Every finding on record at Alliance Health and Rehabilitation Center

Based on record review and an interview with staff, the facility failed to notify the office of the State Long-Term Care Ombudsman of a discharge for one (Residents #104) of three residents whose records were reviewed for transfers/discharges, from a total survey sample of 31 residents. The findings include: A review of the medical record revealed that Resident #104 was admitted to the facility on [DATE] and then discharged on [DATE]. His diagnoses included, but were not limited to, acute on chronic systolic heart failure, cellulitis of the right limb, bacteremia, chronic kidney disease (CKD), and Plural effusion. A review of the Discharge Summary note, dated 12/05/24, revealed that Resident #104 was discharged home at 12:30 PM that day under hospice care. The resident's spouse signed the discharge papers and reviewed the discharge medications. A review of the resident's Minimum Data Set (MDS) assessments revealed a Discharge/Return Not Anticipated MDS assessment with an assessment reference date (ARD) of 12/05/24, indicating a planned discharge. The discharge location was noted as home. Further review of the record revealed that Resident #104 received an AHCA (Agency for Health Care Administration) Nursing Home Transfer and Discharge Notice on 12/04/24 with an effective discharge date of [DATE]. The reason for the discharge was noted as home with hospice services. The areas of the form indicating the date the notice was given to the resident or representative, the date the Ombudsman was notified of the discharge, and the date the clinical record was noted, were all left blank. (Copy obtained) An interview was conducted with the Social Services Director (SSD) on 02/27/25 at 1:20 PM. She confirmed that the facility was supposed to notify the local Ombudsman's office of resident discharges. She was asked to provide verification of Ombudsman notification for Resident #104. She was unable to provide verification. She stated when she notified the Ombudsman's office via fax, she did not keep the confirmation page. On 02/27/25 at 2:10 PM, a telephone interview was conducted with the Ombudsman who confirmed that she had not been notified of Resident #104's discharge. A review of the facility's policy titled Social Services and Case Management: Post-Discharge Plan of Care (undated), revealed the following: Purpose: Pre-Discharge Planning will be coordinated by the Case Management Social Service Department for the development of post-discharge plan of care. 7. Contact those service agencies determined to be needed to support resident's needs, resources, and services upon discharge. These may include such services as: home health, durable medical equipment, therapy services, meals on wheels, transportation, etc.

Based on observations, resident and staff interviews, medical record review, and facility policy and procedure review, the facility failed to ensure the implementation of the comprehensive person-centered care plan for one (Resident #7) of four residents reviewed for falls, out of six residents identified for falls with major injuries, from a total survey sample of 31 residents. Failure to implement the necessary fall interventions on a resident's care plan places them at risk for additional falls and associated injury/pain. The findings include: Resident #7 was observed and interviewed on 02/27/2025 at 9:40 AM. She was lying in bed covered with a blanket up to her chin. No fall mats were observed on the floor on either side of the bed. (Photographic evidence obtained) Resident #7 stated she had been educated on and was encouraged to use her call light prior to trying to get up and walk or transfer. Resident #7 was observed a second time on 02/27/2025 at 9:55 AM. She was lying in bed with her eyes closed. No fall mats were on the floor. A review of the resident's face sheet revealed she was admitted to the facility on [DATE] and then readmitted on [DATE]. Her diagnoses included osteoporosis, atrial fibrillation, cognitive communication deficit, heart failure, unspecified dementia without behavioral disturbance, hypothyroidism, hyperlipidemia, major depressive disorder, chronic pain, chronic obstructive pulmonary disease (COPD), anemia, nondisplaced fracture of proximal phalanx of left great toe, moderate protein calorie malnutrition, and presence of automatic cardiac defibrillator. (Copy obtained) A review of the quarterly [NAME] Data Set (MDS) assessment, dated 01/29/2025, revealed that Resident #7 was assessed with a Brief Interview for Mental Status (BIMS) score of 10 out of 15 possible points, indicating moderate cognitive impairment. No signs or symptoms of mood disorder or impairment in upper or lower extremities were documented. A wheelchair was used for mobility. The resident required set-up or supervision only for activities of daily living (ADLs), and had two or more falls since the last assessment. (Copy obtained) A review of the Care Plan, dated 02/11/2025, revealed the following focus areas: The resident is at risk for falls related to impaired balance/gait, use of psychotropic medications, urinary incontinence. Initiated 03/15/2022. Revised 01/14/2025. Goal: Potential for falls/fall-related injuries will be minimized through next review date. Interventions included fall mats while in bed. Initiated 01/12/2025. The resident has alteration in behavior as evidenced by refusing care at times, has impulsive behaviors, poor safety awareness, will spontaneously get up without calling for assistance and refuses to wear non-skid socks. Falls were documented on 08/27/2024, 9/06/2024, 10/12/2024, 10/28/2024, 12/26/2024, 12/28/2024, and 01/12/2025 x 2. (Copy obtained) During an interview with Certified Nursing Assistant (CNA) A on 02/27/2025 at 10:53 AM, she looked around Resident #7's room and confirmed that there were no fall mats in the room. She did not get the resident up this morning; therapy got her up and helped her dress. She stated the resident usually has fall mats. The resident went to breakfast, came back, got into bed, and then got up just a few minutes ago and left her room. She did not assist the resident to get up this last time either. She stated Resident #7 liked to get up and go back to bed throughout the day. She would prefer to be in bed all day but they encouraged her to get up. During an interview with Physical Therapist B on 02/27/2025 at 11:03 AM, he stated he thought there was a fall mat on the floor on the side of the bed nearest the window, but not one under her wheelchair. He stated he helped the resident get dressed and go to the restroom. He then stated he recalled that there were no fall mats down at all but there should have been. He confirmed that the resident could propel her wheelchair independently. He did not take her to breakfast; she wheeled herself down to the main dining room. He stated the CNAs were responsible for ensuring that the floor mats were in place. During an interview with Resident #7 on 02/27/2025 at 12:49 PM, she was observed in bed under the covers. Fall mats were observed on either side of the bed that looked clean and new. The resident stated the fall mats on the floor were put down this afternoon, and it was the first time they had ever put mats down in her room. She was asked again if they had ever placed fall mats next to her bed on the floor. She chuckled and said, No, not ever. She stated she needed them so she would not get hurt if she fell out of bed. She had never fallen out of bed, but she had fallen on the floor in her room. During an interview with CNA A on 02/27/2025 at 12:53 PM, she stated she put the mats down in the resident's room. She found them in the resident's closet next to her clothes. CNA A stated she had not put the mats in the closet and confirmed that the mats did not belong in the closet with the resident's clean clothing. During an interview with the Director of Nursing (DON) on 02/27/2025 at 1:04 PM, she stated she was unaware that the fall mats were not down on the floor this morning when the resident was in bed. She stated, Well, we will do better. She confirmed that the CNAs were responsible for placing the fall mats down for the resident's safety. A review of the facility's policy and procedure titled Nursing Admission At Risk - Post Fall and Quarterly Evaluation (Copyright 2010, otherwise undated) revealed: Purpose: To evaluate and monitor risk for falls and status for implementation of interventions. To prevent or reduce risk of fall and any associated injury. 5. The licensed nurse will evaluate resident for appropriate fall interventions per responses obtained in effort to minimize residents fall and/or injury. 6. The licensed nurse will inform the resident's physician of fall risk and obtain approval for application of safety devices, if applicable, will complete order for the same and transcribe to the Treatment Administration Record (TAR) for continuity of care. 7. The licensed nurse will ensure the application of safety equipment/interventions and notify staff of resident's risk for fall and related injury. (Copy obtained)

Based on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility, by failing to date mark numerous open food packages in the dry storage room, the refrigerator, and the freezer. Food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: A tour of the kitchen was conducted on 3/6/2023 at 10:29 a.m. During the tour, no date markings were observed on an open box of white potatoes, an open box of celery and cherry tomatoes, an open box of large tomatoes, an open box of green and red peppers, an open box of cabbage, an open bag of lettuce, an open box of sweet potatoes, and two bunches of asparagus sitting in a box on the shelf in the walk-in refrigerator. In the dry storage room, there was one open package wrapped with no date marking. (Photographic evidence obtained) A follow-up tour of the kitchen was conducted on 3/7/2023 at 8:38 a.m., and the same observations were made of the abovementioned food items. At the same time, new observations of one open box with carrots, one open box of cucumbers, one box of mushrooms, and an open bag of onions were on the shelf in the walk-in refrigerator with no date marking. (Photographic evidence obtained) An interview was conducted on 3/9/23 at 1:45 p.m. with Cook F, who confirmed that the facility policy for food storage was to ensure the food was labeled and dated. Open food was to be wrapped, date marked, and discarded after three days. An interview was conducted on 3/9/23 at 1:50 p.m. with Dietary Aide G, who confirmed he was responsible for food storage, but Any Dietary Aide can put away food. He confirmed the First In, First Out system was used when storing food, and all open food was to be dated when opened and discarded after the third day. An interview was conducted on 3/9/23 at 1:55 p.m. with Certified Dietary Manager H, who stated everyone was responsible for maintaining food storage standards, but currently one staff member was assigned to concentrate on that duty. He stated food was kept in boxes to keep the manufacturer codes. He confirmed that the food policy for food storage date marking was that open food should be labeled and dated, then discarded after 72 hours. A review of the facility's policy and procedure entitled Food Storage Overview (Dated 2015), revealed: Purpose: Food is stored by methods designed to prevent contamination. Procedures: 4. Plastic containers with tight-fitting covers are to be used for storing cereals, cereal products, flour, sugar, dried vegetables, and broken lots of bulk foods. Containers are to be labeled . 8. All stock is to be rotated. a. Old stock is always used first (first in - first out method). b. Food should be dated with date received as it is placed on the shelves . f. Foods are to be covered, labeled and dated including month, day, and year. (Copy obtained) Reference: FDA Food Code 2022 Annex 5. Conducting Risk-Based Inspections Annex 5 - C. Intervention Strategies for Achieving Long-term Compliance. 4. Establish First-In-First-Out (FIFO) Procedures. Page 31. https://www.fda.gov/media/164194/download (Accessed on 1/23/2023): Product rotation is important for both quality and safety reasons. First-In-First Out (FIFO) means that the first batch of product prepared and placed in storage should be the first one sold or used. Date marking foods as required by the Food Code facilitates the use of a FIFO procedure in refrigerated, ready-to-eat, TCS foods. The FIFO concept limits the potential for pathogen growth, encourages product rotation, and documents compliance with time/temperature requirements.

Based on observations, a review of resident records, and interviews with staff, the facility failed to ensure a resident's call light was within reach at all times in the event the resident needed assistance for one (Resident #24) of one sampled resident observed with a call light out of reach, from a total of 28 residents in the sample. The findings include: A record review for Resident #24 found she was admitted to the facility on [DATE]. She had diagnoses including, but not limited to, repeated falls, hypertension, malnutrition and hip fracture. Resident #24 required extensive assistance with bed mobility and toilet use, and total assistance with transfers. She used a wheelchair as a mobility aid. An observation of Resident #24 was conducted on 3/7/23 at 9:32 AM. She was in her bed. Her call light was observed hanging from it's wall receptacle behind the resident's bedside table. The cord was looped and the call button was clipped to the cord, approximately four to five feet away from the resident. (Photographic evidence obtained) When asked if she knew how to use her call light, Resident #24 replied, Yes. An observation of Resident #24 on 3/7/23 at 11:10 AM, found she was still in bed and the call light was still clipped to itself in the same location, out of reach. (Photographic evidence obtained) On 3/7/23 at 1:56 PM, Resident #24 was observed again, still in bed. Her call light remained clipped to itself in the same location on the wall. (Photographic evidence obtained) An interview was conducted with the Unit Manager (UM) on 3/7/23 at 2:00 PM. She was asked if Resident #24 knew how to use her call light. She stated the resident should be able to. The UM was alerted to the location of the resident's call light. The UM accompanied the surveyor to Resident #24's room and confirmed the device was out of reach. She relocated the call light, clipping it to Resident #24's blanket, reminding her to use it when she needed assistance.

Based on observation and interview, the facility failed to ensure privacy and confidentiality of medical records for one (Resident #43) in a total of sample of 28 residents. The findings include: On 3/7/23 at 4:45 PM, the medication administration computer was left open on the second floor 300 hall exposing Resident #43's medication administration record. The information could be seen by residents and guests who were observed passing along the hallway. The following information could be seen from the screen: The resident's name, date of birth, room number, diagnoses, allergies and medications. (Photographic evidence obtained) In an interview on 3/7/23 at 4:50 PM, Registered Nurse (RN) D confirmed that she had gone to administer medication to the resident and forgot to hide the screen. A reviewed of the facility's Admission Packet (Page 8, Section 5 - Resident Privacy) read, The facility will maintain the confidentiality of the residents' protected health information, which includes but is not limited to information contained on the resident's medical and financial records, in accordance with the applicable state and federal law. (Photographic copy obtained) .

Based on observations, interviews and record reviews, the facility failed to maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for one (Resident #25) of four residents on transmission-based precautions, and for two (Residents #25 and #234) residents from a total sample of 28. Failure to follow proper infection control standards increases the risk of adverse health outcomes for facility residents, staff, and other facility occupants. The findings include: During a tour on 3/6/23 at 11:50 AM, an occupational therapy assistant (OTA) was observed wheeling Resident #25 to her room. On the resident's door was a kit with personal protective equipment (PPE) and a stop sign instructing those entering the room to see the nurse beforehand. On 3/6/23 at 12: 30 PM, Resident #25 was observed wheeling herself to the bathroom inside her room. On 3/6/23 at 1:00 PM, Resident #234 was observed self-propelling herself in her wheelchair. She stated she had lunch in the dining room and was going back to her room. Resident #234 confirmed that she was Resident #25's roommate. As soon as she got to the room, she wheeled herself into the bathroom. (Shared bathroom for both Resident #234 and Resident #25) On 3/7/23 at 9:45 AM, Residents #25 and #234 were observed in their room. Both residents confirmed that they shared the bathroom. When asked if their bathroom was cleaned after each use, Resident #234 stated no. Both residents confirmed they were continent, required minimal assistance with transfers, and therefore, did not bother to call the staff if they could use the bathroom independently. A review of Resident #25's clinical record indicated that she was admitted to the facility on [DATE] and had a primary diagnosis of urinary tract infection (UTI). Her secondary diagnoses included, but were not limited to, dementia, major depressive disorder, acute angle-closure glaucoma and needs assistance for personal care. The resident's physician's order, dated 3/3/23, revealed she was to be on contact isolation for Vancomycin-Resistant Enterococci (VRE), with Hiprex (Antibiotic) one gram (gm) two times a day (BID) as a UTI preventative, and Microdantin (Nitrofurantoin - Antibiotic) 50 milligrams (mg) every evening for VRE. A review of Resident #25's care plan, initiated on 2/21/23, revealed that Resident #25 had a UTI related to Extended-Spectrum Beta-Lactamase (ESBL). The care plan was then revised on 3/3/23 indicating that urine culture results showed VRE. Interventions included contact isolation precautions due to VRE UTI. Dedicate equipment to this resident - no sharing, wear gown/gloves during care only if risk of exposure to this resident's bodily fluid (Photographic copy obtained). A review of Resident #25's annual Minimum Data Set (MDS) assessment, dated 12/20/22, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points, indicating that she was cognitively intact. She was independent with bed mobility, eating and toilet use, and required supervision with transfers. In an interview on 3/9/23 at 10:39 AM, Certified Nursing Assistant (CNA) C confirmed that both Resident #25 and Resident #234 were continent of bowel and bladder. She added that these residents were expected to call for help to the restroom, but most of the time they did not call. When asked about about the isolation precautions, CNA C stated she was notified to wear PPE while providing care to Resident #25. During an interview on 3/9/23 at 12:42 PM, Licensed Practical Nurse (LPN) E confirmed that Resident #25 was diagnosed with ESBL. A few weeks later, after finishing her antibiotics, the urine culture came back positive for VRE. She also confirmed that Resident #25 had a roommate throughout the course of her antibiotic treatment. When asked to describe the isolation precautions required, LPN E stated Resident #25 was on contact isolation and staff were required to wear PPE only while providing care. When asked if the resident could share equipment, LPN E stated she was not sure and would consult the infection control specialist. In an interview on 3/9/23 at 2:51 PM, the Infection Control Specialist (ICS) stated Resident #25 had VRE as of 3/3/23. She added that the resident was also on contact precautions and staff should wear a gown and gloves whenever they were providing care. She stated it was okay for the resident to go out of her room as long as she did not share the bathroom since she was continent. When asked whether Resident #25 had a roommate, the ICS said no, then looked up the census and stated the resident had a roommate who was a new admission. She added that if they were both continent, one should use a bedside commode and the other should use the bathroom. Staff should empty the commode. A review of Resident #234's clinical record revealed that she was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment, dated 2/25/23, revealed that Resident #234 had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points, indicating intact cognition. She required minimal assistance with bed mobility, toilet use and transfers. A review of the facility's policy and procedure entitled Infection Control-Infection Surveillance (Last reviewed in 2013), indicated that the facility used prevention strategies to reduce the risk of transmission of infection including, but not limited to, barrier precautions, cleaning, disinfection, and education.

Based on observation and staff interview, the facility failed to maintain the ice machine in the facility kitchen to prevent the spread of foodborne illness and ensure the safety of the 70 residents that resided at the facility. The findings include: During an initial tour of the kitchen on 07/26/2021 at 10:22 AM, the interior of the ice machine was observed. The interior roof panel of the ice machine had dark brown, slimy biological growth in several areas. The substance was seen in the corners and deep recesses of the upper compartments and along the horizontal surfaces above the ice. Condensation was visible on and around the substance. (Photographic evidence was obtained) On 07/26/2021 at 11:30 AM, the Dietary Manager (DM) was asked to look inside the kitchen ice machine. Using a flashlight and her cell phone, she inspected the upper recesses of the ice machine and confirmed it had dark brown, slimy biological growth in several areas. During the interview with the DM, she explained the maintenance department was responsible for cleaning and maintenance of the ice machine. When she was asked how frequently the machine was cleaned, she speculated it was approximately every 6 months. The DM then confirmed the ice machine would need to be shut down and emptied to be cleaned.

Based on observations, interviews, medical record review and review of the facility submitted incident report; the facility failed to report in accordance with State law, including to the State Survey Agency, within 5 working days of the verified incident, appropriate corrective action taken for 1 (Resident #1) of 4 residents sampled who were ordered use of a wander guard (Roam Alert) bracelet for the prevention of elopement. The findings include: Record review revealed Resident #1 was admitted to the facility on [DATE] related to progressive illness and poor safety awareness while living independently and relied on long term services for safety. A review of the care plan for Resident #1 revealed the elopement risk screening was marked indicated by a checked box: The resident frequently expressed a desire/serious intent to leave the facility and the resident currently wanders and/or is exit seeking. This was documented as part of the admission to long term care (LTC). The care plan included under psychosocial well-being that Resident #1 was admitted for LTC placement due to her dementia and wandering out of her apartment. Resident #1 was also documented at risk for falls due to poor safety awareness. On 4/28/20 under Elopement, the facility documented use of roam alert monitoring system per facility policy. Document episodes of elopement attempts and interventions used and use 1:1 staff or place in locked unit during day time hours if he/she removes Roam Alert and is attempting elopement. A review of the facility initial report to the state documented the date of an incident related to Resident #1 was June 30, 2020 and included, Resident elopement. There were no additional reported actions by the facility related to follow up. The facility reported analysis of incident (apparent cause) as it appears that the resident's Roam Alert did not sound at the time the resident went out the front door and the corrective action as Roam Alert alarm was added to the other resident's arm to ensure that the signal is read if the resident pass by again. Resident was placed on 1:1 at this time. An interview was conducted with the Director of Nursing on 11/03/20 at 12:12 PM who confirmed that a five day federal report was not entered for the incident of elopement that involved Resident #1 who exited the building through an alarmed door. An interview was conducted with Employee B, LPN, on 11/03/20 1:34 PM. Employee B and asked if she checked the roam alarm for functioning. She said, No, the night shift checks the wander guard to see if it works. Employee B was asked to demonstrate how to test the wander guard functioning and she called Employee A, RN (Unit Manager) who attempted the device testing demonstration. He stated, We don't test the bracelets on the day shift; the night shift tests the bracelets. Employee A struggled with the device testing unit because it was unfamiliar. Employee B was interviewed on 11/03/20 at 3:16 PM who confirmed that Resident #1 was under her care on the date of the elopement (06/30/20) as documented. Employee B stated that she probably passed medications at the time Resident #1 left the floor and she was alerted by Employee F, CNA of Resident #1 who was observed outside and was about to cross the street by the Human Resources office. Employee B also confirmed that she did not document Roam Alert system checks for Resident #1 because the roam alert checks were completed by the night shift. An interview was conducted with the Administrator and the Director of Nursing on 11/03/20 at 3:41 PM. They confirmed that there was no added testing of the roam alert system beyond the day of the incident on 06/30/20 and the facility could not duplicate the alarm failure on that day. The Administrator and the Director of nursing also confirmed that there were no audits of the front door alarm system available for review. The Administrator and Director of Nursing also confirmed that no elopement education was warranted as a result of the elopement of Resident #1 because the facility did not identify a failure for the night shift to test the Roam Alert as the treatment plan indicated for Resident #1. A review of treatment record for Resident #1 documented the elopement treatment by the facility that occurred on 6/30/20. The treatment order read, Roam alert bracelet, check for functioning each night indicated each day or hour of sleep. The facility could not produce evidence of Roam Alert Testing as indicated in the ordered care plan for Resident #1. Resident #1 lived in a room on the second floor. Resident #1 entered an elevator unnoticed by staff and exited the front of the facility which had a roam alert alarm system installed. The facility investigation presented that it appeared that the Roam Alert did not sound when Resident #1 exited the unlocked front door and was observed by Employee F, CNA, at approximately 10:45 AM on 6/30/20, who reported to Employee B. Employee F retrieved Resident #1 from the outside of the building. There was no additional information provided by the facility that supported compliance with the requirement to submit Federal 5 Day Reports and appropriate corrective action as a result of the elopement of Resident #1 on 6/30/20.

Based on observations, interviews, record reviews, a review of the Assure Prism Multi Blood Glucose Monitoring System QA/QC (quality assurance/quality control) reference guidelines, and a review of the Centers for Disease Control and Prevention guidelines, the facility failed to ensure blood glucose meters were cleaned and disinfected to prevent the spread of bloodborne pathogens. During observations of blood glucose monitoring (BGM) via finger stick testing, one (Employee A) of one licensed practical nurses failed to clean and disinfect the glucometer (a device used to measure blood glucose levels) prior to or following utilization of the device during blood glucose monitoring for Resident #68, one of 23 residents who required blood glucose monitoring. A diabetic resident residing in the facility from 7/8 through 7/23/19 was diagnosed with [REDACTED]. These factors all contributed to the likelihood of cross contamination and the spread of blood-borne pathogens such as [MEDICAL CONDITION] (HBV), [MEDICAL CONDITION] (HCV), and human immunodeficiency virus ,[MEDICAL CONDITION]. to the 23 current diabetic residents requiring blood glucose monitoring. The facility also failed to implement the infection control policy and procedure related to contact isolation for one (Resident #64) of two residents on isolation precautions. The findings include: 1. On 8/8/19 at 9:51 a.m., the medication cart on the 300 hallway was observed with Employee N, Licensed Practical Nurse (LPN). There were two glucometers in the top drawer of the medication cart. One of the glucometers was soiled with a red substance (resembling blood). On 8/8/19 at 10:06 a.m., the medication cart on the 100 (even) hallway was observed with Employee P, LPN. There were two glucometers in the top drawer of the medication cart. One of the glucometers was soiled with a red substance (resembling blood). On 8/8/19 at 10:24 a.m., a 600 hallway medication cart audit was conducted with Employee A, LPN. The cart had two glucometers stored in the top drawer. One glucometer was labeled #1 and the other was labeled #2. Observation of both devices revealed that glucometer #1 was soiled with a red substance (resembling blood). An interview was immediately conducted with Employee A, and she stated that she would not be using glucometer #1, because it was broken. She turned the glucometer over, and pointed out that the battery cover was missing. She stated she had asked for another one. On 8/8/19 at 11:31 a.m., Employee A was observed pushing Resident #68 out of her room and up the hallway in a wheelchair. The LPN was observed with a white Styrofoam tray in her hand containing a used insulin syringe, a used alcohol wipe, and the glucometer labeled #1. She stated, I just took her blood sugar. She was asked whether she cleaned the device prior to using it, and she stated, Yes, I cleaned it with an alcohol wipe. Glucometer #1 was observed and it remained soiled in the same location, just as it was observed at 10:24 a.m. this same day. Employee B, Unit Manager, approached the cart and confirmed that it was acceptable to clean the glucometer with an alcohol wipe prior to use. On 8/8/19 at 4:23 p.m., an interview was conducted with the Infection Control/Staff Education Nurse. When asked about cleaning glucometers and what the expectation was, she stated, It's my understanding they are to clean the glucometer before use and after use. A review of the Assure Prism Multi-Use Glucometer Instruction Manual Guidelines revealed: Cleaning: 1) Wear appropriate protective gears such as disposable gloves. 2) Open the cap of the disinfectant container and pull out 1 towelette and close the cap. 3) Wipe the entire surface of the meter 3 times horizontally and 3 times vertically using one towelette to clean blood and other body fluids. 4) Dispose of the used towelette in a trash bin. The meter should be cleaned prior to each disinfection step. Disinfecting: 5) Pull out 1 new towelette and wipe the entire surface of the meter 3 times horizontally and 3 times vertically using a new towelette to remove blood-borne pathogens. 6) Dispose of the used towelette in a trash bin. 7) Allow exteriors to remain wet for corresponding contact time for each disinfectant. 8) After disinfecting, the user's gloves should be removed and be thrown away and hands washed before proceeding to the next patient. A review of the Centers for Disease Control and Prevention (CDC) guidelines for Infection Prevention during Blood Glucose Monitoring and Insulin Administration (6/8/2017) revealed the following, The Centers for Disease Control and Prevention (CDC) has become increasingly concerned about the risks for transmitting [MEDICAL CONDITION] virus (HBV) and other infectious diseases during assisted blood glucose (blood sugar) monitoring and insulin administration. Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected, then it should not be shared. Outbreaks of [MEDICAL CONDITION] virus (HBV) infection associated with blood glucose monitoring have been identified with increasing regularity, particularly in long-term care settings, such as nursing homes and assisted living facilities, where residents often require assistance with monitoring of blood glucose levels and/or insulin administration. A review of the facility's policy and procedure revealed: Number: {No number provided} Page: 1 Effective Date: Revised 5/2019 Subject: Glucometers Policy: It is the policy of The Alliance Center for Health Care to check for proper functioning of glucometers each day and to ensure glucometers are cleaned appropriately prior to each use. Procedure: 1. It is the responsibility of the 11-7 shift to test nightly each glucometer (per mfg. directions). 2. Results are entered on the Glucometer Calibration Log (see attached) which is kept in the front of the MAR (Mediation Administration Record) on each med cart. 3. If the results are out of range, the nurse will remove that glucometer from use and notify the Unit Manager or DON (Director of Nursing). 4. At the beginning of each shift, the on-coming nurse will clean glucometers on the cart as per mfg. (manufacturer's) directions listed on the cleaning agent. This will be completed prior to using. Once they have been cleaned by the on-coming nurse, it is only necessary to clean after each use. 2. During an interview on 08/06/2019 at 10:55 AM with Employee B, Unit Manager (UM), she stated Resident #64 was currently being treated for [REDACTED]. Resident #64 was incontinent of urine and wore a brief. She required assistance by staff to change her brief and to clean up after each incontinence episode. Because she wore a brief, the organism she was being treated for [REDACTED]. She expected the staff to don personal protective equipment (PPE) when they were providing incontinence care, because they would be removing her brief and would be exposed to the organism in her urine. During an interview on 08/06/19 at 11:29 AM with Resident #64, she stated she was on contact isolation for a urinary tract infection. She wore a brief and did not use the toilet. Employee C, Certified Nursing Assistant (CNA), and Employee D, CNA, were observed on 08/07/19 at 09:07 AM providing incontinence care to Resident #64 in her room. Neither of the CNAs had a personal protective equipment (PPE) gown on. Posted outside Resident #64's room was a sign that read: STOP. Please lift this sheet and read the instructions prior to entering this room. The sheet of paper under the STOP sign read: Contact isolation has been indicated for the resident in B bed. Nursing Staff: 3. Gowns are necessary if soiling your clothing is likely. A review of the clinical record for Resident #64 revealed she was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE], revealed the resident was assessed as requiring extensive assistance of one or two staff members for toileting; she was not on a toileting program (had been attempted), and was always incontinent of urine and bowel. A review of the care plan dated 07/19/2019, revealed the following focus areas: Cognitive loss/dementia; activities of daily living (ADL) functional/rehabilitation potential, urinary incontinence, behavior problems, falls, activities, nutritional status, risk of pressure ulcers, pain, alteration in bowel function, and contact isolation. Problem area: (Resident #64) has been placed on contact isolation due to the [DIAGNOSES REDACTED]. Goal: (Resident #64) will have resolution of infection without complications by next review. Contact precautions will be used to prevent spread of infection to family/staff and visitors and prevent additional infections for patient through the next review. Approaches: 1. Institute and follow precautions per policy and procedures 2. Educate visitors on proper hand washing technique. 3. Educate visitors on use of PPE. 7. Universal precautions at all times/during skin care. 8. (MONTH) come out of room for therapy and activities. Focus area: (Resident #64) is on antibiotic therapy for the treatment of [REDACTED]. 7/30/2019-REPEAT URINE STILL POSITIVE FOR ESBL. During an interview with Employee C on 08/07/2019 at 10:22 AM, she stated she had worked at this facility for ten years, and as a CNA for twenty years. She received annual training related to infection control. She had been trained for different types of isolation and protocols to follow. The facility used a computer-based electronic training system. She was aware of the contact isolation for Resident #64. The resident had an infection in her urine. Employee C was to follow the contact isolation precautions posted outside of her room. Resident #64 was incontinent of urine and wore a brief. Employee C was to check/change her every two hours. She stated her understanding was that if the resident was at risk of soiling her clothing while staff were changing the resident's brief, then she was to gown up. She stated if she was changing the resident and thought she would not be getting it on her clothing, she did not have to wear the PPE. She conducted incontinence care in the resident's room or in the shower room, so she had more room. The resident had a decline in standing, so Employee C always made sure there was another CNA to do incontinence care with her when she must change Resident #64. She confirmed that both she and Employee D had gloves on but no gowns during the observed incontinence care provided on 08/07/2019 at 9:07 AM. During an interview with Employee D, CNA, on 08/07/19 11:01 AM, she stated she had worked as a CNA for [AGE] years. She received training annually related to infection control. She was aware that Resident #64 was on contact isolation and had a urinary tract infection. When asked what PPE she should wear when she was providing incontinence care to Resident #64, she stated we use gloves. If you think you're going to get it on your clothes you wear a gown. She did not know that when the brief was removed the organism could contaminate her scrubs, the wheelchair, the resident's clothing and other objects nearby. She stated that the nursing staff just told the CNAs when there was someone on isolation and what organism they had. The nurses did not go into a lot of detail about how the organisms could contaminate the environment. When asked if the computer-based electronic training system went into any detail about the different types of organisms and what PPE she should wear, she stated no. She stated No, they don't tell us anything. We just go by what's on the wall by the door. It says that if we think we will come in contact with the urine, we need to have the gown on. During an interview on 08/07/2019 at 1:57 PM with Employee F, Infection Control Nurse, she confirmed that Resident #64 was in transmission based (isolation) precautions for ESBL in her urine. She stated when a resident was on isolation for ESBL, if the resident was incontinent and wore a brief, the briefs could leak. They should be checked frequently. As long as the urine was contained in the brief, she could leave her room to attend meals and activities in the dining room. The staff should take the resident back to her room for incontinence care. The CNA should don a personal protective equipment (PPE) gown because there was a high likelihood that they would come into contact with the organism, and their clothes would be contaminated from the organism in the urine in the brief. During an interview on 08/08/2019 at 01:32 PM with the Director of Nursing (DON), she confirmed that Resident #64 was on contact isolation for ESBL, and that Employee D and Employee C should have had a PPE gown on when changing Resident #64's brief. A review of the facility's computer-based electronic training entitled Personal Protective Equipment, revealed: PPE is designed to protect you from illness, disease, or injury resulting from workplace hazards. It also helps to prevent the spread of harmful pathogens to others. Many types of diseases are caused by microorganisms that cannot be seen with the naked eye. Gowns protect your skin and clothing from exposure to potentially infectious materials. You must wear a gown during procedures and care activities that are likely to generate splashes or sprays of blood, body fluids, secretions or excretions. A clean, non-sterile gown is adequate for protection against these substances.

Based on observation, staff interview and facility training documents, the facility failed to maintain a clean and sanitary environment in four (rooms 605, 609, 610 and 611) out of fifteen resident rooms on the 600-hall way. The findings include: During the initial tour of the 600-hall way on 08/05/2019 the privacy curtains in rooms 605, 609, 610 and 611 were observed to be soiled with brown and black substances. Rooms 605, 609, 610 and 611 were observed again on 08/07/2019 from 4:14 PM to 4:21 PM. The privacy curtains had not been cleaned and remained soiled. Employee P was observed cleaning rooms on 08/07/2019 from 10:00 AM until 4:00 PM. During an 08/08/2019 interview at 1:41 PM with the Administrator and Employee G, Housekeeping Assistant Director, the Administrator explained that privacy curtains are taken down as needed. They were to be inspected daily by housekeeping staff. They were to report to the Housekeeping Director, and then either maintenance or the floor technicians took them down and replaced them with a clean curtain. When a deep cleaning was done, the privacy curtains were changed. For long-term residents, the curtains were to be inspected daily by housekeeping. During an 08/08/2019 interview at 4:00 PM with Employee B, Unit Manager, and Employee H, Housekeeping Staff, Employee B stated she was unaware that the privacy curtains were soiled and needed to be taken down and washed. She was shown the privacy curtain in room [ROOM NUMBER] near the door and she stated, Oh, no. That's bad. Employee H stated she had been off for the past two days and did not know the curtains needed to be changed. A review of the facility's training for housekeeping staff, revealed the staff received training on 09/18/2018, 01/10/2019, 03/13/2019 and 07/03/2019. Training on 01/10/2019 included new deep cleaning schedule. Training on 09/18/2018 included new housekeeping daily check list and daily and weekly resident rooms tasks. .

Based on record review, observations and interviews, the facility failed to provide an environment free of accident hazards for one (Resident #76) of a total of 42 sampled residents. The findings include: A review of Resident #76's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. On 8/5/19 at 11:19 AM, a container of Lysol bleach wipes was observed in Resident #76's room on the dresser. On 8/7/19 at 11:37 AM, the container of Lysol bleach wipes was again observed in the room on the resident's dresser. On 8/8/19 at 2:17 PM, the container of Lysol bleach wipes was again observed in the room on the resident's dresser. On 8/8/19 at 2:21 PM, an interview was conducted with Employee I, Second Floor Unit Manager/Registered Nurse (RN). She was asked if residents were permitted to have Lysol bleach wipes in their rooms, and she replied, No they shouldn't. When she was told there were Lysol bleach wipes on Resident #76's dresser, she stated, They shouldn't be there. She went to the room, confirmed the Lysol bleach wipes were in the room and removed them. She then stated, The family must have brought them in. She confirmed that having the wipes in the room could be a hazard. On 8/8/19 at 4:05 PM, an interview was conducted with the Director of Nursing (DON) regarding the Lysol bleach wipes in Resident #76's room. She stated that residents should not have any bleach wipes in their rooms, and sometimes families brought in things they shouldn't. When staff saw those things, they should remove them. She confirmed that having the wipes in the room could be a hazard. When asked whether the facility had a policy regarding what residents could and couldn't have in their rooms, she replied, I'm not sure, I'll check. No policy was ever provided for review.

Based on observations, interviews and record reviews, the facility failed to ensure it maintained a medication error rate of less than 5%. There were 27 opportunities and three (3) errors, resulting in a medication error rate of 11.11%. The findings include: On 8/7/19 at 9:20 AM, a medication administration observation was made with Employee J, Licensed Practical Nurse (LPN), for Resident #2. Resident #2's electronic Medication Administration Record [REDACTED]. Employee J mixed the [MEDICATION NAME] with four (4) ounces of water and took it into the resident's room along with all of her other medications. Resident #2 took a small sip of her [MEDICATION NAME] and handed the cup back to Employee J, who placed it on the resident's bedside table. Employee J finished administering the rest of the resident's medications with plain water and then exited the room, leaving the cup with the [MEDICATION NAME] sitting on the bedside table. Upon returning to her medication cart, Employee J documented that she had administered the resident's [MEDICATION NAME]. On 8/7/19 at 9:42 AM, a medication administration observation was made with Employee J for Resident #59. Resident #59's eMAR was reviewed, and it revealed an order for [REDACTED].#59's name and removed one pill. She reviewed the label on the card and compared it to the medication order on the eMAR. The medication card had a warning label with the following instructions: Do not crush or chew. Not to be given through a [DEVICE] (gastrostomy tube/feeding tube). Employee J then crushed the medication, placed it in applesauce, and administered it to the resident. On 8/7/19 at 10:17 AM, a medication administration observation was made with Employee J for Resident #28. Resident #28's eMAR was reviewed, and it revealed an order for [REDACTED]. She failed to have him rinse his mouth after using the inhaler. On 8/7/19 at 10:38 AM, an interview was conducted with Employee J regarding concerns identified during her medication pass. When she was asked about leaving the [MEDICATION NAME] at bedside for Resident #2, but documenting that the resident took the medication, she stated, There is no way to put a percentage in for what she took, so I had to document that she took it. When asked about crushing the Pantoprazole for Resident #59, she stated, Well, I had to because there is no way that she can take her medications whole, so I don't know what you would want me to do. I guess I will have to get that clarified. When asked about not having Resident #28 rinse his mouth after using the [MEDICATION NAME] inhaler, she confirmed that he should have had him rinse after the medication was administered. A review of labeling.pfizer.com revealed it recommended that for patients that can not take Pantoprazole DR tablets whole, obtain an order for [REDACTED].), prevent the medication from working, and prevent the resident from recovering from an illness. A review of [MEDICATION NAME].com revealed the following: Rinse your mouth with water without swallowing after each dose of [MEDICATION NAME] Diskus. This will help lessen the chance of getting a yeast infection (thrush) in your mouth and throat.

Based on observations and interviews, the facility failed to ensure medications were properly stored in one (,[DATE] unit) of two medications rooms reviewed, out of a total of three medication rooms in the facility. The facility also failed to ensure that medications were stored appropriately in two (300 hallway and 600 hallway) of three medication carts reviewed for medication storage, out of a total of six medication carts in the facility. The findings include: An observation was made of the medication room located on the ,[DATE] unit on [DATE] at 9:54 AM with Employee N, Licensed Practical Nurse (LPN). The refrigerator in the medication room was observed, and the temperature in the refrigerator was noted to be thirty (30) degrees Fahrenheit (F). The temperature was read from the thermometer by Employee N, and verified. A review of the temperature log on the refrigerator was reviewed, and it revealed that the refrigerator had just been replaced on [DATE]. Further review revealed that the temperature of 30 degrees noted on [DATE], had been documented earlier on [DATE] at 34 degrees, but no intervention was implemented. At the time of the observation, Employee N confirmed that the refrigerator had just been replaced' on Monday ([DATE]). When asked what had been done when the temperature was discovered to be 34 degrees, she reviewed the temperature log and stated, It appears nothing. She then removed the medications from the refrigerator and stated that she would call pharmacy and have them re-ordered. A review of the facility's temperature control log revealed the following: Temperature Control Log Med Prep Room This log is to be completed daily by the night shift. Record the temperature of the refrigerator and freezer in the appropriate location. If there is no freezer, write N/A in the block. If the temperature is out of range, document what action you took to correct the problem. Refrigerator (,[DATE]) Freezer (32 or below) [DATE] - Refrigerator 34 Freezer -18 (No action was documented to correct the refrigerator temperature.) An observation was made of the medication cart on the 300 hallway with Employee N, LPN, on [DATE] at 10:10 AM. The following concerns were identified: 1) Opened and undated [MEDICATION NAME] Diskus (asthma medication) for Resident #37. 2) An expired [MEDICATION NAME] (nasal spray) for Resident #41. Open: [DATE] Expired: [DATE]. 3) Opened and undated Latanoprost eye drops ([MEDICAL CONDITION] medication) for Resident #67. 4) Multiple loose and unidentifiable pills in the cart drawer. 5) Soiled glucometer in the top drawer. 6) Soiled label/bottle of insulin for Resident #37. 7) White powdered substance (unknown substance) in the top drawer. On [DATE] at 10:24 AM, an observation was made of the medication cart on the 600 hallway with Employee A, LPN. The following concerns were identified: 1) An opened and undated [MEDICATION NAME] Diskus inhaler for Resident #53. 2) Multiple loose and unidentifiable pills in the cart drawer. 3) One of two glucometers in the top drawer was noted to be soiled (glucometer labeled #1). On [DATE] at 10:28 AM, an interview was conducted with Employee A, LPN, regarding the concerns identified with her medication cart. She stated she did not realize the [MEDICATION NAME] inhaler had to be dated. She stated she would remove all of the loose pills and dispose of them, and would not be using the glucometer labeled #1, because it was broken. She turned it over to reveal that the battery cover was missing, and stated that she had asked for a new one.

Based on observations, staff interview and staff training guidelines/policy and procedure review, the facility failed to ensure staff served meals in a safe and sanitary manner, placing the residents at risk of exposure to food-borne illnesses. The findings include: During the lunch meal service on 08/05/2019 at 1:03 PM in the dining room on the 500 and 600-hall units, Employee M, Certified Nursing Assistant (CNA), put her finger inside the milk carton to pull it open when serving milk to an un-sampled resident. She poured the milk out of the milk carton into a glass and served it to the resident. During the lunch meal service on 08/07/2019 at 11:40 AM, Employee K, CNA, was observed handing out lunch trays to residents in the second floor dining room, but was not sanitizing her hands between trays. She did not sanitize or wash her hands during the entire meal service. During an observation on 08/07/2019 at 12:05 PM, Employee E, CNA, was handing out lunch trays to residents on the 400-hall way without sanitizing her hands between trays. During an interview on 08/08/2019 at 1:40 PM with the Director of Nursing, she stated that the CNAs received training on the sanitary distribution of food during orientation. There were in-service trainings provided monthly, but sanitary distribution of food was not covered every month. If it was observed that the staff were not sanitizing, or were touching the food with their bare hands, or the end of the utensils the residents put in their mouths, they were immediately counseled. When informed of the survey team's observations, she stated that the CNAs were to sanitize between resident trays and wash their hands after every third tray. They were not to open the cartons of milk by pulling them open with their bare fingers. A review of the Dietary Guidelines used to in-service the CNAs revealed: Use hand sanitizer between each resident tray set up (x3). You must wash your hands after three times of hand sanitizer. You must wear gloves if you touch a resident's food (like buttering bread). A review of the Customer Service-Dietary training forms revealed: 4. Wash hands between serving trays. 10. Do not touch their food with bare hand-hold bread on plate with fork to add butter or jelly.

Based on record reviews and staff interviews, the facility failed to notify residents/responsible parties in writing of discharges and transfers, and omitted required information including the date of and the reason for the transfer, the location to which the resident was being transferred, a statement of appeal rights, information about the appeal process, and the State Long-Term Care Ombudsman contact information for three sampled residents (Residents #1, #2, and #3) whose records were reviewed, from a total of 5 residents in the sample. In addition, the facility failed notify the Office of the State Long-Term Care Ombudsman of the transfers for 3 sampled residents (Residents #1, #2, and #3), from a total of 5 sampled residents. The findings include: 1. A closed electronic record review for Resident #1 revealed an admission date of [DATE] and a discharge from the facility on 12/24/18. Resident #1 had a discharge return anticipated Minimum Data Set (MDS) assessment with an assessment reference date (ARD) 12/24/18 which noted she was admitted on [DATE] from an acute care hospital and discharged to same. Resident #1 was assessed with [REDACTED]. She required extensive assistance with activities of daily living (ADLs) and transfers, and bed mobility. Active discharge planning was occurring. Resident #1 was care planned to return to the community, and planned to discharge home with the daughter or arrange long term care (LTC) placement. Goal was to improve self-care ability and discharge home or to LTC within 60 days. Resident #1 received a Nursing Home Transfer and Discharge Notice on 12/21/18 for an effective discharge date [DATE]. The location of discharge was home. The reason for the discharge was not noted, and all possible boxes were left blank. Social Services signed the form as the facility designee on 12/21/18, and the resident signed the same day. The lines asking for the dates of when the notice was given to the resident or representative, the date the Ombudsman was notified of the discharge, and the date the clinical record was noted were all left blank. Photos were obtained. Review of nursing progress notes revealed that on 12/24/18, Resident #1 presented with altered mental status (AMS) and was sent to the emergency department for evaluation and treatment. The resident was supposed to have discharged home, but was having AMS. Further review of the record revealed there was no new Nursing Home Transfer and Discharge Notice provided for the transfer, as required. 2. A closed electronic record review revealed Resident #2 was admitted to the facility on [DATE] from an acute care hospital, and had an unplanned discharge to the hospital on [DATE]. A discharge return not anticipated MDS assessment with an ARD of 12/10/18 noted Resident #2 was independent with cognitive skills for daily decision making. She required limited assistance with ADLs and had [DIAGNOSES REDACTED]. Resident #2 was care planned to return to the community, as she was a new admit with discharge potential. The plan was to discharge home with her brothers. The goal was for improvement in the next 30 days, then discharge home. A Transfer and Discharge notice was provided to Resident #2 on 12/6/18 for an effective discharge date of [DATE]. The reason for discharge was that her health has improved sufficiently and she no longer need the services provided by the facility. Resident #2 and the Social Services Director both signed the form on 12/6/18. The lines asking for the dates of when the notice was given to the resident or representative, the date the Ombudsman was notified of the discharge, and the date the clinical record was noted were all left blank. Photos were obtained. Further review of the record revealed that on 12/10/18, one day prior to her scheduled discharge home, Resident #2 had an emergency transfer, and was admitted to the hospital. No new Nursing Home Transfer and Discharge Notice was completed or provided for Resident #2's emergency transfer. 3. A closed record review for Resident #3 revealed an admitted to the facility on [DATE] and a discharge on 12/12/18. A discharge return not anticipated MDS assessment with an ARD of 12/12/18 noted he was discharged to an acute care hospital. He was assessed with [REDACTED]. He required extensive assist with transfers, bed mobility, toileting, and limited assistance with dressing and walking. Active discharge planning was occurring for him to return to the community. Resident #3 was care planned for a new admission, with discharge potential and a stay projected to be of short duration. The plan was to discharge home to his wife within 30 days. A Nursing Home Transfer and Discharge Notice was completed on 12/7/18 for effective discharge date of [DATE]. The reason for discharge was that his health had improved sufficiently and he no longer needed the services provided by the facility. The notice indicated verbal notification of Resident #3's wife by the Social Services Director on 12/6/18. The lines asking for the dates of when the notice was given to the resident or representative, the date the Ombudsman was notified of the discharge, and the date the clinical record was noted were all left blank. Photographic evidence was obtained. A progress note, dated 12/12/18, indicated that while staff was helping assist Resident #3 to bed, he stated he was going to pass out. Resident #3 became unresponsive, and 911 was called. He was transported via ambulance to the emergency department. His wife was notified via telephone, and would meet him at the hospital. Further review of the records found no new Nursing Home Transfer and Discharge Notice was provided for the transfer to the hospital, as required. 4. An interview was conducted with the Social Services Director (SSD) on 2/7/19 at 1:15 pm. She reviewed the closed records for Residents #1, #2, and #3 and confirmed the missing dates on each of the Transfer/Discharge notices. She also confirmed she had not completed new notifications of transfer/discharge upon all three residents' hospital transfers. The SSD confirmed she had not notified the Ombudsman of any discharges or transfers since July, (YEAR). She acknowledged the requirement for notification.

Based on record review and interview, the facility failed to complete a Quarterly Minimum Data Set (MDS) assessment for 2 of 33 sampled residents (#2 #3) every 3 months as required. The findings include: A record review for Resident #3 reported an admission date of [DATE]. A review of the record for the MDS noted a quarterly assessment conducted on 2/20/18 which was completed but not submitted. (photographic evidence obtained) The facility has 14 days to submit an assessment after completion. A record review for Resident #2 was conducted which reported an admission date of [DATE]. The last quarterly MDS assessment was documented on 11/14/17. A new MDS assessment for an annual is in progress with a date of 4/6/18. There was no documentation of a (MONTH) quarterly assessment which would have been due 3 months after the (MONTH) quarterly. (photographic evidence An interview was conducted with Employee E, Licensed Practical Nurse (LPN) on 4/19/18 at 8:50 AM. The LPN confirmed Resident #3's quarterly assessment was completed but not submitted, and Resident #2's quarterly assessment was missed and not done. Employee E stated I am not sure why Resident #3's assessment was not submitted. I submit the assessments once or twice a week. I missed Resident #2's assessment in (MONTH) so on 4/6/18 I started an annual assessment.

Based on observations, interview, and record review, the facility failed to provide respiratory care according to the physician's orders and care plans for 2 of 3 residents (Residents #57 and #92) receiving oxygen that were reviewed in a sample of 33 residents. The findings include: 1. Resident #57 was observed in the dining/activity room on the 500 hall on 4/17/2018 at 10:30 AM. She had an oxygen tank on the back of her wheelchair and was wearing the nasal cannula. Resident #57 was still in the activity/dining room on 4/17/2018 at 10:52 AM. The gage on her oxygen tank was observed and the needle was in the red zone. Observation of the gage on 4/17/2017 at 11:30 AM found the needle on the gage was at zero. There was an activity staff member in the dining room during the observations (Employee I). Employee I was not observed at any time looking at the oxygen tank. A staff member outside the dining room was asked to get Resident #57's nurse by the surveyor. The nurse (Employee K) from the secure unit came in the activity/day room. She confirmed the oxygen was empty and went to get a pulse oximeter to check the Resident #57's oxygen saturation. The activity staff member (Employee I) was asked at the time of the observation, if she checked the oxygen tanks to see if they were empty. She stated she was not aware they needed to be checked. On 4/18/2018 at 1:31 PM, an interview was held with Resident #57's nurse (Employee J). She stated she checks the oxygen every 2-3 hours. She stated if she saw a resident's tank close to empty, she would put the resident on a new tank. She stated she did not know what happened on 4/17/2018 when Resident #57's oxygen tank was empty during the morning activity. Record review for Resident #57 found she was re-admitted to the facility on [DATE]. Review of her 1/30/2018 5-day minimum data set (MDS) found she was coded as receiving continuous oxygen. Further record review found Resident #57 was care planned for alteration in respiration with the approach to administer oxygen per order. Record review of the 4/2018 physician orders for Resident #57 found she had oxygen orders for 2-4 liters/min via nasal cannula at all times beginning 1/23/2018. 2. During an interview with Resident #92 on 4/17/18 at 9:00 AM, Resident # 92 sounded short of breath and was having difficulty talking. She had an oxygen concentrator beside her bed and was asked by the surveyor if she needed her oxygen. She stated, Yes. The nurse (Employee H) standing at a medication cart across the hall from the resident's room was asked to come in the room. Employee H stated, she was not the Resident #92's nurse but would check on her oxygen and get her nurse. She brought the nurse (Employee F) to the room. Employee F checked the resident's oxygen saturation and it was first at 94 and then at 96.6. During an interview Employee F at the time she was checking Resident #92's oxygen saturation, she stated Resident #92's oxygen saturation had been at around 88. She stated the reading of 94 for the resident was good. Employee F then asked the resident who brought her back from breakfast, and did not put her oxygen on. The resident was not able to say. Record review for Resident #92 found she was admitted to the facility 5/30/2013 with her most recent admission on 12/15/2017. [DIAGNOSES REDACTED]. Further record review found Resident #92 had orders effective 4/10/2018 for continuous oxygen at 2 liters via nasal cannula, discontinue as needed oxygen. Further record review found a Hospice communication tool without a date pulse ox at 99% at 3 liters nasal cannula. Lungs with rhonchi in lung bases. On 4/18/18 at 8:28 AM, Resident #92 was observed sitting in her wheelchair beside her bed. She had oxygen on the back of her wheelchair and was observed using it. The gage registered the tank at ¼ full and the level was at 3 liters. The resident stated at the time of the observation she was waiting to go to the chapel. During an interview on 4/18/2018 at 9:19 AM, with the advanced registered nurse practitioner (ARNP) that works with Resident #92's physician, reviewed Resident #92's medical record and was not able to say if the resident should be on 2 or 3 liters of oxygen. He confirmed the physician he worked for signed the order for continuous 2 liters of oxygen. He stated he did not receive a new request to increase the oxygen level. On 4/18/18 at 9:24 AM, during an interview with Resident #92's nurse (Employee F) she stated, she called the Hospice provider yesterday to discuss Resident # 92 staying on the 2 liters continuous per the new order and they agreed. She was not aware the hospice nurse came in the facility. She stated she did not talk to the nurse and was not aware of any increase to 3 liters. During further interview with Employee F on 4/18/18 09:28 AM, she went to the residents room and confirmed the oxygen was at 3 liters. She stated she asked Resident #92's certified nursing assistant (CNA) (Employee G) about the oxygen. She stated Employee G informed her she put the oxygen on 3 liters. Employee F informed the surveyor she changed the setting back to 2 liters and educated the CNA. Record review of the CNA book found a note showing the resident's should be on 2 liters of oxygen. During an interview with Resident #92's CNA (Employee G) on 4/18/2018 at 10:01 AM, she was asked about the oxygen. She stated she turned the oxygen tank on the back of the wheel chair to 3 liters because she did not feel the air was coming out enough. She was asked if she normally changed the settings. She stated, the nurses usually do. Resident # 92 was observed in dining room for her room on 04/18/18 11:50 AM. She had her oxygen tank on the back of her wheelchair and was using the oxygen. The needle on the gage was under ¼ of the tank and close to the red zone. During an interview on 4/18/18 at 12:24 PM, with Resident # 92's nurse (Employee F), she was asked how she monitors portable oxygen to ensure the resident does not run out. She stated when she works in the dining room she checks the tanks. On 4/18/18 at 12:45 PM, Resident #92 was still in the dining room eating lunch. The needle on the gage to the oxygen tank showed the tank was empty. The nurse in the dining room (Employee H) was asked at the time of observation, how she ensures residents that have the portable oxygen tanks do not run out of air. She stated she checks her residents in the morning to make sure their tanks are full. She stated if it was not her patient, she would peak at the tanks while the residents are in the dining room. She was asked if she looked at Resident # 92's tank. She looked at the gage and confirmed it was empty.

Based on resident and family interviews, and clinical record review, the facility failed to ensure face-to-face visitation by the physician or the advanced registered nurse practitioner (ARNP) at least once every 60 days for 1 of 33 sampled residents (Resident #2). The findings include: An interview was conducted with Resident #2 and her family member on 4/17/18 at 12:59 PM. The family member stated she did not feel Resident #2 was being directly involved in her own care by her physician. Recently, the physician failed to speak with Resident #2 directly regarding referral to a Urologist. In an interview with Employee L, Certified Nursing Assistant, on 4/18/18 at 2:14 PM, she stated Resident #2 was able to make all of her needs known. She knew something was wrong with Resident #2 if she became forgetful. Resident #2 was particular about who cared for her, and had strict preferences. An interview was conducted with Resident #2 on 4/19/18 at 9:37 AM. She stated she felt like a persona non grata (an unacceptable or unwanted person). She stated her primary care physician had only seen her face-to- face one time in 4 years. He was treating her on paper, which made her feel this big (she made a gesture using her thumb and forefinger to make the sign to show space one inch tall). The Advanced Registered Nurse Practitioner (ARNP) was here on Monday seeing people. Resident #2 said she made a personal plea to Employee B, Registered Nurse (RN), to ask the ARNP to meet with her. She waited and waited, but he never came. Resident #2 complained This is unheard of! It makes you feel like a pariah! (an outcast). Resident #2 concluded the interview by accurately describing her current medical condition in clear terms to the surveyor. An interview with Employee B on 4/19/18 at 9:49 AM revealed she did not recall Resident # 2 asking her to meet with the ARNP this week. She stated both the ARNP and the physician have gone in to see her. Resident #2 must not remember. Clinical record review for Resident #2 revealed an annual minimum data set (MDS) assessment with an assessment reference date of 4/6/18. Resident #2 had a brief interview for mental status (BIMS) score of 11/15 points, which indicated moderately impaired cognition for daily decision making. Active [DIAGNOSES REDACTED]. Further review of the electronic record revealed Medical Doctor notes for encounters on the following dates: 6/23/17, 7/21/17, 9/22/17 and 10/20/17. The next documented physician's progress note was handwritten, and dated 3/16/18; 5 months later. Photographic evidence was obtained. There was no documented evidence in the clinical record that either the physician or the ARNP saw Resident #2 every 60 days, as required. An interview was conducted with Employee A, Unit Manager, on 4/19/18 at 9:53 AM. She stated Resident #2 did see the ARNP and the physician, and said she believed the physician was required to see her every 90 days. A second interview was conducted with the Unit Manager on 4/19/18 at 11:52 AM. She reviewed the electronic record and confirmed there was no evidence Resident #2 was seen by the physician, or the ARNP, as required.

Based on observations and interview, the facility failed to ensure resident rooms to include privacy curtains, bathrooms and walls were adequately maintained affecting eight residents (#12, #20, #32, #40, #101, #119, #123 and #188) of 38 Stage 2 sampled residents. It was observed spaces dirty with particles and dust debris, room and bathroom floors with brown stains, bathroom doors and walls in disrepair and privacy curtains stained with brown spots and holes. (Photographic evidence attached). The findings include: On 5/31/16 during the initial tour of the facility the following was observed: 1. The wall behind Resident #96's bed with build up gray dust debris along the entire base of the wall behind the headboard. 2. The bathroom floor in Resident #32's room was observed with multiple large spots of brown colored substance smeared on the floor with pieces of toilet paper. 3. The bathroom doors and walls for Residents #12, #40, #96 and #123 were in disrepair with black scuff marks and a large hole was observed to the bathroom door of Resident #123. (photographic evidence obtained) 4. The privacy curtain for Resident #20, #101 and #188 dirty with multiple large brownish spots smeared on several areas of the curtains. 5. The privacy curtain for Resident #119 with multiple large holes. Conducted an interview with Employee CC on 6/3/16 at 1:20 PM. He confirmed the findings and revealed the facility is on a five year renovation plan. He stated nursing staff and housekeeping are tasked to fill out a work order to notify maintenance of disrepair in rooms and bathrooms. Conducted an interview with the Housekeeping Manager on 6/3/16 at 1:30 PM. She confirmed the findings and revealed rooms are cleaned daily and privacy curtains are checked by all staff and washed and replaced as needed. She continued housekeeping aides are tasked daily to clean floors by sweeping and spot mopping daily. They are supposed to spot rooms before exiting to ensure everything is in its place.

Based on observation, record review and staff interviews, the facility failed to properly administer medications, maintain accurate account of controlled medications and to dispose of expired medications for 7 residents (Resident's #3, #5, #7, #87, #111, #140, & #147) out of 108 residents who receive medication administration in the facility. In addition the facility failed to properly store and maintain medication in a secure locked compartment involving 1 facility office and 1 out of the 6 medication carts housed in the facility. The findings include: 1. Medication storage was conducted on 5/31/2016 of the facilities medication cart for the first floor even numbered rooms with Employee S, Licensed Practical Nurse (LPN). A bottle of Novolog injectable insulin for Resident #3 was observed with an open date of 4/28/2016 and a disposal date for 28 days later which would have been 5/26/2016. (See photo) An interview on 05/31/2016 at 8:45 AM with Employee S, LPN, confirmed the Novolog insulin was expired and should have been discarded. Employee S, LPN stated, I will pull this out right now and dispose of it. A review of the Medication Administration Record [REDACTED]. 2. Medication storage was conducted on 5/31/2016 at 9:50 am of Medication Cart for the 300 hallway with Employee K, LPN. A medication card was observed for Resident #111 for the medication Oxycodone 5/325mg give 1 by mouth 3x's a day as needed (PRN) for pain. The pill in the #60 slot is observed half popped out of the card and is no longer secure in the card. A medication card for Resident #147 for the medication Oxycodone 5/325mg 1 by mouth every 8 hours (hrs.) prn pain was observed. The pill in the #27 slot was observed with tape on the medication card keeping the pill in the card. In addition a medication card for Resident #5 was observed for the medication Oxycodone 5mg 1 3x's a day prn pain with the #10 pill taped in the medication card. (Photographic evidence obtained) An interview was conducted with Employee K, LPN on 5/31/2016 at 9:55 AM confirmed there was tape applied to the back of medications cards for Resident # 111, #147, & #5). The employee stated We just received Resident #5 from the ALF so that may of happened over there, but I don't know about the other ones. The employee confirmed the medications should not be taped back into the medication cards but should be disposed of. 3. Medication Storage was conducted on 5/31/2016 at 10:00 AM of the medication cart for the 400 numbered rooms on the 2nd floor along with Employee M, Registered Nurse (RN). An observation was conducted of the medication card for Resident #140 for medication Tramadol 50mg 1 by mouth 2x's a day prn pain with tape applied to the back of the card in the #30 pill slot. A medication card was also observed for Resident #87 for the medication Ativan 0.5mg 1 by mouth every 8 hours PRN was observed with a Directions changed refer to chart sticker applied to the back of the card in the #4 & #14 pill slot. (Photographic evidence obtained) Interview was conducted on 5/31/2016 at 10:05 am with Employee M, RN, confirmed the medications were taped to the back of the cards for Residents #87 and #140 and that was not the facility policy to tape medication back into the card. An interview on 05/31/2016 at 11:34 AM with the Director of Nursing (DON), confirmed the staff should not be taping any medication back into a card after they are popped out even if it's been done accidentally but should be disposed of with a witness. 4. An observation was conducted on 6/2/2016 at 3:55 PM of the Medication Cart for the first floor even numbered rooms unlocked and accessible to resident's, staff and family members who walked by it. An interview on 6/2/2016 at 3:56 PM with Employee T, Registered Nurse (RN), confirmed she left the medication cart unlocked. She stated I just did the narcotic count and must have left it opened. 5. On 6/2/2016 at 9:30 AM, the Infection Control Office door was wide open. There was no one in the room. There was a refrigerator on one of the tables. There was no lock on the refrigerator. The surveyor opened the refrigerator and medications were observed in there: Influenza Vaccine, Pneumovax, and Engerix B. (see photographic evidence). The Infection Control Nurse, Employee J (RN), entered the room on 6/2/2016 at 9:33 AM. She stated that she does not lock her refrigerator door with the medications in them and does not always lock her office door when she goes in and out of it. The facility's Medication Storage (revised 11/10) revealed, All drugs and biologicals are to be stored in a secure and orderly manner. Drugs are to be accessible only to licensed nursing and pharmacy personnel. On 6/2/2016 at 2:30 p.m., Employee J stated she had always left the refrigerator unlocked. It has probably been unlocked for years. She now has a lock on it. 6. On 6/1/16 at 9:15 AM Housekeeper (Employee V) was observed bringing a small plastic cup containing 2 light colored nickel size pills. Employee V stated that Resident #7 did not take her Tums and had left them on the table in the dining room. Record review for Resident #7 found June 2016 orders for calcium antacid chew/Tums 500 milligrams two tablets by mouth three times a day. In an interview with Resident #7's nurse, Employee K, on 6/3/16 at 8:22 AM, she stated the Resident #7 wants her antacid left on the table so she can take them after she eats. Employee K stated because Resident #7 is alert and oriented they allow her to do that. Employee K was asked if Resident #7 had a physician's orders [REDACTED]. She stated there was not a physician's orders [REDACTED].#7 was care planned for taking her own medication and she stated was not aware if she was care planned to have medication left with her. She confirmed she left the medication with the resident. She stated when the housekeeper brought them to her she threw them away and gave her fresh Tums at 9:00 AM. During an interview with Director of Nursing on 6/3/16 at 12:55 PM, she stated they would need a physician's orders [REDACTED]. She stated she was not aware that was being done and that they did not have an order. .