Every finding on record at Baywood Court Health Center

Based on observation, interview and record review, the facility failed to store ready to eat food under sanitary conditions to prevent contamination from dust. This improper food safety practice had the potential for food contamination resulting in food-borne illnesses. Findings: On 10/8/24 at 9:25 A.M. during an initial tour of the facility kitchen with the Executive Chef (EC), there were undated, open plastic bags of various breads: 6 pieces of english muffin, 5 slices of raisin bread, 3 pieces of bagel, 10 pieces of square bread, and 7 pieces of hamburger buns. These food items were exposed to dust and possible splash contamination as they were stored on a corner counter top with binders and small kitchen appliances. During an interview with the EC, she stated the plastics bags had to be closed and the binders and small appliances should have been in a separate area. 2022 Food Code, U.S Food and Drug Administration : 3-305 Preventing contamination from premises 3-305.11 Food Storage indicated food shall be protected from contamination by storing the food: (1) In a clean, dry location (2) Where it is not exposed to splash, dust, or other contamination

Based on interview, observation, and record review, the facility failed to remove discontinued controlled substances from the Med-Cart for Resident 30. The failure to ensure the proper disposition of discontinued controlled substances had the potential for administration to the resident or drug diversion. Findings: During a concurrent observation and interview on 10/8/24 at 10:55 with LVN1 the Med Cart A had multiple controlled medication in the locked bin that had been discontinued for Resident 30. LVN1 stated they are unaware of how long the medication had been there. The controlled discontinued medications included: 1 bottle of Morphine (Schedule II narcotic under the Controlled Substance Act) 100 mg/ml, with 9.25 ml remaining in bottle, 32 tablets of 1 mg Lorazepam (Schedule IV Controlled Substance), 69 tablets of .5 mg Lorazepam. During an interview on 10/8/24 at 12:00 p.m. with Charge Nurse (CN), the CN stated that the discontinued controlled medications should have been given to Charge Nurse or Director of Nursing (DON) for destruction and the medications should not be left in the med cart. During a review of Resident's 30 Face sheet the information indicated Resident 30 was admitted to facility on 11/29/22 with multifactorial encephalopathy (damage or disease that affects the brain), and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). During a review of Resident's 30 medical record and physician's orders, Resident 30 is in Hospice care (a program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions). The Physicians orders noted Morphine 100 mg/5 injection was discontinued on 10/4/24; Lorazepam 0.5 mg was discontinued 9/14/24; and Lorazepam 1 mg was discontinued on 10/3/24. During a review of the facility's policy and procedure (P&P) titled, Medication Storage, Controlled Medication Storage dated 9/08, indicated Medications included in the state and federal Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and record keeping in the nursing care center in accordance with federal state and other applicable laws and regulations. Controlled medications remaining in the nursing care center after the order has been discontinued are retained in the nursing care center in a securely double locked area with restricted access until destroyed as outlined by state regulation.

During Observation, Interview and record review the facility failed to label multidose eye drops designed for multiple administrations for 4 out of 5 Residents. This failure had the potential for cross-contamination. Findings: During an observation on 10/8/24 at 10:55 a.m. with LVN 1, Med-Cart A contained 5 multidose eye drops for Resident 2, 7, 9, 20, and 23. (Artificial Tears, Liquid Gel Refresh, and Refresh Tears) with 4 of the 5 boxes labelled with room number only and not the Resident's name, for Residents 7, 9, 20, and 23. During an interview on 10/8/24 at 12:00 p.m. with Charge Nurse stated that multidose eye drops should have resident's full name on the box and not just the Resident's room number. Charge nurse stated this is done to prevent cross-contamination. During a review of Resident 2's Physician's Orders, dated 12/1/23, the physician ordered Carboxymethylcellulose sodium Refresh Tears (eye drops used to relieve dry, burning, irritated eyes), 1 drop to both eyes, PRN (as needed) for dry eyes. During a review of Resident 7's Physician's Orders, dated 7/3/23, the physician ordered Refresh Tears (Refresh Celluvisc, Carboxymethylcellulose sodium), one drop to each eye, twice a day, for dry eyes. During a review of Resident 9's Physician's Orders, dated 6/10/24, the physician ordered Artificial Tears (drops, gels, or ointments that can help relieve dry, irritated eyes), one drop, three times a day, PRN for dry eyes. During a review of Resident 20's Physician's Orders, dated 12/8/22, the physician ordered Artificial Tears to both eyes, twice a day, to prevent dry eyes During a review of Resident 23's Physician's Orders, dated 4/7/22, the physician ordered Artificial Tears two drops to each eye, once a day, to prevent dry eyes. During a review of the facility's policy and procedure (P&P) titled, Medications and Medication labels dated 1/23, Consultant Pharmacist Services Provider Requirements, the P&P indicated each prescription medication will be labeled to include Resident's name, Specific directions for use, including route of administration.

Based on observation, interview and record review, the facility failed to implement infection control practices for an already compromised resident (Resident 12) when oxygen and suction tubing were undated and of unknown age. This failure put Resident 12 at risk for healthcare-associated infections. Findings: During a review of Resident 12's admission record, Resident 12 was readmitted to the facility on [DATE] with a terminal diagnosis, and required suctioning and the provision of oxygen as needed. During observations on 10/8/24 at 11:05 A.M., 10/9/24 at 9:25 A.M. and 10/11/24 at 8:05 A.M., the suction tubing with a yankauer tip (a tool used to suction secretions in the mouth and throat) attached to it, and oxygen tubing at the bedside of Resident 12 did not have any dates on them. During an interview on 10/10/24 at 10:05 A.M. with Infection Preventionist (IP), IP stated the tubings needed to be dated. During a review of the facility's policy titled, Suctioning and revised August 2014, it indicated: #13. Change and date the suction and tubing every 14 days, or as needed. A review of the facility's policy titled Department (Respiratory Therapy) - Prevention of Infection dated 2001, #7 stated: Change and date the oxygen cannulae and tubing every 14 days, or as needed.

Based on observation, interview, and record review, the facility failed to ensure medications were available and given according to the physician's order; and controlled substance (drugs with high potential for abuse or addiction) medications were fully accounted, when: 1. A prescription medication for itching was not available for a resident upon request. This resulted in the resident enduring the itching unnecessarily. 2. Morphine (a potent medication for pain) was administered not administered as prescribed for Resident 2. This resulted in a medication error. 3. A random controlled medication use audit for four out of five residents (Residents 31, 50, 25, and 45) showed that medications were signed out of the Control Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but were not documented as given to the residents on the medication administration record (MAR). The failure had the potential to result in loss, misuse, and/or diversion of controlled and prescription medications. Findings: 1. During an observation and interview with licensed vocational nurse 4 (LVN 4) on 3/13/23 at 10:04 a.m., Resident 29 requested Hydroxyzine (a prescription drug used to relieve itching caused by allergic skin reactions and help control anxiety and tension) as he wanted to go to the activity room. LVN 4 stated she was unable to find the medication in the medication cart. LVN 4 informed the resident, We are going to order the pill. A review of Resident 29's clinical record indicated a physician's order, dated 2/14/23, for hydroxyzine 25 milligrams (mg, unit of measurement) 1 tablet orally three times a day as needed for itchiness. During a subsequent interview on 3/13/23 at 1:13 p.m., with LVN 4, stated she had called the pharmacy and that the pharmacy's system was down. LVN 4 stated that Resident 23 29 takes Hydroxyzine for generalized itching all over his body. During an interview on 3/13/23 at 3:56 p.m., with the Charge Nurse (CN), she stated the medication has not been brought in yet as Resident 29 's son was going to be bringing it in. During an interview on 3/13/23 at 3:57 p.m., with Resident 29, stated that he had not yet received the medication to relieve the itching and that his body was itchy all over. Resident 29 stated that he moved his body against the wheelchair to help with the itch and that his itchiness was 6-7 out of 10. During a review of facility's policy and procedure titled ORDERING AND RECEIVING NON-CONTROLLED MEDICATIONS dated 2007 it indicated, Timely delivery of new orders is required so that medication administration is not delayed. If available, the emergency kit is used when the resident needs a non-controlled medication prior to pharmacy delivery. 2. During a medication administration concurrent observation on 3/13/23 at 11:00 a.m., with LVN 2, LVN 2 was observed administering 6 medications via the resident's GJ tube (gastrostomy-jejunostomy tube -insert in the abdomen that delivers nutrition and medications directly to the stomach). Then she administered Morphine Sulfate 20 mg/milliliter (ML) by placing 0.25 mL under the resident's tongue. A review of Resident 2's clinical record indicated a physician's order, dated 11/08/22, for morphine concentrate solution: 100 mg/5 mL (20 mg/mL): amount 0.25 mL twice a day at 09:00 and 21:00 for pain. Monitor respirations. Administer by GJ tube. During a subsequent interview on 3/13/23 at 2:34 p.m., LVN 2 stated that the Physician's order indicated to give morphine via GJ tube. LVN 2 stated I made a mistake and gave it via wrong route. During a review of facility's policy and procedure titled Administering Medication, dated April 2019 it indicated, The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication, and .the individual administering the medication records in the resident's medical record .the route of administration . 3. The Controlled Drug Records (CDRs) for five (5) random residents receiving PRN (meaning as needed) controlled medications were requested for review during the survey. During a concurrent interview and record review with the Charge Nurse (CN) on 3/14/23 at 11:00 a.m., she stated any time a controlled medication was needed for a resident, the nurse would remove the medication from the medication cart, sign it out on the CDR (or the count sheet) to indicate it was removed, and document the administration on the MAR. a. Resident 31 had two (2) physician's order, dated 4/16/22, for Norco (hydrocodone -acetaminophen (a potent controlled medication for moderate to severe pain) 5-325 mg, . 1 Tablet by mouth every 6 hours as needed for Moderate Pain (4-7) (A pain scale where 0 means you have no pain; one to three means mild pain; four to seven is considered moderate pain; eight and above is severe pain.) . 2 tablets by mouth every 6 hours as needed for severe pain (8-10). During a concurrent interview and record review with the CN on 3/14/23 at 11:15 a.m., a review of Resident 31's CDR for Norco and the November 2022, December 2022, and March 2023 MARs reflected the following were removed but not documented on the MARs: - Two tablets on 11/4/22 at 6:25 a.m. - One Norco tablet on 12/11/22 at 1 a.m. - One Norco tablet on 3/3/23 at 5:30 a.m. The CN verified the findings and acknowledged 4 Norco tablets were not accounted for. b. Resident 50 had a physician's order, dated 5/9/22, for Oxycodone (a potent controlled medication for moderate to severe pain) 10 mg, 1tablets by mouth for Moderate - Severe Pain (4-10) During a concurrent interview and record review with the CN on 3/14/23 at 11:31 a.m., a review of Resident 50's CDR for Oxycodone and the May 2022 MAR reflected the nursing staff signed out Oxycodone on the CDR but did not document the respective administrations on the MAR on - One Oxycodone tablet on 5/10/22 at 9:00 a.m. - One Oxycodone tablet on 5/15/22 at 8:30 p.m. - One Oxycodone tablet on 5/16/22 at 7:42 p.m. - One Oxycodone tablet on 5/19/22 at 3:00 p.m. The CN verified this finding and acknowledged 4 Oxycodone tablets was not accounted for. CN stated nursing staff are supposed to document in the CDR and the MAR, as the physician will look in the MAR to check if a medication has been administered, not in the CDR [count sheet]. c. Resident 25 had a physician's order, dated 1/13/23, for Promethazine-codeine (a controlled medication for cough) syrup 6.25 -10 mg milligrams (mg, unit of measurement)/5 mL milliliters (mL, unit of measurement), to give 5 mL by gastric tube (a tube inserted through the belly that brings nutrition directly to the stomach) 4 times a day as needed for cough. On 3/14/23 at 11:38 a.m., a review of Resident 25's CDR for Promethazine- Codeine 5 mL 4 times a day as needed for cough and the January 2023 MAR with the CN indicated licensed nursing staff signed on the CDR - 5 mL on 1/13/23 at 2:00 p.m., - 5 mL on 1/18/23 at 9:50 p.m., - 5 mL on 1/21/23 at 9:00 p.m., - 5 mL on 1/22/23 at 9:00 p.m., - 5 mL on 1/25/23 at 9:00 p.m., but did not document on the MARs to show they were administered to the resident. The CN verified 5 missing documentations on the MAR to account for 25 mL of Promethazine - Codeine syrup. d. Resident 45 had a physician's order, dated 2/22/23, for hydrocodone - acetaminophen (a potent controlled medication for moderate to severe pain) 5-325 mg, 1.5 tablets by mouth 30-60 minutes prior to PT (Physical Therapy) for pain management. During a concurrent interview and record review with the CN on 3/14/23 at 11:44 a.m., a review of Resident 45's CDR for Hydrocodone - Acetaminophen and the February 2023 MAR reflected the nursing staff signed out two tablets on the CDR on 2/24/23 at 4:15 p.m. and documented they gave it at that time but did not document the waste of the half tablet. The CN verified this finding and acknowledged 1/2 (0.5) tablet was not accounted for. During a concurrent interview and record review with the director of nursing (DON) on 3/14/23 at 3:18 p.m., she stated when the nurse is pulling a controlled medication from the medication cart, she is to confirm the order, and then prep the medication in the MAR. As soon as the controlled medication is administered, the nurse is to sign the MAR 'as given. She stated, All medications must be documented in the MAR, if it is not documented, it is not given. During a review of facility's policy and procedure titled Administering Medication, dated April 2019 it indicated, The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones.

Based on observation, interview, and record review, the facility failed to ensure expired medications were removed, and medications were labeled and stored according to manufacturer's instructions, and medication refrigerator temperature log was complete, for one out of one medication room and two out of two medication carts, when: 1. Expired and discontinued controlled drugs were not removed from the medication carts. 2. Expired drugs were not removed from the medication room. 3. Expired drugs were not replaced or removed from the emergency Kit (eKit -a kit containing medications for emergency situations) in the medication refrigerator. 4. Medication refrigerator temperature logs were incomplete. These deficient practices had the potential for residents to receive medications with reduced potency and had the potential to result in medication errors. Findings: 1A. During an inspection of the West Wing Medication Cart with licensed vocational nurse 2 (LVN 2) on 3/13/23, at 2:34 p.m., Four expired and discontinued medications were identified in the locked compartment of the medication cart, as follows: a. a. An opened bottle containing Furosemide Oral Solution 10 mg per mL without an open date. The manufacturer's label indicated it was good for 90 days after opening. b. An opened and expired bottle containing Miacalcin (A drug used to treat bone disease in women) 200 Unit Nasal Spray without an open date. The manufacturer's label indicated it was good for 35 days after opening. c. A discontinued bubble pack containing 26 tablets of Tramadol (a potent controlled medication for moderate to severe pain) 50 mg Tablet. LVN 2 stated the medication was discontinued on 3/3/23 (2 weeks ago). d. A medicine pill bottle containing 14 tablets of Zolpidem Titrate (a drug used for temporary sleep problems in adults) 10 mg tablet for a Resident who was discharged on [DATE] (2 weeks ago). During an interview on 3/13/23 at 2:50 p.m., with LVN 2, she verified the findings above and stated she did not know how long the controlled medications were in the cart or in the Medication room and did not know who was responsible for the rotating and removing of the expired medication. LVN 2 verified the above medications were expired and/or discontinued. During an interview with the DON on 3/14/23 at 2:52 p.m., she stated the staff nurse was supposed to give expired and discontinued controlled medications to her right way. The DON verified the above bubble packs should have been removed from the medication cart to prevent loss or medication errors. During a review of the facility's policy and procedure titled Discontinued Medications, dated 10/2007, it indicated, If a prescriber discontinues a medication, the medication container is removed from the medication cart immediately. 1B. During an inspection of the South Wing Medication Cart with licensed vocational nurse 3 (LVN 3) on 3/14/23 at 10:44 a.m., five expired medications were identified in the locked compartment of the medication cart, as follows: a. An opened bottle containing Sodium Chloride (Normal Salt tablets) 1 gm tablets with an expiration date of 01/2023. b. An undated and opened bottle of Breo Ellipta (a drug to treat lung disease) 200-25 mcg (microgram, unit of measurement) inhaler without an open date. The manufacturer's label indicated, Discard 42 days after opening. c. An opened bottle of Brimonidine Tartrate Ophthalmic Solution (a drug used to treat high fluid pressure in the eye) 0.2% 10 ml bottle had an open date of 1/2023. LVN 3 stated it was good for 28 days after opening. d. An opened bottle of Latanoprost (a drug used to treat high pressure in the eye) 0.005% eye drop with a date open labeled 01/13/23. The pharmacy label indicated: Refrigerate until opened, Discard 42 days after opening. e. An unopened, undated, and un-refrigerated bottle of Latanoprost 0.005%. The pharmacy label indicated: Refrigerate until opened, Discard 42 days after opening. During an interview on 3/14/23 at 11:03 p.m., with LVN 3, she verified the above findings, and the sodium chloride tablets had expired; the brimonidine eye drops was good for 28 days after opening; and the Breo inhaler and the latanoprost eye drops should have been dated or kept in the refrigerator until opened. According to Lexi-Comp (www.lexi.com, a nationally recognized drug information resource), store unopened bottle of latanoprost solution in the refrigerator and once opened, the container may be stored at room temperature for 6 weeks (https://online.lexi.com/lco/action/doc/retrieve/docid/pated, assessed on 3/3/23). 2. During an inspection of the medication room with Licensed vocational nurse 2 (LVN 2) on 3/13/23 at 3:37 p.m., four expired medications were identified in the medication room, as follows: a. An unopened bottle containing Vitamin B-6 100 mg with an expiration date of 07/2022 b. A second unopened bottle containing Vitamin B-6 100 mg, with an expiration date of 07/2022 c. A third unopened bottle containing Vitamin B-6 100 mg, with an expiration date of 05/2022 d. An opened bottle of Aspirin 81 mg Tablet an expiration date of 01/2023. During an interview with the LVN 2 on 3/13/23 at 4:15 p.m., LVN 2 stated that she was not aware of who is responsible for the removal of expired medication from the medication cart or how often the expired medications are removed. During an interview with the Charge Nurse (CN) on 03/13/23 at 4:20 p.m., the CN verified the medications were expired and should have been removed from active stock. 3. During an inspection of the medication refrigerator at the nurse's station with the CN on 3/13/23 at 03:12 p.m., 3 expired medications were identified in the medication refrigerator as follows: a. A controlled medication E-kit (an emergency kit which contains medications for use in emergency situations) was identified with expiration date of 1/2023. Inside the E-kit were Novolog R (A rapid acting Insulin) that expired on 1/2023. The CN verified the E-kit was expired. b. A Latanoprost eye drop with an opened date of 1/1/2023. The manufacturer's label indicated, Discard 42 days after opening. c. A Miacalcin nasal spray undated with open date. The manufacturer's instructions indicated it is good for 35 days once opened. During an interview with the CN on 03/13/23 at 03:15 p.m., the CN verified the above findings and confirmed the Ekit expired on 01/2023. 4. During a concurrent record review and interview with the CN on 03/13/23 at 03:15 p.m., the temperature logs for the medication refrigerator from October 2022 to March 2023 were reviewed. The logs of December 2022 and February 2023 were identified to be incomplete. CN stated that it is the responsibility of the AM and PM shift licensed staff to check the medication refrigerator temperature and log accordingly. The CN verified that the logs did not have any entries for PM shift on December 30, 2022, AM and PM shifts on December 31, 2022, and PM shifts for February 24, 25, 26, 27 and 28, 2023. The CN stated that no documentation means the temperature check was not done. The CN stated, It's important to make sure the temp is correct, otherwise the medications will go bad. A review of the facility's policy and procedure titled EMERGENCY PHARMACY SERVICE AND EMERGENCY KITS, dated 2007, indicated, The consultant pharmacist and provider pharmacy designee checks the emergency kits monthly for expiration dating of the content. A review of the facility's policy and procedure titled Storage of Medication, dated 2007, indicated, Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stocks, disposed of according to procedures for medication disposal . and reordered from pharmacy . if a current order exists.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions when: 1. water temperature in hand washing station in the kitchen was cold. 2. two dietary staff did not cover facial hair while inside the kitchen. 3. food items in upstairs kitchen refrigerator was not labeled, undated and was stored beyond used by date. 4. food stored in upstairs freezer was not labeled and dated. 5. vegetables in downstairs walk-in refrigerator was stored beyond use by date. 6. automatic ice machine dispenser had white and yellowish build up residue. 7. automatic ice machine filter was not changed according to manufacturer's guidelines. These failures had the potential to cause food contamination and food borne illness. Findings: 1. During an initial tour of the upstairs kitchen and concurrent interview on 3/13/23, at 9:39 a.m., with MS (Maintenance Director) 1, water in hand washing sink was cold after running it for 45 seconds. MS 1 checked water temperature with a thermometer (a measuring device), water temperature reached 88.3 F (degrees Fahrenheit - temperature scale). MS 1 stated, water temperature for hand washing should be between 105 F - 120 F. During a review of facility's policy and procedure (P&P) titled, Personal Hygiene, (undated), the P&P indicated, .Hand washing ust take at least (20) seconds with hot water.All hand washing stations must have: Hot water. 2. During an observation and concurrent interview on 3/13/23, at 9:28 a.m., CK (Cook) 1 walked across the kitchen without hair protection to cover his facial hair. CK 1 stated he was in the kitchen getting supplies and ingredients, therefore, he did not need facial hair covering. A review of the United States Food and Drug Administration Food Code 2017, under section titled, Hygienic Practices, Hair Restraints, section 2-402.11 indicated, FOOD EMPLOYEES shall wear hair restrains such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; AND UNWRAPPED SINGLESERVICE and SINGLE-USE ARTICLES. During a review of facility's policy and procedure (P&P) titled, BWC Uniform Policy dated, 9/2016, the P&P indicated, .3. Hair restraints: .Food employees with high risk of contaminating exposed food must wear a hat or hair covering, a beard restraint, and clothing that covers body hair. 3. During an observation and concurrent interview on 3/13/23, at 9:53 a.m., with ECDM (Executive Chef Dietary Manager), of the upstairs kitchen, the following items were stored unlabeled and undated, as follows: 1-gallon barbecue sauce, large clear plastic squeeze bottle with solidified green content, 18-ounce jar of mint jelly. ECDM stated, green content in squeeze bottle was 4-cups herb oil that should have been labeled. ECDM further added, mint jelly should have labeled with use-by date. The following items were stored beyond use-by date, as follows: One 8.16 lbs (pound) jar of whole grain mustard labeled open 12/1/22 use-by 02/01/23, romaine lettuce in silver container covered with clear plastic wrap labeled open 3/8/23 use-by 3/10/23, small clear plastic squeeze bottle labeled burger sauce marked with preparation date 3/8/23, use-by 3/11/23, clear bin labeled red onion, marked with preparation date 3/8/23 and use-by 3/11/23. ECDM stated, burger sauce and red onion was beyond use by date and should have been removed from the refrigerator. 4. During an observation on 3/13/23, at 10:03 a.m., CK 3 was observed without hair protection to cover facial hair while cooking food. A review of the United States Food and Drug Administration Food Code 2017, under section titled, Hygienic Practices, Hair Restraints, section 2-402.11 indicated, FOOD EMPLOYEES shall wear hair restrains such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENES; AND UNWRAPPED SINGLESERVICE and SINGLE-USE ARTICLES. During a review of facility's policy and procedure (P&P) titled, BWC Uniform Policy dated, 9/2016, the P&P indicated, .3. Hair restraints: .Food employees with high risk of contaminating exposed food must wear a hat or hair covering, a beard restraint, and clothing that covers body hair. 5. During an observation and concurrent interview on 3/13/23, at 10:15 a.m., with ECDM of the upstairs freezer, the following items were stored unlabeled and undated, as follows: open clear plastic bag of cubed potatoes, open clear plastic bag of fish filets, open clear plastic bag of frozen peas, one 4-pound bag of green beans, one 3.4 frozen garden burger patties, frozen peas and carrots in a blue plastic bag, tater tots in an open light brown bag. 6. During an observation and concurrent interview on 3/13/23, at 10:35 a.m., of downstair produce refrigerator with ECDM, the following items were stored undated; petite carrots in clear plastic wrap. The following items are stored beyond use-by date; 35 wrinkled green peppers with dark black and brown spots marked received date 3/1/23. A review of facility's Produce Storage Guidelines, (undated) indicated, green peppers are stored in the refrigerator for one week. 7. During an observation and concurrent on 3/14/23, at 11:50 a.m., in the downstairs kitchen, with Dietary Supervisor (DS), the following was observed as follows: ice machine had white-yellowish build up residue above liquid reservoir and ice dispenser machine. DS wiped residue with her fingers but build up residue did not come off. Water filter attached to wall and connected to the automatic ice machine was marked 2/2/22. DS stated, date marked on the filter was the last time it was replaced. During a review of facility's planned maintenance report, dated 10/28/22, indicated the need for water filter replacement. The report also indicated, the recommendation to replace water filter was declined. During a concurrent interview and record review on 3/15/23, at 9:38 a.m., with DS, DS confirmed water filter was due to be replaced. DS stated she was not aware of who declined the recommended service filter replacement.

Based on observation, interview and record review the facility failed to ensure infection control practices were implemented when following was noted: 1. Certified Nursing Assistant (CNA) 1 did not perform hand hygiene after handling Resident 33's dirty linen, and prior to handling clean personal clothing for Resident 22. 2. CNA 3 folded Resident 50's clean personal clothing while it was in contact with their own clothing. 3. Residents 10, 19, and 2's oxygen tubing was on the floor. 4. Resident 38's urinary catheter bag and tubing were touching the floor. 5. Resident 2's feeding pump pole had visible dirt and dried matter sticking to the base. 6. Licensed Vocational Nurse (LVN) 4 did not sanitize blood pressure cuff before and after use on Resident 29. 7. LVN 2 and LVN 4 did not perform hand hygiene before and after gloves changes during medication administration for Resident 2 and Resident 29 respectively. These failures placed facility's residents at risk for healthcare-associated infections. Findings: 1. During an observation on 3/14/23, at 11:17 a.m., in the laundry department, CNA 1 carried Resident 33's soiled linen in a clear plastic bag in her left gloved hand, from Resident 33's room to the laundry room. CNA 1 entered the laundry room and placed Resident 33's soiled personal belongings into the washing machine, started the washing machine, and removed her left-hand glove. CNA 1 proceeded to fold Resident 22's clean laundry without performing hand hygiene . During a concurrent interview and record review with Infection Preventionist (IP) on 3/15/23, at 1:06 p.m., facility's Policy and Procedures (P&P) titled Departmental (Environmental Services)-Laundry and Linen dated January 2014 was reviewed. The P&P showed staff were to, wash hands after handling soiled linen and before handling clean linen. IP stated hand washing is important because laundry can be a source of infection. 2. During a concurrent interview and observation on 3/14/23, at 12:45 p.m., in the laundry room, CNA 3 folded Resident 50's clean laundry against her own clothing and placed the clothing in the Resident 50's closet located within their room. CNA 3 stated clothes should be held away from body or they'll be contaminated. During an interview on 3/14/23, at 1:17 p.m., IP stated facility staff did not wear gowns when sorting laundry. IP stated staff shouldn't put clean clothes on scrubs because staff's personal clothing was considered as contaminated. IP also stated clean clothes should be kept at least one arm's length away from body. 47382 3a. During a review of Resident 10's Face Sheet dated 3/13/23, the record indicated Resident 10 was admitted to the facility 2/23. During an observation on 3/13/23, at 11:50 a.m., Resident 10 had a red magnetic sign on the doorframe that read oxygen in use. Resident 10 was lying in her bed with glasses and a nasal cannula on. A green colored oxygen tubing dated 3/13/23, connected to the cannula tubing was coiled and lying on the floor. During an observation and interview on 3/13/23, at 1:06 p.m., IP stated facility used the green extension tubing for the residents who was were to use the bathroom. IP also stated facility kept the extended oxygen tubing on the floor only. IP then stated keeping the oxygen tubing on the floor could result in respiratory infections for Resident 10. 3b. During a review of Resident 19's Face Sheet dated 3/13/23, the record indicated Resident 19 was admitted to the facility 2/23. During an initial observation of Resident 19 on 3/13/23, at 11:42 a.m., a red magnetic sign was on the doorframe that read oxygen in use. Observed Resident 19 with a nasal cannula on and oxygen tubing dated 3/13/23 coiled on the floor. During an interview on 3/13/23, at 12:57 p.m., IP stated oxygen tubing was often made long enough for residents to be able to use the bathroom in their room and the excess tubing was coiled onto the floor. 3c. During a review of Resident 2's Face Sheet dated 3/13/23, the record indicated Resident 2 was admitted to the facility in 8/2012. During an initial observation on 3/13/23, at 12:30 p.m., observed Resident 2 lying in bed with nasal cannula on. Observed the oxygen tubing dated 3/12/23 lying on top of the base of the feeding pump pole (a portable metallic pole with a base, four wheels and feeding pump attached to it to provide liquid nutrition at a controlled rate). The feeding pump pole had pools of a tan-colored substance; visible dirt around the four bolts that held the wheels on, the center pole and over the base; and a small piece of white debris on it. During an observation and interview on 3/13/23 at 1:00 p.m., with Infection Preventionist (IP), observed the oxygen tubing on the base of Resident 2's feeding pump pole. The IP stated the feeding tube pole was dirty and used her right foot to move the tubing off the base of the pole, which fell to the floor. IP stated the risk of the tubing being on the floor was infection, such as respiratory infections and sepsis. 4. During a review of Resident Face Sheet for Resident 38 dated 3/15/23, the record showed Resident 38 was admitted to the facility 2/23 and returned on 3/23 after a hospitalization . During an observation and interview with IP on 3/13/23, at 12:57 p.m., Observed Resident 38 sitting in wheelchair their 3/4 full urinary bag touching the floor. IP stated catheter tubing should be below the bladder and not touching the floor to prevent risk of infections. During a record review of Policy and Procedure (P&P), revised September 2014 and titled Catheter Care, Urinary, the P&P showed be sure the catheter tubing and drainage bag are kept off the floor. 5. During an observation and interview on 3/13/23 at 1:00 p.m., with Infection Preventionist (IP), Observed Resident 2 receiving feeding/nutrition through a gastrostomy tube (a tube inserted through the belly that brings nutrition directly to the stomach). Observed the pump for feeding/nutrition the attached to the feeding pump pole on her right side of the bed. The feeding pump pole had pools of a tan-colored substance; visible dirt around the four bolts that held the wheels on, the center pole and over the base; and a small piece of white debris on it. IP stated the feeding tube pole was dirty. IP pushed the feeding pump pole back toward the bedside table at the head of Resident 2's bed. During an interview with IP on 3/14/23, at 10:01 a.m., IP stated she tried to clean the feeding pump pole with a sponge and paper towel. IP stated she was able to scrape off some of the residue, which she thought was formula feeding, but could not get it all so had to change the pole for Resident 2. During a follow up interview with IP on 3/16/23, at 10:28 a.m., IP stated the risk of using dirty equipment for residents could result in cross contamination. IP stated the pole was connected to Resident 2 via tubing and pathogens could travel to Resident 2 via the tubing. IP stated staff was expected to clean the equipment daily or at least every 72 hours. IP stated visible dirt and residue should be cleaned immediately. 47400 6. During an observation on 02/13/23, at 09:30 a.m., Licensed Vocational Nurse 4 (LVN 4) took the blood pressure measuring device from the medication cart to Resident 29's room, without cleaning or disinfecting LVN 4 applied the blood pressure cuff on Resident 29's left arm. LVN 4 did not disinfect the blood pressure measuring device after use and placed it on the medication cart. During an interview on 3/13/23, at 10:14 a.m., LVN 4 stated she did not wipe down the blood pressure measuring device before and after using it on Resident 29 to prevent cross contamination. During a record review of facility's Policy and Procedures titled Cleaning and Disinfection of Resident-Care Items and Equipment dated September 2022, indicated, Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected .non-critical resident-care items include bedpans, blood pressure cuffs .Reusable items are cleaned and disinfected or sterilized between residents. 7. During an observation on 3/13/23 at 10:03 a.m., after administering morning medication to Resident 29, LVN 4 was observed applying a cream on Resident 29's upper shoulder and back of the legs with gloved hands. LVN 4 then took off her gloves and put on a new pair without sanitizing her hands in between glove change. LVN 4 then administered a breathing inhaler to Resident 29 During an observation on 3/13/23, at 10:09 a.m., LVN 4 walked into Resident 29's room, put on new gloves, removed Resident 29's shirt, assessed the pain medication patch sticking on his upper back, put Resident 29's shirt back on, removed her gloves and without performing hand hygiene exited the room. During an interview on 3/13/23, at 10:15 a.m., LVN 4 stated she should have washed her hands prior to putting on new gloves and after taking off the gloves to prevent the spread of infection. During an observation on 3/13/23, at 11:01 a.m., LVN 2 prepared Resident 2's medications, walked into Resident 2's room, without performing hand hygiene put on new pair gloves, placed Resident 2's medications on the bedside table, picked up Resident 2's medications in her right gloved hand, walked into Resident 2's bathroom, and turned on the faucet with left gloved hand, filled three cups of water, came back to Resident 2, placed water and medications on the bedside table. LVN 2 then removed the gloves, without performing hand hygiene, went out of Resident 2's room, placed Resident 2's medications in the medication cart, entered Resident 38's room, grabbed gloves, put on gloves, exited Resident 38's room, took out stethoscope from a drawer in the medication cart, picked up Resident 2's originally prepared medications and went back into Resident 2's room. LVN 2 then removed the gloves, without performing hand hygiene put on new gloves and administered Resident 2's medications via Gastronomy Jejunostomy tube (a tube inserted through the belly that brings nutrition directly to the stomach) During an interview on 3/13/23 at 11:45 a.m., LVN 2 stated she should have sanitized her hands between gloves changes, after touching high touch surfaces, and prior to administering medications to Resident 2 to prevent spread of infection. During a record review of facility's Policy and Procedures titled, INFECTION CONTORL & PROCEDURE policy dated 04/2010, under section HANDWASHING/HANDHYGIENE showed Employee must wash their hands for twenty (20) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: . Before and after direct contact with residents .After removing gloves . In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations .before and after direct contact with residents, .Before preparing or handling medications; .After removing gloves; The use of gloves does not replace hand washing/hand hygiene.

Based on observation, interview and record review, the facility failed to label and provide a use by date on two of two food items kept in a refrigerator designated for food brought from outside the facility. Additionally, Facility did not ensure safe food handling practices for reheating food brought from outside the facility. These failures placed the facility residents at risk for food borne illnesses. Findings: During a concurrent observation and interview on 3/16/23, at 12:30 p.m., Certified Nurse Assistant 6 (CNA 6) reached into a 3.7 cubic foot refrigerator in the facility's conference room. CNA 6 then opened the freezer section and removed a sandwich-sized resealable unlabeled and undated plastic bag with frozen mixed vegetables. CNA 6 stated the frozen mixed vegetables were for Resident 1. CNA 6 stated facility stored residents food brought from outside the facility in that refrigerator. During a concurrent observation and interview with Charge Nurse (CN) on 3/16/23, at 1:11 p.m., following items were found in the refrigerator designated for food brought from outside the facility. 1. An undated and unlabeled 14-ounce container of [NAME] Dazs vanilla ice cream, with thick ice crystals and yellow-colored leftovers of ice cream. CN stated she could not identify if the ice cream belonged to a resident or staff. CN then threw the ice cream away in a trash bin. 2. A gallon-sized resealable storage bag that contained four portioned sandwich-sized resealable bags of frozen vegetables. CN stated the vegetables were portioned for Resident 1 and nursing staff microwaved them for her. CN wrote Resident 1's name on the storage bag. CN stated food brought from outside the facility should be labeled and kept for 72 hours in the refrigerator. CN stated she did not know when the facility received those mixed vegetables packs for Resident 1. CN stated all food from outside the facility must be labeled with the resident's name, the date and time placed in the refrigerator, and the expiration or use by date on the container. During an interview with CNA 6 on 3/16/23, at 1:40 p.m., CNA 6 stated she put the frozen mixed vegetables in a bowl, microwaved them for two minutes prior to giving it to Resident 1. CNA 6 stated she did not check the temperature before giving them to Resident 1. CNA 6 stated she did not have a thermometer available at the nursing station. During an interview on 3/16/23, at 1:49 p.m., the Director of Staff Development (DSD) stated she was responsible for ongoing training and educating the certified nursing assistants. The DSD stated she did not provide a training or in-service to the nursing staff on safe food handling practices and or reheating resident's food. During a concurrent interview and record review with Director of Nursing (DON) on 3/16/23, at 1:50 p.m., facility's Policy and Procedures (P&P) titled Foods Brought by Family/Visitors revised 2017 was reviewed. The P&P showed, All personnel involved in preparing, handling, serving or assisting the resident with meals or snacks will be trained in safe food handling practices. The P&P also showed, Containers will be labeled with the resident's name, the item and the use by date.

Based on interview and record review, for one of three residents (Resident 1) the facility failed to develop and implement a comprehensive, person-centered care plan for incontinence care based on their comprehensive assessments. This failure resulted in incontinence care not being delivered to Resident 1, which risked Resident 1 developing complications from incontinence including skin breakdown. Findings: During a review of Resident 1's medical record, the record indicated the resident was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to guide care), dated 2/24/20, the MDS indicated Resident 1 had a Brief Interview for Mental Status (BIMS, a tool used to assess mental function score of 7, meaning the resident was severely cognitively impaired. Further review of the MDS indicated Resident 1 was always incontinent of bladder and frequently incontinent of bowels. During an interview on 3/6/20, at 2:04 p.m., with Family Member 1 (FM 1), FM 1 stated she visited Resident 1 in the morning on 2/22/20 and returned later that afternoon. FM 1 stated Certified Nursing Assistant 1 (CNA 1) came into Resident 1's room at 8:00 p.m. to change Resident 1. FM 1 stated when CNA 1 changed Resident 1, Resident 1 was wet and had dried feces stuck to her skin. During an interview on 3/20/20, at 10:43 a.m., with CNA 1, CNA 1 indicated went to check on Resident 1 and changed her. CNA 1 also stated Resident 1's brief was full of dried feces, which were stuck to Resident 1's skin. During a concurrent interview and record review on 3/5/20, at 12:10 p.m., with the Director of Nursing (DON), DON stated that on 2/22/20, there was no care plan for incontinence in Resident 1's medical record. During a review of the facility's policy and procedure (P&P) titled, Bowel and Bladder, dated 9/12, the P&P indicated, It is the policy of (facility's name) that each resident who is incontinent is identified, assessed, and provided appropriate treatment and services to achieve or maintain as much normal urinary function as possible .(Upon admission the facility will) Complete a B&B (bowel and bladder) assessment .Establish a plan of care for incontinence/training (and) communicate plan to line staff.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received necessary bowel and bladder incontinence care. This failure put Resident 1 at risk for developing complications from incontinence, including skin breakdown. Findings: During a review of Resident 1's medical record, the record indicated the resident was admitted to the facility with multiple [DIAGNOSES REDACTED]. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to guide care), dated 2/24/20, the MDS indicated Resident 1 had a Brief Interview for Mental Status (BIMS, a tool used to assess mental function score of 7, meaning the resident was severely cognitively impaired. Further review of the MDS indicated Resident 1 was always incontinent of bladder and frequently incontinent of bowels. During an interview on 3/6/20, at 2:04 p.m., with Family Member 1 (FM 1), FM 1 stated she visited Resident 1 in the morning on 2/22/20 and returned later that afternoon. FM 1 stated Certified Nursing Assistant 1 (CNA 1) came into Resident 1's room at 8:00 p.m. to change Resident 1. FM 1 stated when CNA 1 changed Resident 1, Resident 1 was wet and had dried feces stuck to her skin. During an interview on 3/20/20, at 10:43 a.m., with CNA 1, CNA 1 indicated that late in the shift Certified Nursing Assistant 2 (CNA 2) asked CNA 1 to care for Resident 1, in exchange for caring for one of CNA 2's residents. CNA 1 stated CNA 2 told her that CNA 2 had not been in Resident 1's room at all during the shift because FM 1 did not like her. CNA 1 stated she went to check on Resident 1 and changed her. CNA 1 also stated Resident 1's brief was full of dried feces, which were stuck to Resident 1's skin. CNA 1 indicated it took a while to get Resident 1 cleaned up, and she reported the incident to the charge nurse. During a review of entries for Vitals Taken/Urine, Bowel Movement in Resident 1's electronic medical record, the review showed CNA 2 made an entry on 2/22/20, at 4:42 p.m., indicating Resident 1 had a small amount of urine when CNA 2 changed Resident 1's brief. Further review showed CNA 2 made an entry on 2/22/20, at 6:30 p.m., also indicating Resident 1 had a small amount of urine when CNA 2 changed Resident 1's brief. During an interview on 3/5/20, at 12:20 p.m., with CNA 2, CNA 2 stated she checked Resident 1 every two hours. CNA 2 stated she looked at the brief but did not open it. CNA 2 also stated she was not sure why she documented that she changed Resident 1's brief when she did not. During a concurrent interview and record review on 3/5/20, at 12:10 p.m., with the Director of Nursing (DON), DON stated the facility practice was to change incontinent patients every two hours, or more frequently as needed. During a review of the facility's policy and procedure (P&P) titled, Bowel and Bladder, dated 9/12, the P&P indicated, It is the policy of (facility's name) that each resident who is incontinent is identified, assessed, and provided appropriate treatment and services to achieve or maintain as much normal urinary function as possible.

Based on observation, interview, and record review, the facility failed to provide care with dignity for one of two sampled residents (Resident 21) when a Certified Nurse Assistant (CNA) did not provide privacy for Resident 21 while delivering personal care and preparing the resident for a shower. This deficient practice had the potential to affect Resident 21's sense of self-worth and self-esteem. Findings: A review of Resident 21's Face Sheet indicated Resident 21 was admitted to the facility with multiple diagnoses, including [MEDICAL CONDITION] and age-related physical debility. A review of Resident 21's Brief Interview for Mental Status (BIMS, a tool used to assess mental function) in the Minimum Data Set (MDS, an assessment tool used to guide care), dated 9/13/19, indicated the resident's score was 08, meaning Resident 21's cognitive ability was mildly impaired. Resident 21's MDS also indicated Resident 21 required extensive assistance with bed mobility, moving from one surface to another, dressing, toilet use, and personal hygiene from one or more staff members and required physical help from staff when bathing. During a concurrent observation of Resident 21 and interview with CNA 1 on 10/7/19 at 9:50 a.m., Resident 21 was laying on the bed with her lower extremities fully exposed and the window blinds and privacy curtain fully opened. CNA 1 immediately closed the blinds and privacy curtain, then stated I'm sorry, it's not supposed to be open, I'm supposed to give privacy. A review of the facility's Resident Rights Guidelines for All Nursing Procedures policy, dated 9/08, indicated that staff should either close the entrance door to the room or draw privacy curtains during treatment and personal care to provide residents privacy and dignity.

Based on observation, interview, and record review, for two of two sampled residents (Residents 29 and 10), the facility failed to place their call lights within reach. This failure had the potential for Residents 29 and 10 to not receive urgently needed medical care or assistance with their activities of daily living (ADLs). Findings: 1. A review of Resident 29's Facesheet indicated Resident 29 was admitted with multiple diagnoses, including [MEDICAL CONDITION] (paralysis of one side of the body) and [MEDICAL CONDITION] (weakness on one entire side of the body) affecting her right dominant side following a history of unspecified [MEDICAL CONDITION] disease (loss of blood flow to part of the brain). A review of Resident 29's Minimum Data Set (MDS, an assessment tool used to guide care) dated 9/16/19 indicated Resident 29 needed extensive assistance with bed mobility, moving between surfaces, dressing, toilet use, and hygiene from one or more staff members. During an observation and concurrent interview with Resident 29 on 10/7/19 at 9:08 a.m., Resident 29's call light was hanging on the left side of the bed, below the side rail. Resident 29 stated, I cannot reach my call light. I need someone to take away my tray. Resident 29 further indicated she knows how to use her call light with her right hand, but it is never in reach. During an interview with the Director of Staff Development (DSD) on 10/7/10 at 9:14 a.m. in Resident 29's room, DSD acknowledged Resident 29's call light was not in reach. A review of Resident 29's Urinary Incontinence care plan, dated 8/29/19, indicated the intervention, Call light in reach and answer promptly. A review of Resident 29's Safety care plan, dated 8/22/19, indicated the intervention, Place call light within easy reach. A review of Resident 29's Falls care plan, dated 8/20/19, indicated the intervention, Call light within reach and answer promptly. 2. A review of Resident 10's Facesheet indicated Resident 10 was admitted with multiple diagnoses, including [MEDICAL CONDITION] (a type of dementia that causes problems with memory, thinking, and behavior), history of falling, hypertension (high blood pressure), and a history of compression fracture (loss of bone mass that occurs a part of aging). A review of Resident 10's MDS dated [DATE] indicated Resident 10 needed extensive assistance with bed mobility, moving between surfaces, and toilet use from one or more staff members and was totally dependent on staff for personal hygiene activities, such as brushing her teeth and washing her face. During an observation on 10/10/19 at 8:53 a.m., Resident 10 was asleep in her wheelchair in her room. Resident 10's call light was on the floor, on the left side of her wheelchair. During an interview on 10/10/19 at 8:56 a.m., Licensed Vocational Nurse 1 (LVN 1) acknowledged the call light was not in reach and stated the call light should be on top of Resident 10's bedside table where she can press it with her palm. A review of Resident 10's Falls care plan, dated 3/13/17, indicated Resident 10 was at risk for fall and injury related to: hypertension, a history of falls, severe dementia Alzheimer's, a history of compression fractures, incontinence, use of anti-hypertensives, use of narcotics (pain relievers), and use of cathartics (laxatives). The care plan indicated the intervention for the risk of falls was to keep the Call light within reach and answer promptly. A review of the facility's Answering the Call Light policy, dated 9/08, indicated, All staff will maintain a call light within the resident's reach at all times and further indicated the purpose for this was, To respond to resident's request and needs promptly. The policy also stated, When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on interview and record review, for one of two sampled residents (Resident 35), the facility failed to develop an individualized comprehensive care plan for the use of an antidepressant (a [MEDICAL CONDITION] medication capable of affecting the mind, emotions, and behavior) to treat depression (a mood disorder characterized by a feeling of sadness and a general loss of interest in activities). This deficient practice had the potential to negatively affect the delivery of medical care and services to Resident 35. Findings: A review of Resident 35's Facesheet indicated Resident 35 was admitted to the facility with multiple diagnoses, including major [MEDICAL CONDITION]. A review of Resident 35's Brief Interview for Mental Status (BIMS, a tool used to assess mental function) in the Minimum Data Set (MDS, an assessment tool used to guide care), dated 9/12/19, indicated the resident's score was 15, meaning Resident 35's cognitive ability was fully intact. A review of the progress notes in Resident 35's medical record showed a note written on 9/18/19 at 1:52 p.m. by Registered Nurse 1 (RN 1), indicating Resident 35 had spoken to her physician, requesting an order for [REDACTED].>A review of Resident 35's physician's orders [REDACTED]. A review of Resident 35's Medication Administration History (MAH), covering the period of 9/18/19 through 10/10/19 indicated [MEDICATION NAME], 40 mg, was administered to Resident 35 every morning starting on 9/19/19. A review of Resident 35's medical record showed no comprehensive care plan developed for [MEDICATION NAME], a [MEDICAL CONDITION] medication, ordered on [DATE]. During a concurrent interview and record review with the Minimum Data Set Coordinator (MDSC) on 10/10/19 at 9:39 a.m., MDSC verified Resident 35 did not have care plan for [MEDICAL CONDITION] medication ordered on [DATE]. During an interview with the Director Of Nursing (DON) on 10/10/19 at 10:22 a.m., DON stated the care plan should be done within 48 hours after receipt of the medication order from the doctor. DON further stated Resident 35 did not have a care plan for [MEDICATION NAME] done within 48 hours per protocol. DON also stated RN 1 should have care planned the [MEDICAL CONDITION] medication ordered on [DATE] for Resident 35. During an interview with RN 1 on 10/10/19 at 10:36 a.m., RN 1 stated she received the telephone order for [MEDICATION NAME] on 9/18/19 and did not know she was supposed to create a care plan for the [MEDICAL CONDITION] medication.

Based on observation, interview, and record review, the facility failed to follow safe food storage practices when items in the refrigerators were expired, and not labeled with the name of the food item and/or a use by date. This deficient practice had the potential to place residents who recieved food items from Dietary Services at risk for food-borne illnesses. Findings: During an observation on [DATE] at 7:47 a.m. with Lead Wait Staff (LW), the refrigerator by the kitchen entrance (Fridge 1) had: 1. Prunes in a plastic container without a label stating the food item, open date, or use by date. 2. Applesauce in a metal container, covered with plastic wrap, without a label stating the food item, open date, or use by date. 3. Chopped pineapples in a metal container, covered with plastic wrap, without a label stating the food item, open date, or use by date. 4. Prunes in a metal container, covered with plastic wrap, without a label stating the food item, open date, or use by date. 5. An open bottle of Fontana Caramel sauce without a use by date labeled. During an interview on [DATE] at 7:52 a.m., LW stated, Everything should be labeled with the name and use by date. How will people know when to use it by? During an observation on [DATE] at 7:55 a.m., the refrigerator by the dried storage area (Fridge 2) had cooked macaroni in a plastic container with a use by date of ,[DATE]. During an interview on [DATE] at 7:57 a.m., Utility Worker (UW) stated Everything in the refridgerator should be labeled with a use by date. During an observation on [DATE] at 8:00 a.m., the walk in refrigerator (Fridge 3) had cooked rice pilaf in a plastic container without a use by date. During an interview on [DATE] at 11:11 a.m., the Food and Beverage Director (FBD) stated My expectations are that all food items should be labeled with a use by date. Review of the facility policy and procedure titled, Leftover Foods dated ,[DATE], showed, Leftover food are those that have been prepared for a meal and not served. The policy and procedure further showed that the storage of leftovers should be labeled and dated, and used within 72 hours. Review of the facility Policy and Procedure titled, Procedure For Refrigerated Storage dated ,[DATE], showed that Leftovers will be covered, labeled, and dated.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program to prevent the development and transmission of communicable diseases when staff provided care to Resident 148 without wearing Personal Protective Equipment (PPE- refers to protective clothing, helmets, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection). This deficient practice posed the risk for transmission of infection to other residents, staff and visitors in the facility. Findings: Review of Resident 148's facesheet on 11/20/18 indicated Resident 148 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. During a facility observation and concurrent interview on 11/20/18 at 7:20 a.m., Certified Nursing Assistants (CNA 3 and CNA 4) were observed in the room assisting Resident 148 without wearing PPE. The Director of Nursing (DON), upon observing CNA 3 and CNA 4 in Resident 148's room stated, They should wear PPE. Resident 148 is on contact precautions for MDRO. In an interview on 11/20/18 at 7:45 a.m., the Director of Staff Development (DSD) stated They know what to do, they have been here a long time. In an interview on 11/20/18 at 8:00 a.m., Certified Nursing Assistant (CNA 4) stated she was just helping pass breakfast trays, and was helping CNA 3 pull up and reposition Resident 148. CNA 4 admitted they should wear PPE during care of residents who were on contact isolation precautions. During an interview on 11/21/18 at 9:00 a.m., CNA 3 stated when Resident 148 was calling him, he was excited to go see Resident 148 and did not notice the isolation cart and sign posted by Resident 148's door. CNA 3 acknowledged he should wear PPE for all residents who were on contact isolation precautions. Review of the facility Policy and Procedure titled, Infection Control and Procedure (Transmission-Based Precautions) dated 11/11, indicated, Contact precautions; Wear gloves when entering the room, wear a gown for all interactions that may involve contact with the resident or potentially contaminated items in the resident's environment .

Based on observation, interview and record review, the facility failed to follow pharmaceutical service procedures to ensure the availability of emergency medications when the Oral E-kit ( E-kit- a set of medications reserved for emergency use) was not replaced within 72 hours after it was opened and used. This failure had the potential to result in the unavailability of medications and delayed administration of medication to the residents in an emergency. Findings: During the medication room storage observation and concurrent interview on 11/19/18 at 1:24 p.m., two E-kits had green-colored zip-tie locks on them. One gray E-kit box had a red-colored zip-tie lock on it. The Director of Staff Development (DSD) stated the green-colored zip-ties indicated the boxes have not been opened and the red-colored zip-tie indicated the E-kit had been opened. Review of the E-kit log on 11/19/18 showed the oral E-kit was opened on 11/15/18. The DSD stated the E-kit should be replaced within 72 hours after opening. The DSD further stated, It is overdue. Review of the facility Policy and Procedure titled, Emergency Pharmacy Service and Emergency Kits (E-kits), dated 2007, indicated, Upon removal of any medication or supply item from the emergency kit, the nurse documents the medication or item used on an emergency kit log. One copy of this information should ne immediately faxed to the pharmacy with the original prescriber order or refill request form and placed within the resealed emergency kit until it is scheduled for exchange

Based on interview, and record review, the facility refused to heat up food brought by the visitors of one (Resident 33) of 12 sampled residents. This deficient practice resulted in Resident 33 eating cold food. Findings: Review of the medical record showed Resident 33 was admitted to the facility on [DATE]. Further review of Resident 33's physician order, dated 6/23/18, showed Resident 33 was on a No Added Salt (NAS) regular textured diet (food is seasoned as regular food, with no salt packet on the tray, to help lower blood pressure). During an interview on 11/20/18 at 11:02 a.m., Resident 33 stated she was on a NAS diet. Resident 33 further stated her family brought her food that follows her diet, but staff had told her they cannot reheat food brought in from visitors. Resident 33 stated, I have to eat it cold. During an interview on 11/20/18 at 11:28 a.m., the Food and Beverage Director (FBD) stated There is no policy about reheating food from the outside, but we do not do it because it is a safety issue. It might be too hot for the residents. During an interview on 11/20/18 at 11:30 a.m., Dietary Manager (DM) stated the facility does not reheat outside food. DM further stated that she had suggested to Resident 33's family to only bring her cold food, or to only bring Resident 33 food during her meal times. During an interview on 11/20/18 at 2:30 p.m., the Public Health Nutrition Consultant (PHNC) stated the facility is required to heat up food brought by visitors, and it should be stated in the facility policy. During a concurrent interview, and record review of the facility admission packet, on 11/21/18 at 9:30 a.m., DM and FBD could not find any information in the admission packet stating that food brought in by visitors could not be reheated. During an interview on 11/21/18 at 9:41 a.m., FBD stated he did not want to implement a policy of heating up of food brought in by visitors, because, If I do it for one resident, I have to do it for all.

Based on interview, and record review, the facility failed to transfer one (Resident 3) of 12 sampled residents, with a two person assist. This deficient practice resulted in Resident 3 falling in the facility. Findings: Review of the medical record showed Resident 3 was admitted to the facility on [DATE]. Further review of Resident 3's last quarterly Minimum Data Set (MDS - an assessment tool used to direct health care needs), dated 8/16/18, indicated Resident 3 required a two person physical assist while transferring from bed to chair. During an interview on 11/19/18 at 9:29 a.m., Resident 3's Family Member (FM) stated Resident 3 recently had a fall. FM stated Certified Nursing Assistant (CNA 1) was attempting to transfer Resident 3 from bed to chair by herself, resulting in Resident 3 falling. During an interview on 11/19/18 at 10:59 a.m., the Director of Staff Development (DSD) stated Resident 3 required two persons to assist her with transferring from bed to chair. DSD further stated CNA 1 was by herself when the fall occurred, and was counseled immediately when the incident was reported. During an interview on 11/19/18 at 11:02 a.m., Licensed Vocational Nurse (LVN 1) stated Resident 3 needed two persons to assist in transferring Resident 3 from the bed to a chair. LVN 1 further stated Resident 3's fall was an assisted fall (staff was present to assist the ease of the resident's descent); with no injuries. During an interview on 11/19/18 at 12:47 p.m., CNA 1 stated she did not know Resident 3 required two persons in order to assist her to transfer from bed to chair; even though CNA 1 had been assigned to work with her before. CNA 1 further stated, When Resident 3 tried to get up, she tried to sit back down, and she then slid down the chair. I was able to catch her and she was assisted down.

Based on observation, interview and record review, the facility did not follow infection control practices for one of three sampled residents (Resident 1) when Resident 1's BiPAP sleep mask (bilateral positive air pressure- a non invasive air therapy for breathing problems during sleep) was not clean and ready for the next use. Licensed Vocational Nurse (LVN1) used dirty gloved hand to pick up a clean glove from a clean glove box. These had the potential to spread infection in the facility. Findings: 1. During an observation on 10/20/17 at 9:20 a.m. Resident 1's BiPAP face mask had a smear on the inside. During an interview with Licensed Vocational Nurse (LVN) 1 on 10/20/17 at 10:20 a.m., LVN 1 acknowledged Resident 1's BiPAP-face mask had a smear on the inside (indicating it had not been washed). Record review of the facility policy and procedure titled, CPAP/BIPAP, revised 10/14, indicated, Wash the mask with soap and water, rinse thoroughly and allow to air dry and then place in a clean bag. 2. On 10/20/17 at 9:25 a.m. LVN 1 was caring for Residient 1's feeding tube. LVN 1 was observed using a soiled gloved hand to pick up a clean glove from a glove box. On 10/20/17 at 10:20 a.m., Record review of the document titled, Care of a Feeding Tube, dated 7/10/17 indicated, Wash hands well, put on clean gloves, remove the soiled foam pad or gauze.

Based on observation, interview and record review the facility failed to serve hot beverages at a safe temperature, in order to prevent burns for one (Resident 1) of three Residents. This failure resulted in Resident 1 sustaining a second degree, burn (involves the first two layers of skin and may present as deep, reddening and blistering of the skin) after spilling hot tea unto her left thigh. Additionally, the facility failed to implement safety precautions after the accidental burn incident, potentially placing Resident 1 at risk for another accidental burn from hot water. Findings: On 4/29/16, the following records were reviewed: the Resident Admission Record showed Resident 1 was admitted to the facility's skilled nursing center, in 2/2012, and was over [AGE] years old. The [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, an assessment tool which guides care) showed that Resident 1 was cognitively intact with a 15 of 15 mental status score (15 represents the highest cognitive functioning). Also, Resident 1 could eat independently after tray setup help. The Facility Daily Report of New Cases of Presumed Viral Gastroenteritis, dated 4/28/16, (Viral gastroenteritis is swelling or inflammation of the stomach and intestines from a virus. The infection can lead to diarrhea and vomiting.) showed Resident 1 developed vomiting and diarrhea on 4/28/16. On 4/29/16 at 12:16 p.m., during an observation and interview, Resident 1 was sitting up in bed. When asked how she was, Resident 1 said: I was a lot better before I burned my leg with boiling water. Resident 1 related that she received hot tea with her evening meal yesterday, 4/28/16, and when she set the cup down it caught the edge of the tray and spilled onto her left thigh. There was a dressing encircling the left mid-thigh. Dark reddened skin areas were visible above and below the dressing. On 4/29/16 at 12:20 p.m., during an observation and interview, Licensed Vocational Nurse (LVN) 1 removed the dressing. There was a large, dark reddened skin area, eight inches long, beginning mid-front left thigh and ending lower inner left thigh. The burned skin, spill tract was narrow, 0.5 inches wide at the bottom and two inches at the top, and gradually widened to four inches in the center. There was a three inch diameter, fluid-filled blister at mid inner, left thigh and excoriated (skin removed as in an abrasion--second degree burns) areas around the blister. On the left antero-lateral (front and outer side) thigh there was a five inch by one to two inch pinkish area (first degree burn). LVN 1 said when she dressed the burn yesterday there was no blister. LVN 1 thought it was due to the instability of the paper trays used yesterday. Today lunch was being served on regular trays. LVN 1 said staff poured coffee and hot water into paper cups from aluminum carafes, immediately prior to delivering each tray to a resident. LVN 1 also said, This is the first wing (to be served) so very hot. On 4/29/16 at 12:40 p.m., during an observation and interview, certified nursing assistant (CNA) 2 picked up the tray of food for Resident 1 from the tray carrier and Registered Nurse (RN) 1 filled a paper cup with hot water from a carafe. RN 1 placed the hot water cup into another cup and placed it on Resident 1's tray. The cup was a regular 8 ounce, hot beverage cup, narrower at the bottom than at the top. There was no cap placed on the cup. CNA 2 delivered the tray to Resident 1 by placing it on the overbed table in front of her. RN 1 said he didn't know the temperature of the water in the carafe. Upon request RN 1 checked the temperature of a test cup of water, poured from the carafe. The temperature was 130° F. (The time for a third degree burn to occur when water temperature is 130° F is between 15 seconds and 1 minute. Moritz and Herriques. Studies of thermal injuries as referenced in the American Burn Association Scald Injury Prevention Educator's Guide 2006.) RN 1 said the residents received their food and beverages on paper plates and cups, in their rooms, to comply with the GI outbreak protocol. On 4/29/16 at 1 p.m., during an interview, Registered Dietician (RD) 1 said: We like to keep it (temperature of hot liquids) 160 - 180 °. RD 1 said the kitchen was late serving the trays today and that's why the temperature of the hot liquids dropped below 140°. RD 1 said according to the policy hot beverages should be 170-190° F in the kitchen. RD 1 further stated, We want it to be 160 - 180° when served. Rd 1 said the policy is the same for all residents housed in the facility: skilled nursing, assisted living and independent residents. Further interview on 4/29/16 at 1:10 p.m., and concurrent record review of the Meal Service policy and procedure, dated 3/13, showed the following directions: under the heading of Policy: Meals .will be served .at the appropriate temperatures. Under the heading of Procedure : .The food temperatures will be served on trayline at the recommended temperatures as below and recorded on the daily therapeutic menu in the temperature column .Food item: Soup and hot beverage-170 -190° F* .(*Soups and hot beverages being served immediately may be cooler so as to avoid temperature injury to the resident.) RD 1 said she thought the concern was that the temperature of the water was in the danger zone (below 140° F can promote bacterial growth in foods). RD 1 said she would re-evaluate the recommended beverage temperatures after hearing of Resident 1 being burned On 4/29/16 at 1:20 p.m., during an interview, RD 1 said the temperatures of beverages should be one of the items dietary staff checked and recorded on a daily basis and also during the monthly test tray evaluation by the RD. On 4/29/16 at 1:26 p.m., during interviews and concurrent record review, Dietary Aide (DA) 1 presented a binder with the daily logs of temperatures of foods served. There were no temperatures of beverages recorded. DA 1 said the kitchen only checked the foods. DA 1 said beverages were checked, prior to serving, in the skilled nursing center. Mutual review, with RD 1, of the Test Tray Evaluation monthly log, showed a space for hot beverage temperatures with an Acceptable Temp at trayline of greater than or equal to 160° F; and in the nursing unit of greater than or equal to 140° F. There were no recorded hot beverage temperatures in 2016. RD 1 said after checking with dietary and skilled nursing center staff, no one; in either the kitchen or skilled nursing center, measured and recorded hot beverage temperatures. RD 1 agreed there was no way to determine the temperature of the hot water, on 4/28/16, which caused the second degree burn to Resident 1. During a follow-up interview at 12:40 p.m., Resident 1 said usually the tea water was very hot and that today it wasn't as hot as usual. On 4/29/16, further record review of the Resident Progress Notes, dated 4/28/16 at 6:12 p.m., showed LVN 1 noted the burn to the left inner thigh, placed a petrolatum type dressing, and notified the physician and Resident 1's responsible party. Review of the Care Plan, dated 4/29/16 at 2:14 p.m., had approaches to monitor for pain and infection. The care plan included no safety measures to prevent future burns. On 4/29/16 at 2:10 p.m., during an interview, the Director of Nursing (DON) said usually staff would go over safety measures in the morning, stand-up meeting. Due to the outbreak there was no meeting today. DON said, due to the GI outbreak, residents were not eating at tables in the dining room which may have prevented the hot water spill. DON agreed there should have been some precautions taken for Resident 1 so as not to place her at risk for another burn. On 4/29/16 at 2:20 p.m., during an interview, when LVN 1 was asked what safety precautions could be implemented for Resident 1, LVN 1 said the facility had caps for the paper cups.

Based on interview and record review, the facility failed to ensure one of one sampled residents (1) was free of a significant medication error. Four licensed nurses (RN 1, RN 3, LVN 2, LVN 3) continued to give [MEDICATION NAME] 5 mg (milligrams) a day for four days after Resident 1's PT/INR indicated she was at high risk for bleeding on 9/23/13, resulting in Resident 1 experiencing black tarry stools and vomiting brownish liquid on 9/27/13, which indicated bleeding and required Resident 1 to be hospitalized for [REDACTED]. Immediate Jeopardy was called with the Administrator on 10/9/13 at 11:45 a.m. and lifted on 10/9/13 at 1:30 p.m. when the Administrator presented a plan of correction action. The plan of correction consisted of the following elements: 1. During risk meeting actual lab results will be written down rather than stating "within normal limits." 2. Make it mandatory that the nurse reads the SBAR (resident condition form) to the physician/nurse practitioner. Nurses should call 911 in an emergency and then the physician. This is mandatory for all licensed nurses. 3. Do a check and balance of physician's orders [REDACTED]. The charge nurse will be responsible for checking and the Director of Nurses will follow up to ensure that all labs are completed. On weekends the RN charge nurse is responsible. 4. Actual lab results will be recorded on the "24 hours report" under the "new orders" column. Charge nurse on night shift will make sure that this is completed on the 24 hour report. 5. A column will be added for "abnormal labs" on the 24 hour report. The charge nurse on night shift will make sure that this is completed on 24 hour report. 6. The Administrator will be responsible for all ongoing compliance during daily stand up meeting. Findings: On 10/8/13, record review showed that Resident 1, an [AGE] year old female, was admitted to the facility on [DATE] with a history of [MEDICAL CONDITION] Fibrillation (irregular heart rate which increases risk of clot development which can cause a stroke) and was recovering from a pacemaker placement (pacemaker is a small device that's placed in the chest or abdomen to control abnormal heart rhythms). One of the physician orders [REDACTED]. The order included a lab test for PT/INR on 9/23/13. A care plan titled "Potential for Bleeding" dated 9/21/12, due to [MEDICATION NAME] and Aspirin 81 mg.(milligrams) use for stroke prevention indicated the interventions included monitoring and notifying the Medical Doctor (MD) if the INR ranges were above 1.8 - 2.2 for the elderly with [MEDICAL CONDITION] Fibrillation. The [MEDICATION NAME] Time (PT) ranges were set at 1-1/2 to 2 times the control, Normal PT + 10-13 Sec. According to the Laboratory report dated 9/23/13, completed at 12:03 p.m., Resident 1' PT was 40.2 seconds H (high). According to the aforementioned care plan interventions the range should have been between 15-26 seconds. The INR was 4.07 H. Again, the care planned range was 1.8 to 2.2. During an interview at the facility on 10-9-13 at 11:45 a.m. LVN 1 stated that she received the laboratory results on 9/23/13 and NP 1 was in the facility so she handed the results to her. LVN 1 stated in another telephone interview on 10/21/13 at 1:30 p.m. that she also filled out the "Therapeutic Anti-coagulation Medication Flow Sheet" and placed it in the Medication Administration Record (MAR). She said that she endorsed this information to RN 1 who was taking over the PM shift at 3 p.m. on 9/23/13. LVN 1 stated that she told RN 1 that there were lab reports that came in and needed to be followed up with NP 1. However, she did not remember if she told RN 1 that Resident 1 had an elevated PT/INR or what the exact numbers were. A review of the "Progress Note" dated 9/23/12 and signed by NP 1 revealed her plan for Resident 1 was to "...hold [MEDICATION NAME]" and recheck (the PT/INR). The handwritten order by NP 1 dated 9/23/13 reflected, "...hold PT/INR re(check) PT/INR Wed..." PT/INR ([MEDICATION NAME] Time/International Normalized Ratio (PT/INR): [MEDICATION NAME] time (PT) is a blood test that measures how long it takes blood to clot. The order did not reflect NP 1's intention to hold [MEDICATION NAME] as indicated in her progress note. RN 1 wrote a progress note dated 9/23/13 at 11 p.m. which revealed, "Seen by NP (1) with new orders and carried out." On 10/21/13 at 1:10 p.m. during a telephone interview, RN 1 stated that the evening shift on 9/23/13 was complicated. She stated that she was in charge and had to pass medications and answer calls for the patients. She had to watch the certified nursing assistants (CNAs) and they were all busy. She worked through the registry many times and was familiar with the facility. She stated, "I saw that order and I questioned it. I said 'I'm going to call that NP. I missed it on my thoughts to call. It totally went out of my thoughts." She also stated that the day shift nurse did not endorse to her anything about the labs for Resident 1. She also denied seeing the "Therapeutic Anticoagulation Medication Flow Sheet" in the MAR. She denied knowing Resident 1 had an elevated PT/INR and she was not aware of a lab result in the record nor did she look at the lab section of Resident 1's chart while taking the order off that evening. Additionally she did not read NP 1's progress note which included the plan to hold the [MEDICATION NAME]. During a record review on 10/8/13 the MAR reflected that: RN 1 gave the [MEDICATION NAME] 5 mg. on 9/23/13 at 5 p.m; LVN 4 gave the [MEDICATION NAME] 5 mg on 9/24/13 at 5 p.m.; RN 2 gave the [MEDICATION NAME] 5 mg on 9/25/13 at 5 p.m.; RN 1 gave the [MEDICATION NAME] 5 mg on 9/26/13 at 5 p.m.; and LVN 3 gave the [MEDICATION NAME] 5 mg on 9/27/13. A review of the Therapeutic Anticoagulation Medication Flow Sheet, PT/INR/[MEDICATION NAME] sheet revealed an entry made on 9/23/13 at 3:30 pm showed INR results 4.07, PT results 40.2 Current [MEDICATION NAME] Dose 5 mg every day, date/time MD notified 9/23/13 3/30 pm. The spaces labeled "Dose Change", "Next Date PT/INR" and "Nurse's Signature" were left blank. In a telephone interview on 10/22/13 at 7:30 a.m. LVN 2 stated that on the night shift beginning on 9/23/13 and ending on 9/24/13 she checked the order left by NP 1 for Resident 1. She saw that NP 1 wrote "hold PT/INR" and thought that was what NP 1 wanted and did not question the order. She saw the Therapeutic Anticoagulation Medication Flow Sheet in the MAR but wasn't sure about it. A review of the "IDT (interdisciplinary team) Risk Meeting" record, dated 9/26/13, revealed on the back of the sheet "PT/INR ...WNL (within normal limits), MD aware). In an interview with LVN 1 on 10/9/13 at 11:45 a.m. she stated that she wrote that note on the back of the IDT Risk Meeting. She stated that RN 2 who was the Director of Nurses at the time was dictating from the chart and LVN 1 was writing down the information. She did not know where the DON was getting the information that the PT/INR was within normal limits and that the MD was aware. A review of the medical record on 10/8/13 that there were no PT/INR results from the lab tests drawn on 9/25/13, and according to LVN 1 the PT/INR was not done on 9/25/13 as ordered. According to the nurses note dated 9/27/13 at 11:00 p.m. Resident 1 did not eat dinner and wanted to go back to bed at dinner time. She took all of her medications, including the [MEDICATION NAME] 5 mg. At 6 p.m. Resident 1 started to vomit 100 milliliters of brownish liquid and had a black bowel movement. At around 10:30 p.m. Resident 1 vomited again about 300 milliliters of brownish liquid with some undigested food particles and had another black stool. The nurse notified the MD and received an order for [REDACTED]. (medication that blocks the actions of chemicals in the body that can trigger nausea and vomiting) as needed every 8 hours for 3 days and occult blood times 3. The [MEDICATION NAME] IM was given at 10:45 p.m. and the first stool sample was collected. While collecting the stool sample the nurse noted that there was blood in the stool. She notified the MD again at 11 p.m. The MD stated that she wanted to wait until the morning and see if her condition changes.LVN 3 notified the family and spoke with family member who wanted to send the resident out to the hospital "right now." Resident 1 was sent to the emergency room at 12:15 a.m. on 9/28/13. In a telephone interview on 10/8/13 at 12 noon, NP 2 stated that she was looking at her calendar and she saw her notes regarding the resident's nausea and blood in stool. She had ordered [MEDICATION NAME] and occult blood to check if there was blood in the stool. She couldn't remember how the nurse described the resident's condition or color of emesis, stool or if there was emesis. Also she did not know anything about the resident such as what medications Resident 1 was on or what her [DIAGNOSES REDACTED]. The MD for Resident 1 was present in the room during the telephone interview with NP 2 on 10/8/13 and stated that if it had been him in the situation, he would have asked the nurse what medications the resident was on and what her [DIAGNOSES REDACTED]. In a telephone interview on 10/15/13 at 9:25 a.m. LVN 3 verified the nurses notes dated 9/27/13 and stated that around 6 p.m. Resident 1 started vomiting brownish liquid and had a bowel movement which was black. She went to the MAR and noticed that the resident was on iron, which she knew could make the stool black. Then around 10:30 p.m. Resident 1 was vomiting brownish liquid with food particles and had another bowel movement which was black and paste like. She called NP 2 and told her the resident vomited twice and had black stools, and she asked NP 2 if she could do a test for blood in the stool. NP 2 ordered the [MEDICATION NAME] IM and occult blood test for the stool. LVN 3 noticed when she got the stool sample that there was blood on the diaper so she called the NP 2 back and asked "Should we send her out?" NP 2 said to LVN 3, "there's nothing we can do right now, just monitor and wait until the morning and see if her condition changes." NP 2 then advised LVN 3 that she could call the family and see what the family wanted to do. LVN 3 stated that she knew the resident was on [MEDICATION NAME], but there was no lab data available. She stated that she did not tell the NP that the resident was on [MEDICATION NAME] and, she did not ask what her [DIAGNOSES REDACTED]. A review of the emergency room record at the acute care hospital dated 9/28/13 at 12:46 am. the MP wrote "...pt (patient) brought in from SNF (facility) for n/v (nausea/vomiting) and melena (black stool) started at 6 pm earlier this evening ...Pt just has AICD (pacemaker) placed and is on [MEDICATION NAME] ...General - moaning, opens eyes to voice but unable to answer questions or follow commands, ill-appearing." She was admitted to ICU and receiving PRBCs (packed cells-blood transfusion) and FFP(fresh frozen plasma, the liquid portion of Human blood" that has been frozen and preserved after a blood donation.) as well as vitamin K (promotes clotting). The note reveals at 3:30 a.m. "...pt looks better, color better, eyes open and saying 'help me'..." A critical Care Note written on 9/28/13 revealed, "...Interventions were performed emergently to prevent sudden or life threatening deterioration." The PT and INR results taken in the emergency room were >120.0 and >19.2 respectively. Her final [DIAGNOSES REDACTED]. ________________________________________________________________ CITATION #02-1477- 85-F ********************* AMENDED ******************* THIS SECTION 1424 NOTICE HAS BEEN AMENDED. THE AMENDMENTS CAN BE FOUND IN PARAGRAPH 8, SENTENCE 1 AND PARAGRAPH 12, SENTENCES 2, 3 AND 4 BELOW. ALL OTHER ITEMS OF THE CITATION REMAIN UNCHANGED AND EFFECTIVE. **************************************************************** F333 483.25(m)(2) RESIDENTS FREE OF SIGNIFICANT MED ERRORS The facility must ensure that residents are free of any significant medication errors. This REQUIREMENT is not met as evidenced by: The facility violated the aforementioned regulation by failing to ensure one of one sampled residents (1) was free of a significant medication error. Four licensed nurses (RN 1, RN 3, LVN 2, LVN 3) continued to give [MEDICATION NAME] 5 mg (milligrams) every day for four days after Resident 1's PT/INR on 9/23/13 indicated she was at high risk for bleeding, resulting in Resident 1 experiencing black tarry stools and vomiting brownish liquid on 9/27/13. Resident 1 was bleeding and was admitted to the critical care unit at the local acute care hospital for blood [MEDICAL CONDITION]. On 10/8/13, record review showed that Resident 1, an [AGE] year old female, was admitted to the facility on [DATE] with a history of [MEDICAL CONDITION] Fibrillation (irregular heart rate which increases risk of clot development which can cause a stroke), severe [MEDICAL CONDITION], hypertension, dementia and was recovering from a pacemaker placement (pacemaker is a small device that's placed in the chest or abdomen to control abnormal heart rhythms). Review of the admission physician orders [REDACTED]. The order included a lab test for PT/INR on 9/23/13. A care plan titled "Potential for Bleeding" dated 9/21/12, due to [MEDICATION NAME] and Aspirin 81 mg.(milligrams) use for stroke prevention indicated the interventions included monitoring and notifying the Medical Doctor (MD) if the INR ranges were above 1.8 - 2.2 for the elderly with [MEDICAL CONDITION] Fibrillation. The [MEDICATION NAME] Time (PT) ranges were set at 1-1/2 to 2 times the control, Normal PT + 10-13 Sec. According to the Laboratory report, dated 9/23/13, completed at 12:03 p.m., Resident 1' PT was 40.2 seconds H (high). According to the aforementioned care plan interventions the range should have been between 15-26 seconds. The INR was 4.07 H. Again, the care planned range was 1.8 to 2.2. During an interview at the facility on 10-9-13 at 11:45 a.m. LVN 1 stated that she received the laboratory results on 9/23/13 and NP 1 was in the facility so she handed the results to her. LVN 1 stated in another telephone interview on 10/21/13 at 1:30 p.m. that she also filled out the "Therapeutic Anti-coagulation Medication Flow Sheet" and placed it in the Medication Administration Record (MAR). She said that she endorsed this information to RN 1 who was taking over the PM shift at 3 p.m. on 9/23/13. LVN 1 stated that she told RN 1 that there were lab reports that came in and needed to be followed up with NP 1. However, she did not remember if she told RN 1 that Resident 1 had an elevated PT/INR or what the exact numbers were. A review of the "Progress Note" dated 9/23/13 and signed by NP 1 revealed her plan for Resident 1 was to "...hold [MEDICATION NAME]" and recheck (the PT/INR). The handwritten order by NP 1 dated 9/23/13 reflected, "...hold PT/INR re (check) PT/INR Wed..." PT/INR ([MEDICATION NAME] Time/International Normalized Ratio (PT/INR): [MEDICATION NAME] time (PT) is a blood test that measures how long it takes blood to clot. The order did not reflect NP 1's intention to hold [MEDICATION NAME] as indicated in her progress note. RN 1 wrote a progress note dated 9/23/13 at 11 p.m. which revealed, "Seen by NP (1) with new orders and carried out." On 10/21/13 at 1:10 p.m., during a telephone interview, RN 1 stated that the evening shift on 9/23/13 was complicated. She stated that she was in charge and had to pass medications and answer calls for the patients. She had to watch the certified nursing assistants (CNAs) and they were all busy. She worked through the registry many times and was familiar with the facility. She stated, "I saw that order and I questioned it. I said "I'm going to call that NP. I missed it on my thoughts to call. It totally went out of my thoughts." She also stated that the day shift nurse did not endorse to her anything about the labs for Resident 1. She also denied seeing the "Therapeutic Anticoagulation Medication Flow Sheet" in the MAR. She denied knowing Resident 1 had an elevated PT/INR and she was not aware of a lab result in the record nor did she look at the lab section of Resident 1's chart while taking the order off that evening. Additionally she did not read NP 1's progress note which included the plan to hold the [MEDICATION NAME]. During a record review on 10/8/13 the MAR reflected that: RN 1 gave the [MEDICATION NAME] 5 mg. on 9/23/13 at 5 p.m.; LVN 4 gave the [MEDICATION NAME] 5 mg on 9/24/13 at 5 p.m.; RN 2 gave the [MEDICATION NAME] 5 mg on 9/25/13 at 5 p.m.; RN 1 gave the [MEDICATION NAME] 5 mg on 9/26/13 at 5 p.m.; and LVN 3 gave the [MEDICATION NAME] 5 mg on 9/27/13. A review of the Therapeutic Anticoagulation Medication Flow Sheet, PT/INR/[MEDICATION NAME] sheet revealed an entry made on 9/23/13 at 3:30 pm showed INR results 4.07, PT results 40.2 Current [MEDICATION NAME] Dose 5 mg every day, date/time MD notified 9/23/13 3/30 pm. The spaces labeled "Dose Change", "Next Date PT/INR" and "Nurse's Signature" was left blank. In a telephone interview on 10/22/13 at 7:30 a.m. LVN 2 stated that on the night shift beginning on 9/23/13 and ending on 9/24/13 she checked the order left by NP 1 for Resident 1. She saw that NP 1 wrote "hold PT/INR" and thought that was what NP 1 wanted and did not question the order. She saw the Therapeutic Anticoagulation Medication Flow Sheet in the MAR but wasn't sure about it. A review of the "IDT (interdisciplinary team) Risk Meeting" record, dated 9/26/13, revealed on the back of the sheet "PT/INR ...WNL (within normal limits), MD aware). In an interview with RN 4 on 10/9/13 at 11:45 a.m. she stated that she wrote that note on the back of the IDT Risk Meeting. She stated that the previous DON (Director of Nurses) was dictating from the chart and RN 4 was writing down the information. She did not know where the previous DON was getting the information that the PT/INR was within normal limits and that the MD was aware. A review of the medical record on 10/8/13 that there were no PT/INR results from the lab tests drawn on 9/25/13, and according to LVN 1 the PT/INR was not done on 9/25/13 as ordered. According to the nurses note dated 9/27/13 at 11:00 p.m. Resident 1 did not eat dinner and wanted to go back to bed at dinner time. She took all of her medications, including the [MEDICATION NAME] 5 mg. At 6 p.m. Resident 1 started to vomit 100 milliliters of brownish liquid and had a black bowel movement. At around 10:30 p.m. Resident 1 vomited again about 300 milliliters of brownish liquid with some undigested food particles and had another black stool. The nurse notified the MD and received an order for [REDACTED]. (medication that blocks the actions of chemicals in the body that can trigger nausea and vomiting) as needed every 8 hours for 3 days and occult blood times 3. The [MEDICATION NAME] IM was given at 10:45 p.m. and the first stool sample was collected. While collecting the stool sample the nurse noted that there was blood in the stool. She notified the MD again at 11 p.m. The MD stated that she wanted to wait until the morning and see if her condition changes. LVN 3 notified the family and spoke with family member who wanted to send the resident out to the hospital "right now." Resident 1 was sent to the emergency room at 12:15 a.m. on 9/28/13. In a telephone interview on 10/8/13 at 12 noon, NP 2 stated that she was looking at her calendar and she saw her notes regarding the resident's nausea and blood in stool. She had ordered [MEDICATION NAME] and occult blood to check if there was blood in the stool. She couldn't remember how the nurse described the resident's condition or color of emesis, stool or if there was emesis. Also she did not know anything about the resident such as what medications Resident 1 was on or what her [DIAGNOSES REDACTED]. The MD for Resident 1 was present in the room during the telephone interview with NP 2 on 10/8/13 and stated that if it had been him in the situation, he would have asked the nurse what medications the resident was on and what her [DIAGNOSES REDACTED]. In a telephone interview on 10/15/13 at 9:25 a.m. LVN 3 verified the nurses' notes dated 9/27/13 and stated that around 6 p.m. Resident 1 started vomiting brownish liquid and had a bowel movement which was black. She went to the MAR and noticed that the resident was on iron, which she knew could make the stool black. Then around 10:30 p.m. Resident 1 was vomiting brownish liquid with food particles and had another bowel movement which was black and paste like. She called NP 2 and told her the resident vomited twice and had black stools, and she asked NP 2 if she could do a test for blood in the stool. NP 2 ordered the [MEDICATION NAME] IM and occult blood test for the stool. LVN 3 noticed when she got the stool sample that there was blood on the diaper so she called the NP 2 back and asked "Should we send her out?" NP 2 said to LVN 3, "there's nothing we can do right now, just monitor and wait until the morning and see if her condition changes." NP 2 then advised LVN 3 that she could call the family and see what the family wanted to do. LVN 3 stated that she knew the resident was on [MEDICATION NAME], but there was no lab data available. She stated that she did not tell the NP that the resident was on [MEDICATION NAME] and, she did not ask what her [DIAGNOSES REDACTED]. A review of the emergency room record at the acute care hospital dated 9/28/13 at 12:46 am. the MP wrote "...pt. (patient) brought in from SNF (facility) for n/v (nausea/vomiting) and melena (black stool) started at 6 pm earlier this evening ...Pt. just has AICD (pacemaker) placed and is on [MEDICATION NAME] ...General - moaning, opens eyes to voice but unable to answer questions or follow commands, ill-appearing." She was admitted to ICU and receiving PRBCs (packed cells-blood transfusion) and FFP (fresh frozen plasma, the liquid portion of Human blood" that has been frozen and preserved after a blood donation.) as well as vitamin K (promotes clotting). The note reveals at 3:30 a.m. "...pt. looks better, color better; eyes open and saying 'help me'..." A critical Care Note written on 9/28/13 revealed, "...Interventions were performed emergently to prevent sudden or life threatening deterioration." The PT and INR results taken in the emergency room were >120.0 and >19.2 respectively. Her final [DIAGNOSES REDACTED]. After hospitalization and treatment, Resident 1 was discharged to another SNF and returned to theER on [DATE] for treatment of [REDACTED].

Based on interviews and record reviews, the facility failed to provide adequate assistance for one of three sampled residents, (Resident 1), to prevent a fall. Resident 1 needed the assistance of two persons, or a stand lift, (mechanical lift) when transferring from her bed to a wheelchair, according to the plan of care. As a result, Resident 1 lost her balance while being transferred with one person, and fractured her ankle, which required surgical repair. Findings: The facility reported to the Department of Public Health that Resident 1 sustained a displaced right ankle fracture when she was assisted to the bathroom by her C.N.A. (certified nursing assistant). Resident 1's record was reviewed at the facility on 8/19/13. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly assessment, dated 6/13/13, reflected that she required two plus persons to transfer her between surfaces. She was oriented to the year, month and date. She had functional limitations in range of motion on both side of her lower extremity. Review of Resident 1's care plans, date 5/3/13, showed that the facility identified that Resident 1 needed two persons to assist with her transfers. On 5/3/13, the staff included in Resident 1's Fall Care Plan, that she was to be transferred with two persons assistance or use a stand lift at all times. According to the "24 Hour Resident Skilled Care Notes" dated 8/5/13, at 3:45 p.m., the charge nurse wrote, "Notified that pt. (patient) had, "Assisted fallen" in bathroom by C.N.A. On arrival, pt. sitting supine with back leaning on toilet bowl supported with pillows. Pt. verbally expressing pain in right foot radiating to right knee... NP (nurse practitioner) able to assess pt. and requested resident be transferred to ER(emergency room )" at a local acute hospital. According to the notes, "Pt. transferred from the bathroom floor to bed using a Hoyer lift (mechanical lift) with right leg immobilized as much as possible. She was transferred to a local hospital by ambulance. Review of the acute hospital's "Discharge Summary & Transfer Instruction", dated 8/8/13, showed the result of Resident 1's right ankle X-ray on 8/5/13 as an oblique (slanted) fracture of the proximal (nearest) aspect of the right fibula (leg bone) and a severe trimalleolar (three ankle bones) fracture dislocation of the right ankle joint. The hospital discharge Summary, dated 8/8/13, included a report called, 'Treatment Rendered & Hospital Course'. It reflected that "Patient was admitted in the hospital for ankle fracture after a fall... ORIF (Open Reduction Internal Fixation- surgical procedure used to treatment a bad fracture) was performed." Review of C.N.A. 1's employee file showed she was hired to work at the facility on 1/16/13. The review showed that on 5/13/13, C.N.A. 1 was given a verbal counseling for failing to ensure the alarm was on a resident whom the facility identified as high risk for falls, and that this incident contributed to a resident's fall. The record review showed that on 8/5/13, C.N.A. 1 was counseled for failure to follow instructions on a resident's safe transferring and handling, which caused the resident (1) to sustain a right knee pain and a right ankle fracture. C.N.A. 1 was given a "Safe resident transfer and handling" in-service on 5/29/13. C.N.A. 1 was terminated from the facility after the incident with Resident 1 on 8/5/13. On 8/19/13 at 2:00 p.m., during an interview with Resident 1 she described what happened in the bathroom on 8/5/13, "The girl (C.N.A. 1) tried to pick me up but she couldn't, because I'm heavy. Usually there is two nurses to help me transfer. But this girl always transfer me herself. I was frighten. My ankle was bending over. It was painful. I'm still in pain. Thank God for pain pill. I broke my right ankle. They get me up with a Hoyer lift now. I feel safe." During a telephone interview with C.N.A. 1 on 8/20/13, at 9:30 a.m., she said. "It was 3:20 p.m.. She (Resident 1) said she wanted to go to the bathroom. When she finished using the bathroom, she stood up with her hands on the bar. I was cleaning her while she was standing up holding the bar in the bathroom. Then she said, "My legs. I can't stand up." I tried to get the wheelchair and tried to put it back of her, but she was too low to the floor. I was calling help, but no one came for one to two minutes. The front desk nurse came and help me. I always transfer her by myself. They didn't tell me she was a two person transfer. But everybody is so busy. No one has time to help you transfer the residents." The charge nurse was interviewed on 8/20/13 at 2:10 p.m.. He stated, "Resident 1 requires two person assist with transferring, and the C.N.A. (1) was informed during the shift report."