Every finding on record at Baylor Scott & White Continuing Care Hospital Skil

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which included measurable objectives and timeframes to meet resident's medical, nursing, and psychological needs for 3 of 6 residents (Resident #2, #7, and #32) reviewed care plans. The facility's failed to include that resident had a PEG tube in Resident #32's (08/21/2025) comprehensive care plan. The facility failed to include that resident had a foley catheter in Resident #2's (07/29/2025) and Resident #7's comprehensive care plan.This failure could place residents at risk for not receiving necessary care and services or having important care needs identified and met. Findings included: Record review of Resident #32's face sheet dated 08/21/25 reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #32 had a diagnosis of aspiration pneumonia (a lung infection that develops from inhaling foreign substances like food, liquids, or stomach contents into the lungs.) Record review of Resident #32's admission MDS assessment dated [DATE], reflected that Resident #32 had a BIMS score of 09 which reflected the resident was moderately cognitively impaired. Resident #32's admission MDS assessment reflected that the resident had a feeding tube - nasogastric or abdominal (PEG) while a resident. Record review of Resident #32's Physician's Orders, dated 08/21/25, reflected the resident had an order initiated on 08/08/25 for: Feeding Tube Irrigation: 30 ml; per Feeding Tube Every 4 hours. Comments: Manually irrigate with additional 60 ml appropriate water type every 12 hours unless otherwise ordered by provider. Notify provider if tube gets occluded. For irrigation only. Record review of care plan dated 08/21/2025 reflected Resident #32 had not been care planned for having a PEG tube or enteral tube. In an observation and interview on 08/19/2025 at 10:43 AM Resident #32 was in bed and fall mats were placed on floor. Resident #32's call light was in reach. Resident # 32 awakened to name call but appeared very tired. Resident #32 answered that he was ok and that the staff all took good care of him. Resident #32 then went back to sleep. Resident #32 appeared clean and groomed and was in no sign of pain or distress. In an observation on 08/19/2025 at 10:57 AM, Resident #32's g-tube site was cleansed, and the dressing was changed by a staff member. No concerns were noted. Record review of Resident #2's face sheet, dated 08/21/25, reflected a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included physical debility, hypertension (high blood pressure), type 2 diabetes mellitus (a chronic condition characterized by high blood sugar levels), chronic kidney disease, intractable pain - chronic (constant pain). Record review of Resident #2's admission MDS assessment, dated 08/05/25, Section C reflected a BIMS score of 15 which indicated intact cognition. Section H reflected the resident had an indwelling catheter. Section V reflected Urinary Incontinence and Indwelling Catheter was triggered, and the decision to care plan was marked as yes. Record review of Resident #2's comprehensive care plan, initiated on 07/29/25, reflected the indwelling urinary catheter was not addressed. Record review of Resident #2's physician order, dated 07/29/25, reflected, Indwelling urinary catheter (Adult Insert and Maintain Indwelling Urinary Catheter Panel) Continuous Patient: Adult Indication (s): Acute urinary retention or bladder obstruction. Discontinue indwelling urinary catheter and order: Do not remove. Call provider when patient no longer meets criteria. An observation and interview on 08/19/25 at 11:56 AM, revealed Resident #2 sitting up in a chair, next to the bed, in her room. A catheter drainage bag hanging from the bed frame was observed. The urine in the bag was clear yellow. Resident #2 stated the staff provided catheter care regularly and she did not recall a recent urinary tract infection. Record review of Resident #7's face sheet dated 08/21/25 reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #7 had diagnoses which included: acute hypoxic respiratory failure (a sudden and life-threatening condition where blood oxygen levels are dangerously low, often due to lung injury) and acute kidney injury (the sudden decrease in the kidneys' ability to filter waste and balance fluids, often due to infections, blood loss, dehydration, or certain medications). Record review of Resident #7's admission MDS assessment dated [DATE], reflected that Resident #7 had a BIMS score of 05 which reflected the resident was severely cognitively impaired. Resident #7's admission MDS assessment reflected that the resident had an indwelling catheter (including suprapubic catheter and nephrostomy tube). Record review of Resident #7's Physician's Orders, dated 08/21/25, reflected the resident had an order initiated on 08/07/25 for: Indwelling urinary catheter (Adult Insert & Maintain Indwelling Urinary Catheter Panel) Continuous. Record review of care plan dated 08/21/2025 reflected Resident #7 had not been care planned for having a foley catheter. In an observation and interview on 08/19/2025 at 12:06 PM Resident #7 stated she was doing good and the staff all treated her well. She stated she had a way to call for help and the staff checked on her often. Resident #7 appeared pleasantly confused and her foley catheter drainage bag hung on the walker beside resident's chair. She says the catheter did not bother her in any way and she thought the nurses took care of her catheter, but she did not know. In an interview on 08/20/25 at 1:30 PM, RN B, stated the individual nurses were responsible for initiating care plans and the care plans were an on-going process day by day as things changed. He stated peg tubes and catheters should have been care planned. He stated all nurses were trained on how to initiate and develop care plans. He stated he did not feel as though any resident would have been affected by peg tubes or catheters not being included in the care plans because the staff should have followed the physician's orders to care for the residents. In an interview on 08/21/25 at 9:33 AM, RN A stated all things such as peg tubes, nasogastric tubes and catheters should have been included in a resident's care plan. She stated nurses were trained to initiate the care plans within 24 hours after a resident admitted to the facility. She stated care plans were looked at every shift and updated on residents' condition and if there were no changes there would be no updates. She stated the nurses were not capturing everything they should have been on the care plans. She stated if a resident's care plan had not included peg tubes, nasogastric tubes, or catheters, IV's, foley or suprapubic catheters, it should not have affected a resident in a negative way because the nurses should have known by the physicians orders and assessment to care for the residents properly. In an interview on 08/21/25 at 9:41 AM, facility care plan policy was requested, RN A stated there was no care plan policy for the facility. In an interview on 08/21/25 at 10:44 AM, RN B stated some care plans could have been manually put in and they could have been developed along with the nurse assessing a resident initially. In an interview on 08/21/25 at 11:29 AM, RN C stated she was responsible for initiating and continuing care plans. She stated the care plans were created by meeting with the resident and family, reviewing the resident's medical history, by daily assessment, and by doing that she would have identified the problems that needed to be put in the care plans. She stated care plans were reviewed every shift to ensure all of the resident's problems were listed and to ensure residents goals were being met and if the residents were progressing or not. She stated she had been trained on initiating, continuing, and completing care plans. She stated things such as catheters, enteral tubes, peg tubes, nasogastric tubes, catheters, IV's, foley or suprapubic catheters should have been included in the care plans. She stated if a care plan had not included peg tubes, nasogastric tubes, IV's, foley or suprapubic catheters it could have possibly been a risk of infection to the resident but that was a basic standard of care, so it was being done. In an interview on 08/21/25 at 11:35 AM, facility care plan policy was requested, RN C stated she was unsure if there was a facility policy regarding care plans. In an interview on 08/21/25 at 11:56 AM, the DON, stated the nursing staff were responsible for initiating care plans. She stated an RN initiated the care plans and after that, all of the nurses could have added, adjusted, or tweaked the care plans. She stated care plans were created by having some standard care plans that could have been chosen and also should have included any lines or tubes or wound care initially and the maybe the day after, things such as nutrition could be ordered. She stated the nurses should have initiated care plans that bridged over to whatever the resident's diagnoses or care needed to include. She stated nursing staff had been trained on initiating and completing care plans. She stated things such as catheters, enteral tubes, peg tubes, nasogastric tubes, IV's, foley or suprapubic catheters should have been included in the care plans. She stated the residents and care plans were assessed every shift and all of the lines and tubes should have been documented on daily. She stated if a care plan had not included peg tubes, nasogastric tubes, catheters, IV's, foley or suprapubic catheters, one of those things could have possibly been overlooked. In an interview on 08/21/25 at 11:59 AM, facility care plan policy was requested, the DON stated she was unsure if there was a facility policy regarding care plans, but she was going to have that checked on at that time. 08/21/25 9:41 AM, 11:35 AM, 11:59 AM Facility policy was requested from RN A, RN C, and the DON and not received prior to exit.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to properly screen surveyors for COVID-19 by not sanitizing/cleaning the thermometer between use. This deficient practice could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building. Findings Include: Observation on 11/01/2020 at 10:05 A.M. revealed RN A welcoming surveyors into the building, directing them to the conference room. RN A used an oral thermometer to screen 1st surveyor, did not sanitize her hands, did not don gloves and removed probe with her bare hands. RN A left the room, returned with an infra thermometer, screened 3 surveyors, touching their forehead with the thermometer without cleaning the surface of the infra thermometer. The 4th surveyor cleaned the surface before getting screened. In an interview on11/03/2020 at 12:45 P.M. the DON stated that oral thermometers are used for everyone as they did not have infrared thermometer at the time. She stated they do not have a policy in place in case someone shows up and no one is available to screen. She stated this is a SNF and SNF regulations should be followed. In an interview on 11/03/2020 at 1:25 P.M. with the Infection Preventionist Manager she stated they are expected to follow regulations for a SNF. She also stated, if an oral thermometer is used, it should be sanitized before and after each use and if it is not clean it is considered cross contamination. If it touched a person's head, then it is contaminated and should be clean after each use. She ended by saying, this is for any equipment, it should be clean after each use. In an interview on 11/03/2020 at 1:41 P.M. RN A stated staff use oral thermometers to screen themselves and complete screening questions. She also stated, she asked the surveyors to screen themselves because that is what she is used to. She stated she was supposed to wear gloves before taking surveyors oral temperature because of saliva and it should have been wiped down after use. She stated she should have cleaned the infrared thermometer between temperature checks, but she was caught off guard because no one screens them. Review of facility policy titled Environmental and Equipment Cleaning with an effective date of 02/03/2020 reads Portable Equipment used by departments (e.g., Radiology, EKG, Respiratory, Transport) in patient care areas is cleaned by that department's personnel after each patient use and reads when visibly soiled. Review of facility policy titled COVID-19: Interim Infection Prevention and Control Recommendations for Patient Under Investigation (PUI) or confirmed Cases of COVID 19 in Healthcare Settings with an effective date of 10/30/2020 reads Enhanced Precautions, Hand Hygiene 1. Use a BSWH approved alcohol-based hand sanitizer or soap and water for routine hand hygiene. 2. When hands are visibly soiled, wash hands with soap and water. Review of Chapter 19 COVID-19 EMERGENCY RULE reflected the following: (d) A nursing facility must screen according to the following timeframes: (2) each employee or contractor before entering the facility at the start of their shift.

Based on interviews and record review the facility failed to conduct and document a facility-wide assessment in that facility did not have a completed Facility Assessment. This deficient practice could affect all 22 residents and contribute to insufficient staffing and/or a lack of necessary resources to provide necessary care to residents. The findings included: During entrance conference on 7/09/18, at 09:45 AM, ADM and DON were provided the Entrance Conference Checklist which instructed the facility to provide the survey team the facility's document of Facility Assessment within 4 hours of the entrance. During an interview on 7/09/18 at 3:00 PM, DON stated she was unsure of what Facility Assessment was. Review of records titled Emergency Management Strategic Plan, Continuing Care Hospital FY (YEAR), and Hazard Vulnerability Analysis-FY2018 received as Facility Assessment did not reflect any evidence facility evaluated its resident population and identified the resources needed to provide the necessary care and services the residents required (facility-wide assessment). During an interview on 7/10/18 at 12:15 PM, DON stated facility currently did not have any records for an annual documented Facility Assessment. Request for policy on Facility Assessment was made but DON stated facility did not have a policy on Facility Assessment. DON further stated she will create a new Facility Assessment and revealed a copy of a CMS guideline and tools for creating a Facility Assessment. During an interview on 7/11/18 at 9:00 AM, DON stated she was more than half way done in creating a Facility Assessment and revealed a work in progress copy of a Facility Assessment. Review of CMS form 672 dated 7/09/18 reflected the facility census was 22.

Based on observation, interviews, and record reviews, the facility failed to ensure staff were able to demonstrate competency in the provision of skills and techniques necessary to provide incontinence care when: One of 2 CNAs (CNA A) and 1 of 1 RN (RN B) failed to follow proper incontinence care techniques and failed to perform hand hygiene as indicated for 1 of 2 residents (Resident #9) observed during incontinence care. These deficient practices could affect 6 residents who are occasionally or frequently incontinent of bladder, and/or 6 residents who are occasionally or frequently incontinent of bowel at risk for transmission of microorganisms, cross contamination of bacteria, and the spread of infection which could potentially result in deterioration in condition and the need for additional treatment and/or medication. Findings included: Review of Resident #9's face sheet dated 7/11/18 reflected a [AGE] year old female admitted on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #9's MDS dated [DATE] reflected a BIMS score of 15 which indicated a cognitively intact status. Further review reflected she required a two-person physical assist for bed mobility, and one-person physical assist for dressing, toilet use, personal hygiene, and bathing. Further review reflected she was frequently incontinent of bowel and bladder. Review of Resident #9's most recent care plan dated 6/15/18 reflected self-care deficit in being able to perform self-care activities. Interventions included providing education, altered elimination, and perineal care (incontinence care). During perineal care performed by RN B and CNA A on 7/11/18 at 9:35 AM, RN B was observed cleaning Resident #9's buttocks area with moderate to large amount of light brown substance. During this process, RN B used same surface of disposable wipes to wipe multiple times in a back and forth motion. RN B also wiped from the tail bone area toward the rectum and perineal area. RN B then changed gloves without hand hygiene and assisted Resident #9 into a supine (laying on back) position. CNA A then proceeded to clean Resident #9's labia and thigh area. While cleaning the thigh area with visible light brown substance, CNA A was observed folding soiled wipe with both hands. During this process, CNA A's gloved hands came in contact with the soiled, inner surface of the folded wipe and she continued to use the wipe to clean the resident's thigh area. CNA A repeated this step approximately 5-6 times. While cleaning the labia, neither RN B nor CNA A held the labia open until both sides of labia and between labia were cleaned. CNA A then pulled Resident #9's gown with same gloved hands and also put away the remaining disposable wipe container on to the shelf located in corner of room. CNA A then changed gloves without hand hygiene. RN B then removed an old dressing from Resident #9's lower abdomen area, cleaned the area with wound cleanser, then placed a new dressing without performing hand hygiene or glove changes between dressing changes. RN B continued repositioning Resident #9, touching her gown, pillows, blankets, and call light in the process. RN B then took gloves off and performed hand hygiene. During an interview on 7/11/18 at 9:49 AM, CNA A stated in-service on perineal care was done couple months ago. She further stated she did not hold the labia open until both sides of labia and between labia were cleaned but should have to prevent recontamination. She further stated she should not have touched Resident #9's gown with same gloved hand. She further stated she did not remember folding wipes to reuse while cleaning Resident #9's thigh area. She further stated when washing the buttocks area, procedure was to wash from tailbone area toward rectal area. During an interview on 7/11/18 at 10:02 AM, RN B stated the direction for washing buttocks area was from rectal area to tailbone area. She further stated if there was a fairly large amount of stool to clean, she would not fold a disposable wipe to reuse but admitted doing so today. She further stated she would not use same surface of wipe more than once but admitted doing so today. She further stated she was supposed to perform hand hygiene between glove changes. She further stated she should have changed gloves before touching Resident #9's gown, pillows, blankets, and call light. She further stated she should have changed gloves after old dressing was removed and before placing new dressing on Resident #9's abdomen. She further stated in-service on wound care was done annually, and perineal care a few years ago. She further stated while helping CNA A with cleaning the labia, she should not have let go of the labia before both inner sides of labia and between the labia were cleaned. During an interview on 7/11/18 at 11:30 AM, DON stated hand hygiene should be performed between glove changes, expected staff to clean from rectum to tailbone area to prevent recontamination, and staff were not allowed to fold disposable wipes if significant amount of bowel were being cleaned. She further stated staff were not allowed to use the same surface of wipe multiple times, expected staff to change gloves and perform hand hygiene after perineal care and before moving on to touch a resident's gown, pillow, blanket, and call light. She further stated once labia are spread, it should not be released until all sides and between labia are cleaned to prevent recontamination. She further stated after a old dressing on a wound is removed, staff were expected to perform hand hygiene and put on new gloves before applying a new dressing. Review of facility provided policy on Hand Hygiene with effective date of 11/1/2016 reflected the following under general indications for hand hygiene and hand antisepsis: - 4. Hand hygiene must be performed (b) before donning gloves, (e) after contact with body fluids or excretions, and wound dressings, (f) before moving from contaminated body site to a clean body site during individual patient care, (h) after removing gloves. Review of facility provided policy on Perineal Care with the printed date of 7/11/18 reflected the following under female perineal care: - 1. Perform hand hygiene and don gloves. - 8. Gently separate the labia with the nondominant hand. - 9. With the dominant hand, wash downward from the pubic area toward the rectum. - 16. Discard supplies, remove gloves, and perform hand hygiene. Review of in-services for (YEAR) and (YEAR) reflected staff including CNA A and RN B were trained in variety of topics. Topics included Introduction to Infection Prevention, Perineal Care, and Urinary Catheter Care. During an interview on 7/11/18 at 2:10 PM, DON stated in-service topic of Urinary Catheter Care were for RNs and included perineal care. Review of CMS form 672 reflected 6 residents who are occasionally or frequently incontinent of bladder, and/or 6 residents who are occasionally or frequently incontinent of bowel.

Based on observation, interview and record review the facility failed to ensure it was free of medication error rate of 5 percent or greater. Twenty-five opportunities were observed with a total of 5 (five) errors, resulting in a 20 percent (%) medication error rate by one of four licensed nurses observed (RN C). RN C administered 5 medications ([MEDICATION NAME], Etravirine, Emtricitab, potassium and insulin) at 9:50 a.m. to Resident #12. Medications were ordered by the physician to be given with meals. Resident had eaten at 8:20 a.m. These failures could affect 5 residents with medications being administered by RN C by placing them at risk for not receiving the intended therapeutic benefit of their medications and at risk for unintended side effects of their medications. The findings included: During an observation of medication pass on 7/10/18 at 9:50 a.m. RN C administered the following medications to Resident #12: - [MEDICATION NAME] 40 mg tablet - Humalog insulin injection 17 units - Emtricitab 200-25-25 mg tablet - Etravirine 200 mg tablet - Potassium 40 mEq tablet During observation of medication pass on 7/10/18 at 9:50 a.m. RN C stated to Resident #12 Some of your meds are a little off (late), supposed to be at 8:00 a.m. I will have to call the pharmacy to adjust. Review of the physician orders for Resident #12, dated (MONTH) (YEAR), reflected the following orders: - [MEDICATION NAME] 40 mg tablet daily with meals - Humalog insulin injection three times daily with meals - Emtricitab 200-25-25 mg tablet daily with meal - Etravirine 200 mg tablet 2 times daily with meals - Potassium CR 40 mEq tablet daily with meal. In an interview on 7/11/18 at 11:40 a.m. the DON stated she expects medications to be administered as per the physician orders. The DON further stated medications administered at 9:50 a.m. instead of at 8:20 a.m. when the resident was eating would be considered a medication error. Review of the facility policy titled Timing of Medication Administration, dated 4/4/18, reflected the following: Policy Standardized administration times are incorporated to facilitate the medication administration process, ensuring safe and timely administration of medications. Review of the daily staffing assignment sheet provided by the DON, dated 7/10/18, reflected RN C was assigned to provide care for 5 residents.

Based on observation, interviews, and record reviews, the facility failed to ensure proper hand hygiene procedures were followed by staff involved in direct resident care, nor standard and transmission-based precautions were followed to prevent spread of infections when: One of 2 CNAs (CNA A) and 1 of 1 RN (RN B) failed to follow proper incontinence care techniques and failed to perform hand hygiene as indicated for 1 of 2 residents (Resident #9) observed during incontinence care. These deficient practices could affect 6 residents who are occasionally or frequently incontinent of bladder, and/or 6 residents who are occasionally or frequently incontinent of bowel at risk for transmission of microorganisms, cross contamination of bacteria, and the spread of infection which could potentially result in deterioration in condition and the need for additional treatment and/or medication. Findings included: Review of Resident #9's face sheet dated 7/11/18 reflected a [AGE] year old female admitted on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #9's MDS dated [DATE] reflected a BIMS score of 15 which indicated a cognitively intact status. Further review reflected she required a two-person physical assist for bed mobility, and one-person physical assist for dressing, toilet use, personal hygiene, and bathing. Further review reflected she was frequently incontinent of bowel and bladder. Review of Resident #9's most recent care plan dated 6/15/18 reflected self-care deficit in being able to perform self-care activities. Interventions included providing education, altered elimination, and perineal care (incontinence care). During perineal care performed by RN B and CNA A on 7/11/18 at 9:35 AM, RN B was observed cleaning Resident #9's buttocks area with moderate to large amount of light brown substance. During this process, RN B used same surface of disposable wipes to wipe multiple times in a back and forth motion. RN B also wiped from the tail bone area toward the rectum and perineal area. RN B then changed gloves without hand hygiene and assisted Resident #9 into a supine (laying on back) position. CNA A then proceeded to clean Resident #9's labia and thigh area. While cleaning the thigh area with visible light brown substance, CNA A was observed folding soiled wipe with both hands. During this process, CNA A's gloved hands came in contact with the soiled, inner surface of the folded wipe and she continued to use the wipe to clean the resident's thigh area. CNA A repeated this step approximately 5-6 times. While cleaning the labia, neither RN B nor CNA A held the labia open until both sides of labia and between labia were cleaned. CNA A then pulled Resident #9's gown with same gloved hands and also put away the remaining disposable wipe container on to the shelf located in corner of room. CNA A then changed gloves without hand hygiene. RN B then removed an old dressing from Resident #9's lower abdomen area, cleaned the area with wound cleanser, then placed a new dressing without performing hand hygiene or glove changes between dressing changes. RN B continued repositioning Resident #9, touching her gown, pillows, blankets, and call light in the process. RN B then took gloves off and performed hand hygiene. During an interview on 7/11/18 at 9:49 AM, CNA A stated in-service on perineal care was done couple months ago. She further stated she did not hold the labia open until both sides of labia and between labia were cleaned but should have to prevent recontamination. She further stated she should not have touched Resident #9's gown with same gloved hand. She further stated she did not remember folding wipes to reuse while cleaning Resident #9's thigh area. She further stated when washing the buttocks area, procedure was to wash from tailbone area toward rectal area. During an interview on 7/11/18 at 10:02 AM, RN B stated the direction for washing buttocks area was from rectal area to tailbone area. She further stated if there was a fairly large amount of stool to clean, she would not fold a disposable wipe to reuse but admitted doing so today. She further stated she would not use same surface of wipe more than once but admitted doing so today. She further stated she was supposed to perform hand hygiene between glove changes. She further stated she should have changed gloves before touching Resident #9's gown, pillows, blankets, and call light. She further stated she should have changed gloves after old dressing was removed and before placing new dressing on Resident #9's abdomen. She further stated in-service on wound care was done annually, and perineal care a few years ago. She further stated while helping CNA A with cleaning the labia, she should not have let go of the labia before both inner sides of labia and between the labia were cleaned. During an interview on 7/11/18 at 11:30 AM, DON stated hand hygiene should be performed between glove changes, expected staff to clean from rectum to tailbone area to prevent recontamination, and staff were not allowed to fold disposable wipes if significant amount of bowel were being cleaned. She further stated staff were not allowed to use the same surface of wipe multiple times, expected staff to change gloves and perform hand hygiene after perineal care and before moving on to touch a resident's gown, pillow, blanket, and call light. She further stated once labia are spread, it should not be released until all sides and between labia are cleaned to prevent recontamination. She further stated after a old dressing on a wound is removed, staff were expected to perform hand hygiene and put on new gloves before applying a new dressing. Review of facility provided policy on Hand Hygiene with effective date of 11/1/2016 reflected the following under general indications for hand hygiene and hand antisepsis: - 4. Hand hygiene must be performed (b) before donning gloves, (e) after contact with body fluids or excretions, and wound dressings, (f) before moving from contaminated body site to a clean body site during individual patient care, (h) after removing gloves. Review of facility provided policy on Perineal Care with the printed date of 7/11/18 reflected the following under female perineal care: - 1. Perform hand hygiene and don gloves. - 8. Gently separate the labia with the nondominant hand. - 9. With the dominant hand, wash downward from the pubic area toward the rectum. - 16. Discard supplies, remove gloves, and perform hand hygiene. Review of in-services for (YEAR) and (YEAR) reflected staff including CNA A and RN B were trained in variety of topics. Topics included Introduction to Infection Prevention, Perineal Care, and Urinary Catheter Care. During an interview on 7/11/18 at 2:10 PM, DON stated in-service topic of Urinary Catheter Care were for RNs and included perineal care. Review of CMS form 672 reflected 6 residents who are occasionally or frequently incontinent of bladder, and/or 6 residents who are occasionally or frequently incontinent of bowel.

Based on interview and record review the facility failed to coordinate assessments with the pre-admission screening and resident review program (PASRR) to ensure that individuals with mental illness and mental [MEDICAL CONDITION] receive the care and services they need in the most appropriate setting for 1 (Resident 10) of 10 residents reviewed for a PASRR. This deficient practice could diminish the well-being all residents discharging from this skilled nursing facility and admitting into another skilled nursing facility. Findings include: Review of Resident #10 ' s patient information form with an admitted ,[DATE]//16 with a [DIAGNOSES REDACTED]. Review of Resident #10 ' s PASRR with an assessment date of 4/7/16 reflected no data in section C stating if this resident had a mental illness, intellect disability or a developmental disability. During an interview on 6/9/16 at 2:35 p.m. the Social Worker (SW) stated she is responsible for doing the PASRR for residents discharging to another skilled nursing facility. The SW stated she does not complete section C of the PASRR because she believes she is not authorized to so. The SW stated she is not a mental health provider, and she would be representing herself as one if she filled out the section C portion of the PASRR. During an interview on 6/10/16 at 10:00 a.m. the Director of Nurses (DON) stated the SW is the person responsible for completing the PASRR. The DON also stated the facility is not required to a do a PASRR on residents if they are not admitting to another nursing facility. The DON further stated they do not complete a PASRR if a resident is returning home or back into the community. According to the facility ' s DON the census was 28.

Based on observation, interview and record review the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs as identified through resident assessments, and described in the plan of care for two (2) of two (2) residents (Resident #'s 7 and 8) reviewed for incontinent care provided by three (3) of three (3) Certified Nurse Aides (E, F, and G). A) CNA F failed to cleanse Resident # 8's inner labia and failed to change gloves until she had completed incontinent care and applied cream to the rectal area. B) CNA E failed to remove soiled gloves and wash her hands after completing incontinent care for Resident # 7, before touching a clean pad. C) CNA G failed to cleanse Resident # 8 ' s inner and outer labia when providing incontinent care. This deficient practice placed eight (8) residents who received incontinent care at risk for urinary tract infections and/or skin breakdown. Findings Include: A) Observation on 07/21/2015 at 2:45 PM revealed Resident # 8 received incontinent care for bladder incontinence. CNA F was observed to fail to cleanse the inner labia. CNA F did not change gloves or wash her hands until after she applied Sensicare Cream and [MEDICATION NAME] Cream to the rectal area. In an interview on 07/22/2015 at 9:00 AM, CNA F stated she should have opened the labia and cleansed the area and should have changed her gloves and washed her hands before she applied cream to the rectal area. B) Observation on 07/22/2015 at 11:35 AM revealed Resident # 7 received incontinent care for bladder and bowel incontinence. CNA E was observed to apply two (2) gloves to each hand. CNA E removed a large amount of feces, removed her top gloves and then continued to cleanse Resident # 7's buttocks and rectum of additional feces. CNA E applied a clean pad with the same soiled gloves. In an interview on 07/22/2015 at 12:30 PM, CNA E stated she should have changed her gloves and washed her hands after cleansing feces from Resident # 7 ' s rectum/buttocks and before touching a clean pad. C) Observations on 07/22/2015 at 11:50 AM revealed Resident # 8 received incontinent care for bladder incontinence. CNA G was observed to turn Resident # 8 on her right side and wipe from front to back between Resident # 8 ' s legs with a disposable washcloth. CNA G failed to cleanse Resident # 8 ' s inner and outer labia. In an interview on 07/22/2015 at 12:00 PM, CNA G stated since Resident # 8 was not soaked with urine or had a bowel movement, he felt it was sufficient to wipe between Resident # 8's legs from the front back to the rectum and buttocks. In an interview on 07/23/2015 at 1:55 PM, the DON stated that the CNA ' s attend a review of CNA Competencies. The DON stated the last Competency Classes were 05/25-05/26/2015, but did not include a specific review of incontinent care. In a second interview on 07/23/2015 at 2:15 PM the DON stated the facility uses Mosby's Skills as the policy for performing incontinent care. The DON stated she expected the CNA's to perform incontinent care according to their policy and to change their gloves and wash their hands after coming in contact with urine or feces, and before touching clean sheets or pads. Review of the Mosby's Skills, Bathing: Bed Bath, Clinical Nursing Skills and Techniques (8th ed.), St. Louis: Mosby, 2006-2015 reflected the following: 12. Provide perineal care. Do this during the daily bath and after each episode of urine or fecal incontinence.b. For a female, clean the outer and inner labia. Cleanse, rinse, and dry thoroughly. c. Assist patient into prone or side-lying position. Place towel lengthwise along the patient's side. D. Enclose any fecal material in a fold of underpad or toilet tissue, and remove with disposable wipes. f. Cleanse buttocks and anus, washing from front to back. Rinse and dry thoroughly. Review of facility policy, Hand Hygiene, Revision Date 04/03/2013, reflected the following: Gloves, 2. Immediately remove gloves after providing care or completing the task with potential contamination. 3. Do not wear the same pair of gloves for the care of more than one patient or when moving from one potentially contaminated body site to another on the same patient.5. Perform hand hygiene immediately after removing gloves. The facility provided CMS Form 672 which reflected the facility had eight (8) residents who were incontinent.

Based on observation and interview, the facility failed to prominently display in the facility written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits. This deficient practice could place 28 residents at risk of not having access to contact and application information for Medicare and Medicaid and could delay receipt of services. The findings include: Observation on 7/22/15 at 5:30 p.m. reflected there were no postings regarding Medicare and Medicaid benefits in any of the five facility hallways, nurses station or by the elevator upon entry to the floor. During an interview on 7/23/15 at 2:55 p.m. the DON and Director of Regulatory Services stated the information was probably in the residents admission packet; however, the posters were not hanging with the other postings in the facility and would not be located anywhere else. Review of the CMS-672 reflected a census of 28.

Based on observation, interview and record review the facility failed to post the name, address and telephone number of the State Ombudsman on 3 of 3 nursing units (2 North, 3 North and 2 South). This deficient practice could infringe on the resident ' s right to contact the State Ombudsman for advocacy purposes for 37 residents. Findings include: Observation on 6/12/13 at 1:25 PM revealed a bulletin board near the two (2) North, three (3) North and three (3) South nurses ' station. The following was posted on the bulletin board: 1. Notice of Accepted Plan of Correction for Life Safety Code survey dated 6/6/12. 2. Notification of electronic monitoring 3. Hospital Licensure 4. Texas Department of Human Services A. To file a complaint- Department of Aging and Disability Services Hotline number. B. For facility information-Department of Aging and Disability Services Hotline number. C. The consumer advocate phone number which was different, but lead to the same Department of Aging and Disability Services Hotline. There was no posting regarding the State Ombudsman's name, address or contact telephone number. In an interview on 6/12/13 at 1:35 PM Registered Nurse (RN) A stated she was not sure what was supposed to be posted. In an interview on 6/12/13 at 1:40 PM the Nursing Director stated, " What do I need to have posted? I ' ll do it right now. " Review of the facility generated CMS 672 reflected a census of 37.

Based on observation, interview and record review the facility failed to make the results of the most recent survey of the facility conducted by State Surveyors and the facility's plan of correction available for examination on 3 of 3 nursing units (2 North, 3 North and 3 South). This deficient practice infringes on the resident's right to be informed of the facility's need for improvement and the facility's plan to improve for 37 residents. Findings include: Observation on 6/12/13 at 1:25 PM revealed a bulletin board near the two (2) North, three (3) North and three (3) South nurse' station. The following was posted on the bulletin board: 1. Notice of Accepted Plan of Correction for Life Safety Code survey dated 6/6/12. 2. Notification of electronic monitoring 3. Hospital Licensure 4. Texas Department of Human Services A. To file a complaint- Department of Aging and Disability Services Hotline number. B. For facility information-Department of Aging and Disability Services Hotline number. C. The consumer advocate phone number which was different, but lead to the same Department of Aging and Disability Services Hotline. There was no posting of the current Federal Health Survey. In an interview on 6/12/13 at 1:35 PM Registered Nurse (RN) A stated she was not sure what was supposed to be posted. In an interview on 6/12/13 at 1:40 PM the Nursing Director stated, "What do I need to have posted? I'll do it right now." Review of the facility generated CMS 672 reflected a census of 37.

Based on observation, interview and record review the facility failed to ensure accurate coding on the Admission Minimum Data Set (MDS) for one of two residents (Resident #6) that required [MEDICAL CONDITION] (continuous positive airway pressure) or [MEDICAL CONDITION] (Bilevel positive airway pressure) treatments. This deficient practice affected one resident (Resident #6) and could contribute to residents not receiving special respiratory treatments when assessments are inaccurate; therefore,care plans and delivery of care may be inaccurate. Findings include: An observation on 6/4/12 at 10:00 AM revealed Resident #6 in a specialty bed with the head up. He had a [MEDICAL CONDITION] (a surgical opening in the windpipe (trachea). It is made by cutting the neck below the Adam's apple (below the vocal cords). A tube is placed in the opening, and air goes in and out through the tube instead of through the mouth and nose) with a heated mist collar. There was a dressing on the back of his neck and on his coccyx. He had a two port PICC line (peripherally inserted central catheter (PICC) line involves the insertion of a flexible thin plastic tube, or catheter into a blood vessel to provide an effective method of drawing blood or delivering medications and nutrients into a patient's bloodstream over a period of time) in the upper inner left arm. There was a PEG tube (a feeding tube through the skin and the stomach wall, directly into the stomach) used to instill nutrition and medication. There was a Foley Catheter (tube in the bladder to drain urine) draining clear yellow urine with sediment in the tubing. There were multi-podus boots on his feet bilaterally to prevent foot drop and pressure points. Review of Resident #6's facesheet reflected a [AGE] year old male, admission on 4/16/12 from another facility with [DIAGNOSES REDACTED]. following a motor vehicle accident in 2011. Review of the admission MDS dated [DATE] in Section O under 'Respiratory Treatments'- letter G. [MEDICAL CONDITION]/[MEDICAL CONDITION] ([MEDICAL CONDITION] is a continuous positive airway pressure system with a time-cycled or flow-cycled change of the applied [MEDICAL CONDITION] level) were not checked for (1.) While NOT a resident here; or (2.) While a resident here. 'Respiratory Treatments'- letter F. Ventilator or Respirator were checked for (1.) While NOT a resident here or (2.) While a resident here. An observation on 6/6/12 at 10:15 AM revealed no [MEDICAL CONDITION] machine seen in the room. Review of admission orders [REDACTED]'. Review of the current orders dated 5/15/12 reflected '[MEDICAL CONDITION] routine every six hours as needed daily until discontinued'. An interview on 6/6/12 at 2:20 PM with Registered Nurse (RN) B revealed she was not sure if Resident #6 was still using a [MEDICAL CONDITION] machine or not. She stated, "They didn't say anything in report and I didn't see it in the room". An interview on 6/6/12 at 2:40 PM with RN A revealed she did not know why she didn't check it ([MEDICAL CONDITION]/[MEDICAL CONDITION]). She stated, "We don't take patients on ventilators or respirators anymore. So I don't know why that was checked. I think I checked that instead of [MEDICAL CONDITION]. The floor nurses do the care plans." The CMS form 672 indicated a census of 35 with two residents using [MEDICAL CONDITION] or [MEDICAL CONDITION].

Based on interview and record review the facility failed to develop a policy and procedure for reporting all alleged violations and all substantiated incidents of abuse/neglect (including injuries of unknown origin), mistreatment and misappropriation of property to the Department of Aging and Disability Services (DADS). This deficient practice could result in alleged or suspected incidents of abuse/neglect (including injuries of unknown origin), mistreatment and misappropriation of property to go unreported to the proper State regulatory service agency which could affect 35 residents residing in the facility. Findings include: Review of the Facility Policy and Procedure provided to DADS Surveyors at the time of this Annual Survey as the only documentation for this request, was titled 'Victims of Abuse/Neglect' dated 7/2011. The document reflected that possible victims of abuse or neglect are identified and assessed by health care professionals and provided with referral information. Suspected cases of child or adult abuse/neglect must be reported in accordance with state statutes. II. Procedure: Attachment A: Abuse Reporting Criteria Elder/Disabled Abuse: "...a person having cause to believe that an elderly or disabled person is in the state of abuse, neglect, or exploitation shall report the information ..." Reports shall be made to the Texas Department of Family and Protective Services by phone, in person, online or in writing. Attachment B: Abuse Assessment Criteria Physical Signs, Behavioral Signs, Signs of Mental/Emotional Abuse, Signs of Neglect, Signs of Financial Abuse and Signs by the Caregiver may be clues that a problem exists, and that a report needs to be made to law enforcement or to the Texas Department of Family and Protective Services. In an interview on 6/6/12 at 3:30 PM Registered Nurse /Quality Program Director stated that when they get a complaint or abuse/neglect is suspected, the report usually goes to the Nursing Director. She stated that from the Nursing Director it gets reported to Quality Management and then to the legal department and an investigation is initiated. She stated that complaints can also go directly to Human Resources, Patient Relations, Quality Management or to the legal department. She stated that the facility (main hospital) investigates incidents of potential abuse/neglect and reports to Adult Protective Services or Child Protective Services at the Department of Family and Protective Services and/or Law Enforcement when necessary. She stated that they did not report incidents to the Department of Aging and Disability Services. She stated that upon hire, staff received information about reporting abuse or neglect of a patient. The RN/Quality Program Director then presented the following, undated, document, titled, 'To Report Abuse and Neglect or Illegal, Unprofessional or Unethical Conduct' . The document reflected that a person has the duty to report to the appropriate state health care regulatory agency any abuse or neglect of a patient. Reports may be made to the following entities: -Department of State Health Services-Health Facility Compliance Division-Complaint Hotline. -Department of Family and Protective-Abuse/Neglect Reports Hotline. -Department of State Health Services-Consumer Rights for Mental Health Services. -Department of State Health Services-Substance abuse consumer/family with a complaint. The Department of Aging and Disability Services Hotline was not listed. The federal regulations reflects these 'Must be reported in accordance with state statutes' for compliance with Long Term Care Regulatory. Review of the facility's CMS 672 reflected a facility census of 35.

Based on observation, interview and record review the facility failed to develop, review, and revise comprehensive care plans for the (3) of 11 sampled residents (Resident #1, #5 and #6) to describe the services that are to be furnished to attain or maintain the resident's highest practicable physical well-being. This deficient practice could affect the care and services for continuum of care and services for Resident #1, #5 and #6 and could affect the care and services for an additional 8 residents when medical interventions are not included in the plan of care. Findings include: 1.) Review of the Kardex (a paper card file listing daily care and services) for Resident #1 reflected she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Nursing [DIAGNOSES REDACTED]. Nursing [DIAGNOSES REDACTED]. 2.) Alteration in nutrition related to disease process and 3.) Alteration in bowel elimination related to disease process. Review of the Interdisciplinary Care Plan (ICP) dated 4/26/11 and updated 5/31/11 reflected goals in the following areas but lacked definitive interventions by the interdisciplinary team: 1. Activities-Resident #1 will participate in group and individual activities to include board games and puzzles. Interventions for activities included encouraging attendance and providing an activity schedule. 2. Nutrition-Resident #1 will be able to maintain adequate nutrition with TPN (Total [MEDICATION NAME] Nutrition)(intravenous nutrition). Interventions were to administer TPN as ordered. 3. Self care deficit related to bowel elimination/[MEDICAL CONDITION]. 2.) Review of the Kardex for Resident #5 reflected she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She received oxygen by [MEDICAL CONDITION] collar during the day and [MEDICAL CONDITION] (non-invasive ventilatory assist machine) at night. Observation on 6/2/11 at 8:00 AM revealed Resident #5 sitting on the side of her bed receiving oxygen by [MEDICAL CONDITION]. There was a [MEDICAL CONDITION] machine next to her bed. She had a Foley Catheter to bedside drainage. Review of the Nursing [DIAGNOSES REDACTED].) Impaired Gas Exchange related to [MEDICAL CONDITION]/[MEDICAL CONDITION] as evidenced by the need for a [MEDICAL CONDITION], oxygen, Respiratory Therapy and breathing treatments. 2.) Nutrition: More than body requirements related to Obesity and Diabetes as evidenced by the need for insulin and blood sugar monitoring. 3.) Alteration in Elimination related to disease process as evidenced by need for Foley Catheter, suppositories and Senna (laxative). 4.) Anxiety related to disease processes as evidenced by the need for [MEDICATION NAME] (antianxiety medication). Review of the ICP dated 4/26/11 and updated 5/31/11 reflected goals in the following areas but lacked definitive interventions by the interdisciplinary team: 1.) Anxiety. Interventions would be to administer [MEDICATION NAME] as ordered by the physician. 2.) Alteration in Bowel and Bladder elimination. Interventions were to assist with bowels as needed and provide Foley care every shift. 3.) Impaired gas exchange. Interventions were to check oxygen saturation and provide [MEDICAL CONDITION] care as needed. 4.) Alteration in nutrition. Interventions were to check Resident #5's blood sugar four times a day and assess for signs of [DIAGNOSES REDACTED] or [MEDICAL CONDITION]. The nutritional plan for Resident #5 was to encourage oral intake of a mechanical soft diet. 3.) Review of Resident #6's Nursing [DIAGNOSES REDACTED]. Resident #6 had 1.) Infection related to osteo[DIAGNOSES REDACTED] right foot as evidenced by need for IV antibiotics. 2.) Pain related to left foot osteo[DIAGNOSES REDACTED] as evidenced by need for pain medications. 3.) Impaired mobility related to left foot osteo[DIAGNOSES REDACTED] as evidenced by need for Physical Therapy. 4.) Nutrition: Diabetes Mellitus- related to disease process as evidenced by need for Chemsticks (blood sugar test by obtaining a small droplet of blood from the finger), Diabetes Mellitus diet. An observation on 6/1/11 at 8:30 AM revealed Resident #6 was propelling himself in a wheel chair in the hallway. His right foot was wrapped with a clean bandage. He had a PICC (peripherally inserted central catheter) line in this upper left arm. Review of the ICP dated 5/31/11 reflected Resident #6 was independent in Activities of Daily Living (ADL)s except transfers with nursing assist. Nursing care interventions 1.) Assist with transfers as needed. 2.)Alteration in comfort-medicate for pain and assess pain using pain scale. 3.) Infection -Nursing administer IV antibiotics and monitor for signs and symptoms of infection. 4.) Alteration in nutrition-Nursing chemsticks four times daily and check for [DIAGNOSES REDACTED] and [MEDICAL CONDITION]. There was no care plan for skin. The only reference was Podiatry for wound care. The care plan lacked definitive interventions by the interdisciplinary team. An interview on 6/1/11 at 1:10 PM with Registered Nurse (RN)/Nurse Manager D and RN G revealed they have no measurable goals/interventions. They have a program on their electronic charting but staff had not been inserviced about it yet and not being used. In an interview on 6/2/11 at 3:10 PM Nurse Manager D stated they have weekly care plan meetings and document on the Interdisciplinary Care Plan Meeting sheet. She stated that that sheet and the Nursing [DIAGNOSES REDACTED]. She stated, "No, interventions are not documented on the care plans." Review of CMS form 672 dated 6/2/11 reflected a census of 35 residents.

Based on observation, interview and record review the facility failed to ensure one (1) of six (6) staff (Registered Nurse (RN) F) accurately administered medications according to the Plan of Care for 1 of 16 residents (Resident #7) observed receiving medications. RN F administered medication to Resident #7 by Gastrostomy Tube ([DEVICE] surgically placed through the abdominal wall into the stomach to provide fluids, nutrition and/or medication) instead of orally as ordered by her physician. This deficient practice affected one (1) resident (Resident #7) with a [DEVICE] and could affect 7 additional [DEVICE] residents when physician's orders [REDACTED]. Findings include: Observation on 6/2/11 at 12:00 PM revealed Resident #7 in bed with the head of her bed elevated. She had [DEVICE] feeding infusing at 55 milliliters per hour. In an interview on 6/2/11 Licensed Vocational Nurse (LVN) C stated, "Most of Resident #7's intake is by [DEVICE]. Resident #7 has an order for [REDACTED]. An observation on 6/3/11 at 8:00 AM revealed RN F prepared medication for administration to Resident #7. The resident was alert and responsive. RN F prepared medications as follows: [MEDICATION NAME] (treats [MEDICAL CONDITION] reflux) was dissolved in 10 cc of water. Aspirin 325 milligram (mg) tablet (blood thinner), [MEDICATION NAME] 0.25 mg (controls heartrate), [MEDICATION NAME] 20 mg tablet (treats high blood pressure), [MEDICATION NAME] 25 mg (treats high blood pressure and prevents chest pain) were crushed and dissolved in 30 cc of water. Using a piston syringe she administered the medication by gravity into the GT. Review of physician's orders [REDACTED]., [MEDICAL CONDITION] and agitation. Medications were ordered to be given orally, not by G tube. Take all medications as prescribed. In an interview on 6/3/11 at 11:15 AM LVN C stated, "When Resident #7 was admitted I tried to administer her medications by mouth as ordered but she (Resident #7) held the medicine in her mouth instead of swallowing it". She stated "Her (Resident #7's) family member suggested that her medications be administered through her [DEVICE] and they had been administered that way ever since. There should be a physician's orders [REDACTED]. In an interview on 6/3/11 at 11:40 AM the Nursing Director revealed he had contacted Resident #7's physician and received an order to administer medications through the [DEVICE]. Review of facility procedure for MEDICATION ADMINISTRATION revised 5/2009 reflected the following: III PROCEDURE: A. Administration: 1. Medications administered by staff are given according to accepted methodology. The physician's orders [REDACTED]. Review of CMS form 672 dated 6/2/11 reflected a census of 35 residents. Eight (8) residents had GTs.

Based on observation, interview, and record review the facility failed to ensure a medication error rate of less that 5 % when two (2) of six (6) staff (Registered Nurse (RN) A and Licensed Vocational Nurse (LVN) C) had three (3) errors during 53 opportunities for two (2) of 16 residents (Residents #2 and #11) observed receiving medications for a medication error rate of 5%. 1. The wrong dosage of Iron was administered to two (2) residents (Residents #2 and #11) by two (2) different staff (RN A and LVN C); and 2. [MEDICATION NAME] eye drops was administered in the right eye only to 1 resident (Resident #2) by 1 staff (RN A) when administration in both eyes was ordered. This deficient practice could contribute to less than therapeutic benefits of ordered medications to maintain 35 residents' health and well being. Findings include: 1. An observation on 6/1/11 at 8:40 AM revealed LVN C administered routine medications to Resident #11. Iron 324 mg tablet 1 orally (supplement) was administered. Review of physician's orders [REDACTED]. No more recent orders were found. There was no order for Iron 324 mg. 2. An observation on 6/1/11 at 9:20 AM revealed RN A administered routine medications to Resident #2 including eye drops. [MEDICATION NAME] eye drops-1 drop in right eye (used to lower pressure in the eyes) and Iron 324 mg tablet 1 orally (supplement) Review of physician's orders [REDACTED]. [MEDICATION NAME] (Feratab) 325 mg 1 orally twice daily ordered 4/20/11. No more recent orders were found. [MEDICATION NAME] ([MEDICATION NAME] 0.2-0.5%) 1 drop in each eye twice daily ordered 4/21/11. No more recent orders were found. An interview on 6/1/11 at 10:25 AM with Nurse Manager D revealed she didn't know why staff were administering 324 mg of Iron instead of Feratab 325 mg as ordered. She placed a call to the Hospital's pharmacy who said, "Iron 324 mg is what is on their formulary so that's all they carry". An observation on 6/2/11 at 9:00 AM revealed when examining Resident #2's four (4) different eye drops, the [MEDICATION NAME] eye drops had a strip label with a large 'R' hand written on it in black marker. The other eye drops had the letter 'L' hand written on the strip label. An interview on 6/3/11 at 11:40 AM with the Nursing Director revealed he was not aware of the problem with the iron or the eye drops. He stated he would call the pharmacy and physician to clarify the above orders. An interview on 6/3/11 at 1:00 PM with the Nursing Director revealed he the physician was notified to clarify orders and he corrected the instructions on the eye drops. Review of CMS form 672 dated 6/2/11 reflected a census of 35 residents.

Based on observation, interview and record review the facility failed to ensure 2 of 6 staff (Licensed Vocational Nurse (LVN) B and LVN C) on 2 of 3 units (3 N and 3 S) followed the Infection Control Program to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of infection when: 1.) LVN C entered an isolation resident room on 3 North and picked up a trash bag without gloves; and 2.) LVN B entered a contact isolation room on 3 South gowned and gloved with a scanner to identify the resident, then came out of the room to the computer keyboard without removing soiled gloves. This deficient practice could cause infectious outbreaks and cross-contamination for 23 residents on 3 N and 3 S when staff are not using transmission-based precautions in addition to standard precautions. Findings include: 1. An observation on 6/1/11 at 8:40 AM revealed LVN C entered room [ROOM NUMBER] to administer medications. There was a sign on the door for contact isolation. LVN C picked up a trash bag containing debris and trash off the floor without gloves on and carried it into the bathroom. Then she proceeded to wash her hands and apply gloves to identify the resident by the arm band using the scanner (used in conjunction with the Computer on Wheels to identify residents and medications ordered for that resident) before administering medications. 2. An observation on 6/2/11 at 4:50 PM revealed LVN B gowned and gloved to enter an isolation room to hang an intravenous antibiotic. LVN B carried the scanner into the resident's room to scan the arm band to identify the resident. Without removing her gloves she went back to the Computer on Wheels and pushed the keys on the keyboard, gathered her supplies and re-entered the room in the same gown and gloves to hang the antibiotic and flush. She removed her gown and gloves in the room, washed her hands and wiped down the scanner with a germicidal wipe. She did not wipe down the keyboard she touched with her soiled gloves. An interview on 6/3/11 at 1:00 PM with the Nursing Director revealed staff should be taking off their gloves when they need to get on the keyboard and then re-glove when they re-enter the room. He stated, "I think I'll swab the keyboards and see if anything grows. (referring to bacteria that may be on the keyboards). This was not done before exit from the facility. The facility used Center for Disease Control Guidelines for infection control including hand hygiene and Standard and Transmission-Based Precautions. * Wash hands with antimicrobial soap when hands are visibly soiled (at least 15 seconds) * Alcohol hand rinse if not visibly soiled * Decontaminate hands before and after patient contact * Decontaminate hands before donning sterile gloves * Decontaminate hands before patient care procedures Review of the facility matrix reflected a census of 11 residents on 3 North and 12 residents on 3 South.

Based on observation, interview and record review the facility's assessment for 1 of 11 sampled residents (Resident #3) failed to accurately reflect the resident's status. Resident #3's 14 day Minimum Data Set (MDS) 3.0 did not reflect Resident #3's condition in relation to active diagnoses, health conditions, skin conditions, treatments, and procedures. This deficient practice could affect the individual care and services for Resident #3 and has the potential to affect care and services for an additional 10 residents. Findings include: Review of the clinical record for Resident #3 reflected she was admitted to the facility from a local hospital on [DATE] following a fall that resulted in a left elbow fracture and a left [MEDICAL CONDITION]. Additional [DIAGNOSES REDACTED]. Review of the Kardex (a paper card file listing daily care and services) for Resident #3 reflected she had [MEDICAL TREATMENT] (a treatment to filter blood to rid your body of harmful wastes, extra salt and water in the absence of normal kidney function) treatment three days a week and she was receiving physical therapy for wound care. Observation on 5/17/11 at 11:50 AM revealed Resident #3 was not in her room. In an interview on 5/17/11 at 11:55 AM Licensed Vocational Nurse (LVN) C stated that Resident #3 was in [MEDICAL TREATMENT]. She stated that Resident #3 attends [MEDICAL TREATMENT] three days a week. Observation on 6/1/11 at 11:35 AM revealed Resident #3 lying in bed on a specialty mattress for reducing pressure. She was alert and oriented and stated that she was admitted to the facility for rehabilitation following her fall. She stated that she broke her left hip and elbow. She further stated that when she was admitted to the facility she had sores on her heels and her buttocks that she is now receiving treatment for. Resident #3 also stated that she goes to [MEDICAL TREATMENT] three days a week. In an interview on 6/1/11 at 1:30 PM Physical Therapist (PT) F stated that Resident #3 was admitted to the facility with deep tissue injuries to her heels and sacral area. Review of the Minimum Data Set ((MDS) dated [DATE] Section I reflected Resident #3 had active [DIAGNOSES REDACTED]. Hip or Other Fractures was not checked and End Stage [MEDICAL CONDITION] was not listed as a [DIAGNOSES REDACTED]. Review of Section M reflected Resident #3 did not have one or more unhealed pressure ulcers Stage I or higher. Section M0300(E)(F)(G) reflected Resident #3 was not checked as having unstageable pressure ulcers. Review of Section O, 0100(J) reflected Resident #3 was not checked as receiving [MEDICAL TREATMENT] treatment in the last 14 days. In an interview on 6/2/11 at 10:15 AM MDS coordinator E stated that falls/fractures, pressure ulcers and [MEDICAL TREATMENT] should be checked and End Stage [MEDICAL CONDITION] should be listed as a [DIAGNOSES REDACTED]. Review of CMS form 672 dated 6/2/11 reflected a census of 35 residents.

Based on observation, interview and record review the facility failed to ensure one (1) of six (6) staff (Registered Nurse (RN) F) accurately administered medications as ordered to one (1) of 16 residents (Resident #7) observed receiving medications. RN F administered medication to Resident #7 by Gastrostomy Tube (GT-Tube surgically placed through the abdominal wall into the stomach to provide fluids, nutrition and/or medication) instead of orally as ordered. This deficient practice affected one (1) resident (Resident #7) and could affect an additional 7 residents with [DEVICE]s when procedures for medications were not coordinated and evaluated by a pharmacist but given per staff choice. Findings include: Observation on 6/2/11 at 12:00 PM revealed Resident #7 in bed with the head of her bed elevated. She had [DEVICE] feeding infusing at 55 milliliters per hour. In an interview on 6/2/11 Licensed Vocational Nurse (LVN) C stated, "Most of Resident #7's intake is by [DEVICE]. She has an order for [REDACTED]. An observation on 6/3/11 at 8:00 AM revealed RN F prepared medication for administration to Resident #7. The resident was alert and responsive when RN F identified her by scanning her wrist band (using a portable scanner used in conjunction with the computer on wheels). RN F prepared medications as follows: Prevacid Solutab (treats gastoesophageal reflux) was dissolved in 10 cc of water. Aspirin 325 mg tablet (blood thinner), Digoxin 0.25 mg (controls heartrate), Lisinopril 20 mg tablet (treats high blood pressure), Lopressor 25 mg (treats high blood pressure and prevents chest pain) were crushed and dissolved in 30 cc of water. RN F did not check tube placement prior to administration of medications. She administered the medications using a piston syringe and gravity. Review of physician's orders [REDACTED]. In an interview on 6/3/11 at 11:15 AM LVN C stated, when Resident #7 was admitted I tried to administer her medications by mouth as ordered but she (Resident #7) held the medicine in her mouth instead of swallowing it". She stated, "Resident #7's family member suggested that her medications be administered through her [DEVICE] and they had been administered that way ever since. There should be a physician's orders [REDACTED]. Review of facility procedure for MEDICATION ADMINISTRATION revised 5/2009 reflected the following: III PROCEDURE: A. Administration: 1. Medications administered by staff are given according to accepted methodology. The physician's orders [REDACTED]. Review of the facility procedure (Excerpted and adapted from' Clinical Nursing Skills and Techniques', 2010 Mosby included the following: 1. Check accuracy and completeness of each Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Check patient's name, medication name and dosage, route of administration, and time for administration. 2. Assess for any contraindications to patient's receiving medications enterally. 3. Before administration of medications, verify placement of the feeding tube. 4. Explain procedure to patient, including description of medication to be instilled into enteric tube... 6. Ensure the six rights of medication safety: right medication, right dose, right time, right route, right patient, and right documentation... 16. Check placement of feeding tube by observing gastric contents and checking pH of aspirate contents. Gastric pH should be 4 or less. 17. Check for gastric residual. a. Connect syringe to end of feeding tube, then pull back slowly to aspirated gastric contents. b. Return aspirated contents to stomach. Review of CMS form 672 dated 6/2/11 reflected a census of 35 residents. Eight (8) residents had GTs.

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals were stored in a locked compartment or remained in staff's line of vision during a medication pass on one (1) of three (3) units (3 South) by one (1) of six (6) staff (Registered Nurse (RN) A). This deficient practice could contribute to drug diversion and availability of medications for 12 residents residing on 3 south unit. Findings include: An observation on 6/1/11 at 9:20 AM revealed RN A gowned and gloved to enter an isolation room. He left Resident #2's medication on top of the computer on wheels (a locked three compartment medication distribution unit that secures resident medications) and the front drawer of the computer on wheels open while he entered the room and went behind the privacy curtain to ask the resident if he wanted his insulin. An observation on 6/1/11 at 9:35 AM revealed RN A entered the room again and identified Resident #2's identity by scanning the arm band using the portable scanner used with the computer on wheels. He could not see the computer on wheels in front of the entrance from where he was located in the resident's room. Review of the facility policy for Medication Administration revised 5/2009 reflected the following: 11. If the patient is on isolation, scan the medication outside the room. Position the cart in the doorway to provide line of sight. Scan the patient's armband. Once you leave the patient's room, wipe the scanner down with a germicidal wipe. Review of the facility matrix reflected 12 residents resided on the 3 south unit. Review of CMS form 672 dated 6/2/11 reflected a census of 35 residents.