gown . During an interview on 4/29/2026 at 4:15 PM, with the Director of Nursing (DON), the DON was asked should a nurse wear a gown to administer medications by PEG tube in an enhanced barrier procedure room. The DON stated, Yes. 4. Review of the medical record revealed Resident #93 was admitted to the facility on [DATE], with diagnoses including Sleep Apnea, Diabetes Mellitus, Dementia, and Glaucoma. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #93 had a Brief Interview for Mental Status (BIMS) score of 2, which indicated severe cognitive impairment. Review of the MAR dated 3/25/2026, revealed Enhanced Barrier Precautions (EBP) in place due to indwelling device [Urinary Catheter] .EBP to remain in Place as long as catheter is needed. Review of the MAR dated 4/10/2026 revealed Brimonidine Tartrate Solution [a medication that is administered in the eye to treat glaucoma] 0.1% [percent] Instill 1 drop in both eyes every 12 hours for glaucoma . Observation on the 200 Hall on 4/29/2026 at 8:09 AM, revealed RN B gathered medications and went down the hall to Resident #93, who was in a wheelchair sitting at the nurses' station. RN B gave Resident #93 some oral medications and water first. RN B donned gloves and administered 1 drop of Brimonidine Tartrate 0.1% to the right eye, touching the tip of the bottle to the lower eyelid. Then without cleaning the tip of the eye drop bottle, RN B administered 1 drop of medication into the resident's left eye. RN B removed her gloves and went back to the medication cart, disposed of trash in the trash container on the medication cart, placed the eye medication bottle back into a plastic bag and returned the bag to the drawer of the medication cart. RN B contaminated the eye drop bottle when she touched the tip of the bottle to the Resident #93's eyelid and failed to clean the bottle of eye drops after use. During an interview on 4/29/2026 at 3:53 PM, RN B was asked should the tip of the eye medication bottle touch the resident's eyelid. RN B stated, No. RN B was asked should you have cleaned the bottle of eye medication before putting it back in the bag and drawer of the medication cart. RN B stated, Yes, I should have . During an interview on 4/29/2026 at 4:15 PM, the DON was asked when administering eye medication should the tip of the bottle touch the resident's eyelid. The DON stated, No.

Based on the Centers for Disease Control and Prevention (CDC) guidelines, Geriatric Medication Handbook, policy review, Employee Time Punch Reports, Employee Screening Logs, observation, and interview, 3 of 5 nurses (Registered Nurse (RN) #2 and Licensed Practical Nurse (LPN) #1 and #2) failed to maintain infection control practices during medication administration for 4 of 7 sampled residents (Resident #43, #56, #61, and #71) and the facility failed to follow CDC infection control guidelines to ensure practices to prevent the potential spread of Covid-19 when 14 of 132 staff members (Hospitality Aide #1, #2, and #3, Certified Nursing Assistant (CNA) #2, #5, #6, #7, and #8, Occupational Therapist (OT) #1, Registered Nurse (RN) #3 and #4, Licensed Practical Nurse (LPN) #3, Life Enrichment Coordinator, and the Administrator) failed to complete screenings for prevention and detection of COVID-19 prior to work for 4 of 4 days (2/18/2022, 2/19/2022, 2/20/2022, and 2/21/2022) reviewed. This had the potential to affect the 94 residents residing in the facility. The findings include: Review of the GERIATRIC MEDICATION HANDBOOK, 10TH EDITION, revealed .EYEDROP ADMINISTRATION .If administering medication to BOTH eyes in resident with suspected or active eye infection, change gloves between eyes . Review of the facility's undated policy titled, Hand Hygiene, revealed .All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel. Residents, and visitors .The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves .Between resident contacts .Before performing resident care procedures . Review of the facility's undated policy titled, Medication Administration, revealed .Medications are administered by licensed nurses .in accordance with professional standards of practice, in a manner to prevent contamination or infection .Wash hands using facility protocol and product . Observation in the resident's room on 3/9/2022 at 8:35 AM, revealed RN #2 knocked on Resident #43's door, failed to perform hand hygiene and donned a clean pair of gloves. RN #2 obtained a stethoscope, tapped his smart watch, listened to Resident #43's heart, and tapped his smart watch again. RN #2 obtained a clean 60 milliliter (ml) syringe and connected it to Resident #43's Percutaneous Endoscopic Gastrostomy (PEG) tube, and listened to Resident #43's abdomen with the stethoscope. RN #2 administered medications through Resident #43's PEG tube. RN #2 removed his gloves, did not perform hand hygiene, and returned to the medication cart. RN #2 did not remove his gloves and perform hand hygiene after touching inanimate objects and the resident or before exiting the room after the procedure. Observation in the resident's room on 3/9/2022 at 12:20 PM, revealed LPN #1 used a lancet (a small blade with a sharp point) to obtain a blood sample from Resident #71. LPN #1 placed the lancet and the blood glucose monitoring strip which contained the blood sample in the trash can in Resident #71's room. During an interview on 3/9/2022 at 12:25 PM, LPN #1 confirmed the contaminated lancet and monitoring strip should have been placed in the sharp's container and not in the regular trash in the resident's room. Observation in the resident's room on 3/9/2022 at 12:31 PM, revealed LPN #1 prepared to administer [MEDICATION(S)] Eyedrops (used to treat an eye infection) to Resident #56. LPN #1 donned clean gloves, touched a wheelchair to move it, and administered the eyedrop medication to Resident #56's right eye. LPN #1 then administered the eyedrop medication to Resident #56's left eye. LPN #1 failed to remove the gloves and perform hand hygiene after touching inanimate objects in the room and before administering the eyedrop medication and failed to change gloves and perform hand hygiene between placing the eyedrop medication in each eye. Observation at the 400 Hall medication Cart on 3/10/2022 at 8:53 AM, revealed LPN #2 prepared medications for resident #61. LPN #2 locked the cart and did not perform hand hygiene. LPN #2 entered Resident #61's room and administered the oral medications. LPN #2 did not perform hand hygiene and donned clean gloves. LPN #2 then administered an inhaled medication to Resident #61. During an interview on 3/11/22 at 11:50 AM, the Director of Nursing (DON) confirmed staff should perform hand hygiene before preparing meds, before donning, and after doffing gloves. The DON confirmed staff should not touch their smart watch with gloved hands during PEG med administration and that lancets and blood glucose monitoring strips should be disposed of in the sharp's container and not the regular trash. Review of the Centers for Disease Control and Prevention (CDC) document titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 9/10/2021, revealed .Establish a process to identify anyone entering the facility, regardless of their vaccination status .so that they can be properly managed .Options .include .individual screening on arrival at the facility .before entering the facility . Review of the Employee Time Punch Reports and Employee Screening Logs from 2/18/2022 to 2/21/2022, revealed the following employees worked on the following days and failed to screen for signs and symptoms of COVID-19: a. 2/18/2022 - CNA #2 and the Life Enrichment Coordinator. b. 2/19/2022 - CNA #2, #5, and #6, Hospitality Aide #1, #2, and #3, and OT #1. c. 2/20/2022 - CNA #5, Hospitality Aide #1, #2, and #3, RN #3 and #4, and LPN #3. d. 2/21/2022 - CNA #7, CNA #8, Hospitality Aide #1, #2, and #3, OT #1, and the Administrator. During an interview on 3/11/2022 at 3:59 PM, the Administrator confirmed all staff should be screened for COVID-19 upon entering the facility and prior to beginning work.

Based on policy review, medical record review, and interview, the facility failed to have required discharge and transfer documentation for 2 of 3 sampled residents (Resident #49 and #284) reviewed for hospitalization . The findings include: Review of facility's undated policy titled, Transfer and Discharge ., revealed .Emergency Transfers/ Discharges initiated by the facility .Obtain physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .a Transfer Form .Document assessment findings and other relative information regarding the transfer in the medical record . Review of the medical record, revealed Resident #49 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Nurses' Progress Note dated 12/18/2021, revealed .Res [resident] w/ [with] complaints of chest pain .also stating that R [right] arm had no feeling .Res .stating she felt she was having [CONDITION(S)] again .EMS [Emergency Management Services] called . Review of a Nurses' Progress Note dated 12/18/2021, revealed .Resident was admitted to [Named Hospital] . The facility was unable to provide a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 3/10/2022 at 5:35 PM, the Director of Nursing (DON) confirmed she was unable to provide transfer documentation related to the 12/18/2021 hospitalization . Review of the medical record, revealed Resident #284 was admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Nurse's Progress Note dated 1/31/2022, revealed .Resident returning at facility at this time from [Named Hospital] emergency department. Resident re-entering facility and returning to room. New orders received . The facility was unable to provide a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 3/11/2022 at 8:53 AM, the DON confirmed she was unable to provide transfer documentation related to the 1/31/2022 emergency room visit.

Based on policy review, observation, and interview, the facility failed to ensure food was served under sanitary conditions when 6 of 17 staff members (Certified Nursing Assistant (CNA) #1, #2, #3 and #4, Registered Nurse (RN) #1, and the Life Enrichment Coordinator) touched foods with their bare hands and failed to perform hand hygiene for 13 of 88 sampled residents (Resident #15, #22, #28, #38, #40, #46, #48, #58, #64, #69, #82, #84, and #337) observed during dining. The findings include: Review of the facility's policy titled, Dining Service, dated 8/23/2017, revealed .During delivery of the dining service the staff will .prevent the eating surfaces from coming in contact with staff clothing .Handle cups/glasses on the outside of the container .Handle knives, forks, and spoons by the handles .Keeping their hands away from their hair and face when handling food . Review of the facility's undated policy titled, Hand Hygiene, revealed .All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents .This applies to all staff working in all locations within the facility .The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves .Between resident contacts .Before applying and after removing personal protective equipment (PPE) .Before and after handling clean .linens .Before performing resident care procedures .Before and after providing care to residents in isolation .After assistance with personal .functions . Dining observation in the resident's room on 3/7/2022 at 12:37 PM, revealed CNA #1 performed hand hygiene, setup Resident #28's lunch tray, and exited the room without performing hand hygiene. CNA #1 retrieved a straw from the medication cart, returned to Resident #28's room, placed the straw in his cup, and exited the room without performing hand hygiene. CNA #1 retrieved Resident #40's lunch tray, placed it on the over bed table, raised the head of the bed, removed Resident #40's bread from the plastic bag with his bare left hand, and placed it on her plate. Dining observation in the resident's room on 3/7/2022 at 12:45 PM, revealed CNA #1 set up Resident #15's lunch tray, removed the bread from the plastic bag with his bare left hand, and placed it on her plate. CNA #1 failed to perform hand hygiene, went to Resident #46's bedside, assisted her up in the bed, raised the head of her bed, and returned to the meal cart. CNA #1 failed to perform hand hygiene when he returned to the meal cart and retrieved Resident #46's lunch tray. CNA #1 set up Resident #46's lunch tray, removed the bread the plastic bag with his bare left hand, and placed it on her plate. Dining observation in the resident's room on 3/7/2022 at 12:48 PM, revealed CNA #1 raised Resident #64's bed, lowered the head of her bed, failed to perform hand hygiene, and went to the linen cart and obtained a clothing protector. Dining observation on the 100 Isolation Hall on 3/7/2022 beginning at 1:20 PM, revealed the following: a. RN #1 donned isolation gown, shoe covers, and gloves and entered Resident #38's room to deliver the lunch tray. RN #1 doffed her PPE, exited the room, and went to the meal cart to get a cup of coffee. RN #1 donned gloves, failed to perform hand hygiene, and returned to Resident #38's room with the cup of coffee. b. CNA #3 placed Resident #69's lunch tray on her over bed table. Resident #69's daughter stated the resident was in too much pain to eat and asked CNA #3 to remove the tray. CNA #3 returned the tray to the meal cart and placed it back on the cart with the clean trays. c. RN #1 delivered Resident #337's tray, dropped multiple small items on the floor, picked up the items from the floor with her right hand and threw them in the trash while holding the tray in her left hand, placed the resident's lunch tray on the over bed table using both hands. RN #1 removed the lid from the tray, opened the resident's flatware and drinks, and gave them to the resident without performing hand hygiene after collecting the items on the floor. d. CNA #3 took Resident #82's lunch tray into the room, picked up the resident's urinal with urine inside, and hung the urinal on his trash can with her right hand while holding the resident's lunch tray with her left hand. CNA #3 placed the resident's lunch tray on the over bed table with both hands and set up the resident's lunch tray without performing hand hygiene. Dining observation in the resident's room on 3/8/2022 at 7:31 AM, revealed CNA #1 entered Resident #58's room and placed her breakfast tray on her over bed table. CNA #1 lowered the head of the resident's bed, moved the resident up in the bed, covered her with a sheet, placed a pillow under her knees, and moved the over bed table to the resident's bedside. CNA #1 failed to perform hand hygiene, removed the lid from the resident's oatmeal, emptied a sugar packet in her oatmeal, and slid his bare finger across the top of her oatmeal, leaving an indention in the oatmeal. CNA #1 did not obtain a new bowl of oatmeal for Resident #58 after his bare finger touched the oatmeal. Dining observation in the resident's room on 3/8/2022 at 7:37 AM, revealed CNA #2 failed to perform hand hygiene, retrieved Resident #48's breakfast tray from the meal cart, and set up the tray. CNA failed to perform hand hygiene, returned to the meal cart, poured the resident a cup of coffee, and delivered the coffee to the resident. Dining observation in the resident's room on 3/8/2022 at 7:45 AM, revealed CNA #2 placed Resident #22's breakfast tray on his over bed table, exited the room without performing hand hygiene, retrieved a clothing protector from the clean linen cart, and returned to the resident's room. CNA #2 raised the head of Resident #22's bed, applied the clothing protector, poured orange juice in his cup, and retrieved a straw from the hydration cart on the 100 Hall, without performing hand hygiene. Dining observation on the 100 Isolation Hall on 3/8/2022 at 8:03 AM, revealed CNA #4 donned gloves without performing hand hygiene and delivered Resident #84's breakfast tray. Dining observation on the 100 Isolation Hall on 3/8/2022 at 8:10 AM, revealed the Life Enrichment Coordinator retrieved Resident #82's tray from the meal cart, delivered it to the resident, and set up the tray without performing hand hygiene or donning gloves. During an interview on 3/11/2022 at 11:15 AM, the Administrator confirmed staff should perform hand hygiene before donning and after gloves, should not touch the residents' food with their bare hands, should always perform hand hygiene before and after each resident contact, and before removing items from the clean linen cart, medication cart, or hydration cart, after each tray is delivered, and after touching residents or their belongings. The Administrator confirmed dirty trays should not be returned to the meal cart that contained clean trays and should always sanitize their hands when they remove dirty gloves and prior to donning a clean pair of gloves.

Based on policy review, service agreement, medical record review, and interview, the facility failed to ensure accurate medical records for medication orders, medication administration, diagnoses, and discontinued medications for 2 of 22 sampled residents (Resident #17 and #386) reviewed. The findings include: Review of the facility's titled, Physicians Orders, dated 12/2017, revealed .Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .When receiving an order .repeat the order to clarify and ensure the following necessary information is received .Dosage .Route of administration .diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the .[Named Behavioral Health Services] .AGREEMENT . dated 6/5/2019, revealed .Provide Psychological and/or Psychiatric .as available to the residents of the Facility .Provide psychiatric medication management .Maintain all respective medical record documentation including assessment and progress notes in accordance with the Facility's established Medical Record Policy and in compliance with all the pertinent provisions and regulations . Review of the medical record, revealed Resident #17 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] a.[MEDICATION(S)] Tablet Delayed Release 250 mg [milligrams] .1 tablet by mouth at bedtime for Anticonvulsant . b.[MEDICATION(S)] Tablet Delayed Release 500 mg .2 tablet by mouth at bedtime for Anticonvulsant . Review of the Physicians Visit Summary dated 1/25/2022, revealed, .Discontinued [MEDICATION(S)] [an antidepressant] . Review of the Behavioral Health Service visit dated 2/8/2022 and 2/22/2022, revealed Resident #17 was seen for follow up and medication management. The following medications were listed: a.[MEDICATION(S)] .Q [every] HS [hours of sleep] for mood . b.[MEDICATION(S)] .PO [by mouth] QHS for [CONDITION(S)] . During an interview with the Minimum Data Set (MDS) Coordinator on 3/11/2022 at 8:17 AM, confirmed Resident #17 did not have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #1 put an order in for the anticonvulsant. The MDS Coordinator confirmed Resident #17 was not on [MEDICATION(S)] on 2/8/2022 and 2/22/2022. The MDS Coordinator confirmed the practitioners should review medication orders and diagnoses. During an interview with the Director of Nursing (DON) on 3/11/2022 at 8:52 AM, confirmed Resident #17 does not have a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON confirmed he should have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record, revealed Resident #386 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Progress Note dated 3/5/2022, revealed .[MEDICATION(S)] Tablet 10 MG .Give 10 tablets by mouth every 6 hours as needed for pain .The system has identified this order as being outside the recommended dose for this drug: [MEDICATION(S)] Tablet 10 MG .Give 10 tablets by mouth every 6 hours as needed for pain . During an interview on 3/9/2022 at 8:40 AM, Registered Nurse (RN)#1 confirmed Resident #386's medications are in the Cubex (automated medication dispensing system). RN #1 stated, .we have recently had a pharmacy change and have not received his medication card from the pharmacy . RN#1 confirmed the order should have been for one tablet of [MEDICATION(S)] instead of 10 tablets every 6 hours as needed for pain. During a telephone interview on 3/9/2022 at 9:39 AM, Licensed Practical Nurse (LPN) #4 was asked if she received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #4 confirmed the order for 10 tablets was an error. LPN #4 stated, It was a typo [typographical error] . During an interview on 3/9/2022 at 9:55 AM, the DON confirmed the order for [MEDICATION(S)] 10 mg to give 10 tablets every 6 hours as needed for pain was a typo. The DON confirmed the medication (1 tablet) was removed from the Cubex and was not signed out on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 3/11/22 at 1:00 PM, LPN #5 confirmed one tablet of [MEDICATION(S)] 10 mg was administered to Resident #386 on 3/7/2022 and 3/8/2022. LPN #5 stated, I remember giving the [MEDICATION(S)] .I can't believe I did not sign it out or make a note 2 days in a row .

Based on policy review, medical record review, observation, and interview, the facility failed to obtain a Physician's Order for oxygen therapy for 1 of 3 sampled residents (Resident #386) reviewed for respiratory services. The findings include: Review of the facility's undated policy titled, POLICY Oxygen Administration, revealed .Oxygen is administered under orders of a physician . Review of the medical record, revealed Resident #386 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record, revealed there was not a Physician's Order for oxygen. Review of the Baseline Care Plan dated 3/4/2022, revealed .Oxygen therapy - while a resident . Review of the Nurse's notes dated 3/4/2022, revealed .new admit .on O2 [oxygen] at 4L [liters] . Observation in the resident's room on 3/7/2022 at 4:22 PM, 3/8/2022 at 5:00 PM, 3/9/2022 at 8:24 AM and 11:05 AM, and 3/10/22 at 8:19 AM and 9:55 PM, revealed Resident #386 was receiving oxygen per bi-nasal cannula at 4 liters per minute. During an interview on 3/10/2022 at 12:07 PM, the Director of Nursing (DON) confirmed Resident #386 did not have a Physician's Order for oxygen and residents with oxygen therapy should have a Physician's Order for oxygen.

Based on Pre-Admission Screening and Resident Review (PASRR) User Guide for Medicaid Certified Nursing Facilities, medical record review, and interview, the facility failed to resubmit a PASRR after the resident had the addition of a new mental health diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Review of the PASRR User Guide for Medicaid Certified Nursing Facilities, dated 12/11/2018, revealed .Resident Review--you will submit the Level I if the individual has .a significant change in status .Potential Outcomes--PASRR Level II . Review of the medical record, revealed Resident #17 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] Tablet Delayed Release 250 mg [milligram] .by mouth at bedtime for Anticonvulsant .[MEDICATION(S)] Tablet Delayed Release 500 mg .by mouth for at bedtime for Anticonvulsant .[MEDICATION(S)] [[MEDICATION(S)]] Tablet 60 mg Give 1 tablet .for depression .[MEDICATION(S)] Tablet 15 mg Give 1 tablet .at bedtime for depression . Review of the medical record, revealed no documentation a PASRR had been resubmitted for Resident #17 after the addition of the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 3/11/2022 at 8:52 AM, the Director of Nursing (DON) confirmed Resident #17 took [MEDICATION(S)] for mood and had depression. The DON confirmed residents with changes in psychiatric diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record, revealed Resident #39 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record, revealed Resident #39's PASRR was dated 5/19/2017, there was no documentation that a PASRR had been resubmitted after the addition of the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #39 had a psychotic disorder diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record, revealed Resident #64 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the PRE-ADMISSION SCREENING and RESIDENT REVIEW: PASRR, dated 3/7/2013, revealed the PASRR Level I assessment documented Resident #64 did not have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Behavioral note dated 5/17/2021, revealed .Psych [psychiatric] Meds [medications] .[MEDICATION(S)] 25mg [milligrams] .for psychotic disorder .start date .01/03/20 [1/3/2020] .Primary Psychiatric DX [diagnosis] Code .Psychotic Disorder with hallucinations due to known physiological condition . Review of the quarterly MDS dated [DATE], revealed Resident #64 had a psychotic disorder diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record, revealed no documentation a PASRR had been resubmitted for Resident #64 after the addition of the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 3/10/2022 at 10:44 AM, the MDS Coordinator confirmed that residents should have an updated PASRR submitted when they have a significant change in psychiatric diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 3/11/2022 at 8:17 AM, with the MDS Coordinator confirmed the residents should have had an updated PASRR. The MDS Coordinator stated, .some had been missed .

Based on policy review, observation, and interview, the facility failed to ensure medications were labeled and stored appropriately when opened multidose bottles did not have an open date and medications were stored past their expiration date in 1 of 4 medication storage areas (400 Hall Medication Cart) and when unsecured medications were observed 1 of 60 resident rooms (Resident #336's room). The findings include: Review of the facility's undated policy titled, Medication Storage, revealed .It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms .All drugs and biologicals will be stored in locked compartments .The pharmacy and all medication rooms are routinely inspected .for discontinued, outdated .medications . Observation in the resident's room on 3/7/2022 at 10:49 and 4:53 PM, and 3/8/2022 at 12:55 PM and 7:12 PM, revealed an [MEDICATION(S)] inhaler on Resident #336's bedside table. Observation of the 400 Hall Medication Cart on 3/8/2022 at 5:45 PM, revealed for following: a. 1 opened and undated multidose bottle of [MEDICATION(S)] 1 percent. b. 1 bottle of [MEDICATION(S)] 0.4 milligrams with an open date of 1/9/2022. During an interview on 3/9/2022 at 4:36 PM, the Director of Nursing (DON) confirmed medications should not be stored at the resident's bedside. During an interview on 3/10/2022 at 4:29 PM, the Consultant Pharmacist stated, .I like to replace it [[MEDICATION(S)]] every month .with [MEDICATION(S)] when it is opened and air gets to it, it starts to deteriorate .30 days is my reference . During an interview on 3/11/2022 at 11:23 AM, the DON confirmed opened medications should have an opened date and [MEDICATION(S)] should be discarded 30 days after the open date.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were followed when 1 of 1 (Licensed Practical Nurse (LPN) #3) nurse failed to perform proper hand hygiene and failed to cleanse the stethoscope during [MEDICAL CONDITION] care, and when 2 of 2 (LPN #1 and #2) nurses failed to perform proper hand hygiene during wound care. The findings included: 1. Review of the facility's undated [MEDICAL CONDITION] Care policy documented, .8 .pull soiled glove over dressing and discard .9. Wash hands .8. Put on sterile gloves . 2. The facility's undated Hand-hygiene technique policy documented .The use of gloves does not replace hand washing . 3. Medical record review revealed Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations of [MEDICAL CONDITION] care in Resident #3's room on 10/31/18 beginning at 9:23 AM, revealed LPN #3 removed her dirty gloves and donned sterile gloves without performing hand hygiene. LPN #3 removed a stethoscope from around her neck, auscultated Resident #3's lung sounds and placed the stethoscope back around her neck without cleaning it. Interview with LPN #3 on 10/31/18 at 10:05 AM, on the 200 hall, LPN #3 was asked if she performed hand hygiene when she removed the dirty gloves and before she put on sterile gloves. LPN #3 stated, No. LPN #3 was asked if she cleaned the stethoscope after used on Resident #41. LPN #3 confirmed she did not. Interview with the Director of Nursing (DON) on 10/31/18 at 11:08 AM, in the conference room, the DON was asked what the nurse should do between glove changes. The DON stated, Perform hand hygiene. The DON was asked when the nurse should clean the stethoscope. The DON stated, Clean before you take it out of the room .She should have cleaned it with a sani-wipe. The DON was asked if it was acceptable for nurses to wear stethoscopes around their necks. The DON stated, No they should not wear them around their necks. 4. The facility's Clean Dressing Change policy dated 10/17 documented .PR[NAME]EDURE .9. Position resident to allow of dressing removal. 10. Remove gloves, wash hands and apply clean gloves .11. Remove dressing .12. Remove gloves, wash hands and apply clean gloves .13. Perform wound cleansing .15. Remove gloves, wash hands and apply clean gloves .16. Apply cover dressing .17. Reposition .dispose of soiled supplies, remove gloves, perform hand hygiene . 5. Observations in Resident's #45 room on 10/31/18 at 9:50 AM, revealed LPN #1 and LPN #2 positioned Resident #45 for dressing removal, then LPN #1 removed her gloves and donned another pair of gloves without performing hand hygiene. LPN #1 removed the soiled dressing, removed her gloves, and donned a new pair of gloves without performing hand hygiene. LPN #1 cleansed the wound with Normal Saline, removed her gloves, walked into the bathroom, performed hand hygiene, returned to the room, touched the bathroom door and the resident's door, threw a packet of skin prep on top of the clean barrier, and then donned a new pair of gloves. LPN #1 asked LPN #2 to take the keys that were dangling from her neck and over the wound, and put them in her pocket. LPN #2 removed her gloved right hand from Resident #45, put the keys in LPN #1's pocket, then placed the same gloved hands back on Resident #45 for positioning, without removing her gloves and performing hand hygiene. LPN #1 applied Collagen to the wound bed, removed gloves, and donned a new pair of gloves without performing hand hygiene. LPN #1 applied a cover dressing to the wound, gathered the soiled supplies, put them in a biohazard bag, and removed her gloves without performing hand hygiene. LPN #1 carried the biohazard bag with her unwashed bare hands down the hall to the Biohazard Room. LPN #1 entered the Biohazard Room, disposed of the biohazard bag, and looked around the room for soap. No soap was available. LPN #1 rinsed her hands using water, came out of the Biohazard Room. Interview with the DON on 10/31/18 at 11:15 AM, in the conference room, the DON was asked what was the proper procedure when removing gloves and donning gloves. The DON stated, When they remove their gloves they should wash hands and before donning the next pair of gloves. The DON was asked if was acceptable to wash hands without soap. The DON stated, No.

Based on review of the GERIATRIC MEDICATION HANDBOOK, 13TH EDITION provided by the American Society of Consultant Pharmacists, facility protocol review, medical record review, observation, and interview, the facility failed to ensure 1 of 5 (Registered Nurse (RN) #1) nurses administered medications free of significant medication errors. The findings included: 1. The GERIATRIC MEDICATION HANDBOOK, 13TH edition provided by the American Society of Consultant Pharmacists documented, .Diabetes: Injectable Medications .[MEDICATION NAME] .Rapid-Acting Insulin .ONSET .15 min (minutes) .TYPICAL ADMINISTRATION/COMMENTS .5-10 minutes before meals . 2. The facility's undated INSULIN protocol documented, .Rapid-Acting .[MEDICATION NAME] .Onset .10-20 min .When given .meals should occur when Insulin is at peak effect .5-10 min before meals . 3. Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] .20 unit (units) subcutaneously with meals for diabetes . Observations in Resident #25's room on 10/30/18 at 5:52 PM, revealed RN #1 administered [MEDICATION NAME] 20 units to Resident #25's abdomen. Observations in Resident #25's room on 10/30/18 at 6:32 PM, revealed Certified Nursing Assistant #1 delivered Resident #25's supper meal to her. Interview with RN #1 on 10/30/18 at 6:35 PM, at the 300/400 Nurses' Desk, RN #1 was asked how long after a [MEDICATION NAME] injection should a resident receive a substantial meal/snack. RN #1 stated, Within 15 minutes. RN #1 was asked if Resident #25 received a substantial meal/snack within 15 minutes of her [MEDICATION NAME] injection. RN #1 stated, No . Interview with the Director of Nursing (DON) on 10/31/18 at 4:02 PM, in the conference room, the DON was asked how long after a [MEDICATION NAME] injection should the nurse provide a substantial snack or meal. The DON stated, 15 minutes. The failure of the nurse to provide a meal or substantial snack within 15 minutes of administration of the [MEDICATION NAME] inuslin injection resulted in a significant medication administration error.

Based on policy review, observation and interview, the facility failed to ensure food was prepared and served under sanitary conditions as evidenced by a trash can near the hand sink covered with dirt, a plate lid with dried brown food substance stored on a clean dish rack, wet bowls on the serving lines, a gas stove covered with dried food substance, a toaster, four ovens and a large pot with carbon build-up, the floor under the equipment with brown greasy substance, and the base boards in the dish room with chipped tiles and brown substance. The facility had a census of 115 with 112 of those residents receiving a meal tray from the kitchen. The findings included: 1. The facility's DRY STORAGE - DISHES AND UTENSILS policy documented, .Dishes must be stored to promote air drying .use dish racks or trays with plastic mesh that allow air to circulate and air dry the dishes . 2. The facility's STOVE TOP policy documented, .Wipe off burner grids using clean cloth and detergent .Take to pot and pan sink and scrub or send through dishmachine .Take to pot and pan sink and scrub . 3. The facility's OVEN - CONVENTIONAL, GAS policy documented, .Remove spills, spillovers, and burned food deposits .Wipe cool oven's exterior and interior with wet cloth .Remove and scrape drip pans; send through dishwasher cycle and allow to air dry .Remove oven racks; take to designated area for spraying .Use oven cleaner and allow racks to stand . 4. The facility's TOASTER-ROTARY policy documented, .Wash in pot and pan sink .Clean interior and exterior of machine with cleaning solution . 5. The facility's POTS AND PANS-SANTIZING SOLUTION policy documented, .Scrub pots and pans in first tank using scouring pad or appropriate cleaning tool .Rinse pots and pans free of detergent in second tank .When items are dry .store in proper storage area .Pots and pans need to be free of black buildup . 6. The facility's FLOORS/FLOOR MATS/BASEBOARDS policy documented, .Mop an area 9 by 12 feet at a time .Weekly wipe down the baseboards with cleaning cloths and detergent . Observations in the kitchen on 11/5/17 at 10:53 AM, and 11/6/17 at 10:24 AM, revealed a dirty trash can near the hand sink. Observations in the kitchen on 11/5/17 at 10:55 AM, revealed a plate cover with dried dark food particles on a clean dish rack . Observations in the kitchen on 11/5/17 at 10:57 AM, revealed 16 wet soup bowls in use on the serving line. Observations in the dining room on 11/5/17 at 12:09 PM, revealed 64 wet soup bowls on the serving line. Observations in the kitchen on 11/6/17 at 10:19 AM, revealed 20 wet soup bowls on the serving line. Observations in the kitchen on 11/5/17 at 10:59 AM, revealed a gas stove covered with dried burnt food particles. Observations in the kitchen on 11/5/17 at 11:02 AM, and 11/6/17 at 10:24 AM, revealed carbon build-up on the toaster. Observations in the kitchen on 11/5/17 at 11:02 AM, and 11/6/17 at 10:24 AM, revealed carbon build-up in 2 convection ovens with a sheet pan at the bottom of each oven with a large amount of burnt dark substance, and 2 conventional ovens with carbon build-up. Observations in the kitchen on 11/6/17 at 10:25 AM, revealed a large pot with carbon build up. Observations in the kitchen on 11/5/17 at 10:57 AM, 11/6/17 at 10:24 AM, and 11/7/17 at 10:47 AM, revealed a brown greasy build-up on the floor under the kitchen equipment. Observations in the kitchen on 11/5/17 at 11:00 AM, 11/6/17 at 10:25 AM, and 11/7/17 at 10:48 AM, revealed the base boards in the dish room with chipped tiles and brown build-up on the bottom of the walls. Interview with the Dietary Manager on 11/6/17 at 10:28 AM, in the kitchen, the Dietary Manager was asked to describe the facility's process for drying the dishes before use in the kitchen. The Dietary Manager stated, We let them dry in the dish area .then we bring them to the serving line . The Dietary Manager was asked if it was acceptable to have wet dishes on the serving lines. The Dietary Manager stated, No. The Dietary Manager was asked if it was acceptable to have carbon build up on the equipment and a pot in the kitchen. The Dietary Manager stated, No. The Dietary Manager was asked if it was acceptable to have a dirty trash can in use in the kitchen. The Dietary Manager stated, No. The Dietary Manager was asked if it was acceptable to have burnt food substance on the gas stove. The Dietary Manager stated, No. Interview with the Dietary Manager on 11/7/2017 at 10:32 AM, in the kitchen, the Dietary Manager was asked if it was acceptable to have a plate lid with food particles on the clean dish rack. The Dietary Manager stated, No it should be clean . The Dietary Manager was asked if it was acceptable to have chipped tiles and brown build-up on the kitchen base boards. The Dietary Manager stated, .No .you're not supposed to have chipped tile or build-up on the walls . The Dietary Manager was asked if it was acceptable to have greasy build-up on the floor under the kitchen equipment. The Dietary Manager stated, No.

Based on observation, interview and record review, the facility failed to ensure measures to prevent safety accidents by not maintaining controlled substances under a double lock system for 1 of 2 (medication storage room for the on the 300/400 hall) medication storage rooms observed during the survey. The finding included: Review of the facility's policy entitled, Medication Ordering, Receiving and Storage received 9/2/2016 at 11:30 AM from the Director of Nursing (DON), effective date January 1, 2015, indicated, .Controlled Substances .Policy .The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances .General Guidelines .5. Controlled substances must be stored in the medication room in a locked container, separate from container for any non-controlled medications, or per state regulation. This container will remain locked at all times, except when it is accessed with key or access code to obtain medications for residents On 8/30/16 at 10:49 AM, an observation of the 300/400 Medication room was conducted. Licensed Practical Nurse (LPN) #2 was the 400 Hall nurse that day and assisted with the observation by unlocking the 300/400 Medication storage room and remaining during the observation. A small refrigerator in the 300/400 medication storage room was observed to have a small clear container with a key in the lock. LPN #2 stated at that time, .that is where the refrigerated controlled substances are kept .we cannot get the key out of the lock In an interview on 9/1/16 at 3:30 PM the DON stated, .the key should not be left in the lock .we should have a 2 lock system for all controlled substances.

Based on observation and interview, the facility failed to ensure food was prepared and served under sanitary conditions when frying pans, baking sheets and a roaster had a buildup of carbon on them and 7 of 10 (Kitchen Staff (KS) #1, 2, 3, 4, 5, 6, and Director of Nutritional Services) kitchen staff members did not completely cover their hair in the kitchen. The facility had a census of 105, with 104 of residents received a meal tray. The findings included: 1. Observations in the kitchen on 7/20/15 at 10:30 AM, revealed 2 large frying pans, 6 baking sheets, and a roaster had carbon build-up. Interview with KS #1 on 7/20/15 at 10:50 AM, in the kitchen, KS #1 was asked what is on the pan. KS #1 stated, That is carbon. 2. Observations in the kitchen on 7/20/15 at 10:30 AM, revealed KS #1 and 2 did not have their hair completely covered, and KS #2 had no facial hair cover for his mustache. 3. Observations in the kitchen on 7/22/15 at 11:30 AM, revealed the Director of Nutritional Services (DONS) and KS #1, 2, 3, 4 and 5 did not have their hair completely covered. 4. Observations in the kitchen on 7/22/15 at 4:57 PM, revealed the DONS did not have her hair completely covered. 5. Observations in the kitchen on 7/24/15 at 9:05 AM, revealed the DONS, KS #1 and #6 did not have their hair completely covered and KS #6 had no facial hair cover for his mustache. 6. Interview with DONS on 7/24/15 at 4:20 PM, in the office next to the Director of Nursing's (DON) office, the DONS was asked if hair should be covered with hair restraints. The DONS stated, When preparing food they should have their hair covered. The DONS was asked if staff with facial hair should wear beard covers. The DONS stated, Yes.

Based on medical record review, observation and interview, the facility failed to ensure medical records were accurate related to medication administration, pressure ulcer identification, admitted and bathing records for 4 of 24 (Residents #14, 19, 132 and 186) sampled residents of the 70 residents included in the stage 2 review. The findings included: 1. Medical record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The wound assessment reports revealed the following: a. 11/24/14 to 12/8/14 - .Wound Type Pressure Ulcer. Stage 1. b. 12/9/14 to 2/11/15 - .Wound Type Pressure Ulcer. Stage 2. The Departmental Notes revealed the following: a. 11/24/14 - LATE ENTRY. Coccyx. sloughing area to the center. b. 2/22/15 - Stage II to sacral wound now presents as a stage III. The Director of Nursing (DON) entered the conference room on 7/24/15 at 8:35 AM and handed the surveyor the Departmental Notes and showed the surveyor the late entry dated 11/24/14 at 9:49 PM, that documented, .white sloughing area to the center. The DON stated, She was admitted with a stage 3 not a stage 1, when you have slough it is a 3. The surveyor stated, So you are telling me the wound assessments are not accurate. The DON stated, Yes. 2. Medical record review revealed resident #19 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. The physician's telephone order dated 7/20/15 documented, .Imipenem 500 mg (milligrams) IV (Intravenous) q (every) 6 h (hours) x (times) 7 day. The Medication Administration Record [REDACTED] a. IMIPENEM-CILASTATIN 500 MG. give q 6 hrs (hours) x 5days Order Date 7/20/15 Start Date 7/21/15. The Imipenem-cilastiatin was documented as given on 7/21/15 at 8:00 PM and on 7/22 at 2:00 AM and 8:00 AM. b.IMIPENEM-CILASTATIN 500 MG. per PICC (Peripherally Inserted Central Catheter) line q6hrs x7days Order date 7/21/15 Start Date 7/21/15. The Imipenem-cilastiatin was documented as being given on 7/21/15 at 8:00 PM and on 7/22/15 at 2:00 AM and 8:00 AM. Observations on 7/20/15 at 4:59 PM, on 7/21/15 at 8:11 AM, 9:43 AM, 1:06 PM and 4:10 PM and on 7/22/15 at 7:50 AM, in Resident #19's room revealed the resident had no IV access. Observations on 7/22/15 at 9:55 AM, in Resident #19's room revealed Resident #19 lying in bed and staff in the room to place a PICC line. Interview with the DON on 7/22/15 at 2:30 PM, in the conference room, the DON was asked when the PICC line was placed. The DON stated, Documented at 12:08 PM, on 7/22/15. The surveyor read the orders on the MAR for both orders for Imipenem. The DON was asked if documentation for 7/21/15 at 8:00 PM and on 7/22/15 at 2:00 AM and 8:00 AM for both orders on the MAR indicated [REDACTED]. 3. Medical record review revealed Resident #132 was admitted to the facility on [DATE] and readmitted [DATE] and 5/20/15, with the latest re-admission on 7/23/15 with [DIAGNOSES REDACTED]. Review of a Hospitalist Discharge Summary dated 5/19/15 documented, .FINAL DISCHARGE Diagnoses: [REDACTED]. Review of the Departmental Notes dated 5/19/15 documented, Resident arrived at facility at 8:15 PM, via EMS (Emergency Medical Services) from (Named Hospital). The medical record was not accurate when the admitted was documented as two different dates. 4. Medical record review documented Resident #186 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The Activities of Daily Living (ADL) roster documented Resident #186 received a bed bath and a shower on 7/15/15 at 9:05 PM. Interview with Certified Nursing Assistant (CNA #4) on 7/24/15 at 2:21 PM, in the conference room, CNA #4 was asked about the documentation on the ADL roster that Resident # 186 received a shower and a bed bath on 7/15/15 at 9:05 PM. CNA #4 stated, It was a bed bath. CNA #4 was asked if the shower documentation was an error. CNA stated, Yes.

Based on policy review, observation and interview, the facility failed to provide effective housekeeping services necessary to maintain a sanitary, orderly and comfortable environment as evidenced by non functioning paper towel dispenser; dirt and grime on the floors; missing tiles; black buildup at the door facings; scuff marks on floors, walls and doors and a black substance in the entryway to the rooms in 20 of 60 rooms (Rooms 102, 205, 209, 303, 305, 307, 308, 311, 312, 313, 316, 400, 402, 403, 405, 406, 407, 408, 410 and 411). The findings included: 1. The facility's Work Practices Controls for Environmental Services policy documented, The workplace will be maintained in a clean and sanitary condition. 2. Observations during the initial tour on 7/20/15 beginning at 10:25 AM revealed the following: a. Room 102 - the paper towel dispenser was not functioning. b. Room 205 - there were holes in the bathroom wall. c. Room 209 - the bathroom shower floor was dirty around at the drain. d. Rooms 303, 305, 307, 308, 312, 313, 316, 400, 402, 403, 405, 406, 407, 408, 410 and 411 - had missing floor tiles with the presence of glue at the entryway. 3. Observations in the bathroom of room 307 on 7/20/15 at 10:30 AM and 4:19 PM and on 7/21/15 at 7:39 AM, revealed a buildup of dirt at the door facing and cracked tiles, the paint was peeled off the wall behind the bed, the floor was dirty at the entryway, the laminate was off both sides of the door and had dirt around the bathroom door. 4. Observations in room 308 on 7/2015 at 4:26 PM and on 7/22/15 at 4:12 PM, revealed the tile was stained and dirty around the base of the commode and the baseboard was loose under the sink, the plaster was missing on the wall on left side of the bed, next to the bathroom, the floor was dirty, and the plaster was missing on the wall beside the closet. 5. Observations in room 311 on 7/20/15 at 4:35 PM and on 7/21/15 at 7:54 AM, revealed the bathroom floor was dirty and sticky, a black substance was around the base of the entryway and the floor was dirty and the bathroom floor was dirty with stains in front of the commode and the laminate was missing around the door handle of the bathroom door. 6. Observations in room 315 on 7/2015 at 4:26 PM and on 7/21/15 8:05 AM, revealed the plaster was missing around the door frame on the left side of the bathroom entry, floor was dirty especially at the entryway and laminate was missing on the bathroom door. 7. Interview with the Administrator on 7/21/15 at 4:10 PM, at the 300/400 nurses' station, the Administrator was asked what is your plan for the floor. The Administrator stated, We started the end of last year (2014) , the primary focus is the floor. We want to have the floor completed by the end of the year (2015).

Based on policy review, medical record review, and interview, the facility failed to ensure a comprehensive care plan was developed to address refusal of care/treatment, aspiration precautions/head of bed elevation, antipsychotic, antidepressant, and/or antianxiety medications for 4 of 24 (Residents #80,132,180, and 183) sampled residents of the 70 included in the stage 2 review. The findings included: 1. The facility's Care Planning - Interdisciplinary Team policy documented, .for developing individualized comprehensive care plans for each resident. Any area of difficulty or concern that prevents the resident from reaching his/her fullest potential. Problems must be stated in behavioral and/or functional terms associated with the [DIAGNOSES REDACTED]. 2. Medical record review revealed Resident #80 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the dietary notes revealed the following: a. 1/25/15 - .Refuses all interventions. b. 4/19/15 - Resident #80 refused daily weights and refused adaptive equipment and therapy referral. Review of the nurses' notes revealed the following: a. 4/23/15 - .Resident refused 5pm medication. b. 5/29/15 - .Attempted oral hygiene brushing teeth, patient refused. c. 6/10/15 - .Resident refuses to wear heel/foot protectors. d. 6/12/15 - .Resident refused shower. resistant to pericare. e. 6/15/15 - .Nurse reported patient refused oral care. f. 6/28/15 - .Refusing oxygen. g. 7/3/15 - .Resident refused to allow reconnect of feeding. Review of the therapy notes revealed the following: a. 6/11/15 - .Pt (patient) refusing to get out of bed today in several attempts. b. 6/12/15 - .Attempted. to have pt (patient) participate in therapy in which the pt said no both times and became increasingly agitated. Review of the care plan dated 5/21/15 did not include approaches for Resident #80's refusal of care and treatment. Interview with Licensed Practical Nurse (LPN) #2, on 7/24/15 at 2:05 PM, in the conference room, LPN #2 was asked whether Resident #80's refusal of care and treatment should be documented on the care plan. LPN #2 stated Yes. 3. Medical record review revealed Resident #132 was admitted to the facility on [DATE] and readmitted [DATE] and 5/20/15, with the latest re-admission on 7/23/15 with [DIAGNOSES REDACTED]. Review of a Hospitalist Discharge Summary dated 5/19/15 documented, .FINAL DISCHARGE Diagnoses: [REDACTED]. Review of the Departmental Notes dated 5/19/15 documented, Resident arrived at facility at 8:15 PM, via EMS (Emergency Medical Services) from (Named Hospital). Review of a care plan dated 5/19/15 did not document a problem for aspiration pneumonia and no intervention for keeping head of bed elevation at 30 degrees. A physician order [REDACTED]. Interview with the Director of Nursing (DON) on 7/24/15 at 2:57 PM, in the DON's office, the DON was asked, Would you expect a resident on a tube feeding with a history of aspiration pneumonia to have a care plan that would reflect interventions to prevent further aspiration? The DON stated, Yes. 4. Medical record review revealed Resident #183 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS with ARD 7/15/15 documented Resident #183 was moderately cognitively impaired and received antipsychotic, antianxiety and antidepressant medications during the past 7 days. The physician orders [REDACTED]. The comprehensive care plan dated 7/21/15 did not address antipsychotic, antidepressant, or antianxiety medications. Interview with LPN #2 on 7/23/15 at 6:56 PM, in the MDS office, LPN #2 was asked if the comprehensive care plan should address Resident #183's antipsychotic, antidepressant and antianxiety medications. LPN #2 stated, Yes.

Based on policy review, medical record review, observation and interview, the facility failed to ensure urinary catheters were maintained in a manner to prevent the spread of infection when the foley bag was touching the floor for 2 of 3 (Residents #14 and 138) residents and when catheter care was provided without the use of soap or an antibacterial agent for 1 of 3 (Resident #80) sampled residents with a catheter of the 70 residents included in the stage 2 review. The findings included: 1. The facility's Foley Catheters, Care of, Infection Control and Insertion Guidelines policy documented, .To maintain safety with the use of Foley catheter. To prevent and control Foley catheter associated urinary tract infection. 2. Medical record review revealed Resident #14 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #14 had an indwelling catheter. Observations in Resident #14's room on 7/22/15 at 4:12 PM, revealed Resident #14's foley catheter bag was touching the floor. 3. Medical record review revealed Resident #80 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The care plan dated 6/3/15 documented Resident #80 required use of an indwelling urinary catheter. perform catheter care as ordered or per facility protocol. Observations and interview in Resident #80's room on 7/23/15 at 8:17 AM, revealed Certified Nursing Assistant (CNA) #7 performed foley catheter care for Resident #80 using water. CNA #7 was asked what she used to clean the catheter. CNA #7 confirmed that she used only water. Interview with the Director of Nursing (DON) on 7/24/15 at 10:30 AM, in the conference room, the DON was asked what hygiene product she expected the staff to use when performing foley catheter care. The DON stated, Soap and water. The DON was asked if it was acceptable for the staff to use only water. The DON stated, No. They should use soap or periwash. 4. Medical record review revealed Resident #138 was admitted on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. The admission MDS for Resident #138 dated 5/12/15 documented Resident #138 had an indwelling urinary catheter. Observations in Resident #138's room on 7/22/15 at 4:31 PM, revealed the foley catheter bag laying on the floor. Interview with the DON on 7/24/15 at 3:00 PM, in the DON's office, the DON was asked if the foley catheter bag should be laying on the floor. The DON stated, No.