Every finding on record at Brookshire Healthcare Center

Based on interviews and record reviews, the facility failed to ensure a copy of Resident Identifier (RI) #30's transfer notice was provided to the ombudsman as soon as practicable after RI #30 was sent to the emergency room in 11/2021 due to medical concerns. This affected one of one resident reviewed for a transfer to the hospital. Findings include: A policy related to notifying the ombudsman of resident transfers/discharges was requested from the facility. On 03/17/2022 at 3:31 PM, Employee Identifier (EI) #2, the Director of Nursing (DON), indicated there was no facility policy on notifying the ombudsman of resident transfers/discharges. A review of an Admission Record revealed RI #30 had a hospital stay from 11/20/2021 to 11/24/2021 and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a Progress Note, dated 11/20/2021 at 3:52 PM, indicated the responsible party (RP) was notified and the Certified Registered Nurse Practitioner was informed that RI #30 was not eating or drinking much and that the family was okay with RI #30 going to the hospital. The note indicated an order was received to send RI #30 to the emergency room for evaluation. In an interview on 03/17/2022 at 10:05 AM, Employee Identifier (EI) #9, Social Service Director, was asked for the ombudsman notification for the resident's transfer to the hospital in November 2021. EI #9 indicated she was unsure about who completed the ombudsman notification. In a joint interview with EI #1, the Administrator, and EI #9, on 03/17/2022 at 12:01 PM, EI #1 stated there was no ombudsman notification for RI #30's transfer to the hospital on 11/20/2022. In an interview on 03/17/2022 at 2:07 PM, EI #2, the DON, indicated the ombudsman was to be notified of discharges weekly or monthly and stated the notification should have been done within 30 days of the transfer. In an interview on 03/17/2022 at 2:42 PM, EI #1 stated he expected the ombudsman to be notified monthly and he was aware that the ombudsman was not notified about RI #30.

Based on record review and interview, the facility failed to ensure behaviors and side-effects of [CONDITION(S)] medications were monitored and documented for Resident Identifier (RI) #27, one of five residents reviewed for unnecessary medications. Findings included: A policy related to tracking the potential side effects or behaviors of residents receiving [CONDITION(S)] medications or related to unnecessary medications was requested from the facility. On 03/17/2022 at 1:14 PM, Employee Identifier (EI) #1, the Administrator, indicated he did not believe the facility had a policy and procedure. A review of RI #27's Admission Record indicated the resident was admitted on [DATE] with diagnoses which included Alzheimer's Disease, Displaced Fracture of Left Humerus, Lack of Coordination, Cognitive Communication Deficit, Difficulty Walking, Muscle Weakness, Acute Kidney Failure, Diabetes Mellitus Type 2, Mood Disorder, Major Depressive Disorder, and Anxiety. A review of RI #27's significant change Minimum Data Set (MDS), dated [DATE], revealed the resident had short and long-term memory problems and was moderately impaired in cognitive skills for daily decision-making per a staff assessment for mental status. The MDS indicated the resident rejected care on four to six days of the assessment period and had verbal behaviors (cursing/yelling/screaming) directed at others daily during the assessment period. The MDS also indicated RI #27 received antipsychotic and antidepressant medications seven out of seven days of the look-back period for the assessment. A review of RI #27's care plan, dated 05/13/2021, revealed RI #27 used antidepressant and antipsychotic medications. Interventions included to administer medication as ordered and observe for side effects and effectiveness every shift, observe/document/report any adverse reactions including unsteady gait, tardive dyskinesia, extrapyramidal symptoms (EPS), frequent falls, refusal to eat, difficulty swallowing, depression, isolation, blurred vision, diarrhea, fatigue, [CONDITION(S)], loss of appetite, weight loss, muscle cramps, vomiting, and unusual behavior symptoms. A care plan focus area, dated 05/06/2021, indicated the resident sometimes had behaviors which included screaming for help, get me out of here, and talking with family. Interventions included to give medications as ordered, offer a diversion, and engage in group activity to keep mind occupied. A review of RI #27's Order Summary Report revealed the resident was prescribed the following: - [MEDICATION(S)] 50 milligrams (mg) one tablet at bedtime for mood disorder, ordered 03/03/2022, - [MEDICATION(S)] 15 mg one tablet once a day related to mood disorder, ordered 03/03/2022, - [MEDICATION(S)] 50 mg one tablet at bedtime for Alzheimer's disease, ordered 12/26/2021. A review of the resident's Medication Administration Record (MAR) for January 2022, February 2022, and March 2022, revealed no behavioral or side effect monitoring was documented on the MARs related to [CONDITION(S)] medication administration. An interview with EI #1, the Administrator, and EI #2, the Director of Nursing (DON), on 03/15/2022 at 4:22 PM revealed the kiosk monitors in the hallways that were used by the certified nursing assistants (CNAs) for charting had been down for several months. EI #1 stated the corporate IT (information technology) department had come in and made suggestions to fix the kiosks. He stated the IT department sent the facility desktop computer monitors instead of kiosk monitors, so that further delayed the charting by the CNAs. EI #2 stated the CNAs could chart their activities of daily living (ADL) care on the nursing computers at the nurses' station but had no other way to chart their ADL care. An interview with EI #22, a CNA, on 03/16/2022 at 2:58 PM revealed CNAs told the nurse about behaviors including fighting, arguing, cursing, and physical behaviors. EI #22 stated the nurses told the CNAs about any behaviors and the abilities of the residents. She stated CNAs had no access to resident care plans. She indicated side effect monitoring was reported with behaviors, and the nurses informed the CNAs when and whom to watch for sedation, drowsiness, behavior increases, or refusal of food. She revealed she would let the nurse know about anything that was not normal for a resident. She stated behavior and side-effect monitoring were important to help residents calm down or get sent out for evaluation. She indicated the nurses documented behaviors in their notes in the residents' charts. She stated CNAs did not document behaviors anywhere. She indicated RI #27 was monitored for drowsiness and yelling and if she observed these behaviors, she would tell the nurse. An interview with EI #8, a Licensed Practical Nurse (LPN), on 03/16/2022 at 3:20 PM, revealed in the event of new behaviors, the nurses completed an SBAR (Situation, Background, Assessment, Recommendation) report, informed the physician, and documented what happened. EI #8 stated the nurses made a note of the situation and informed the physician, who could make medication changes. She indicated a physician's order for [CONDITION(S)] medications would include behavior and side effect monitoring. She stated behaviors and side-effects that were reported to them from the CNAs were documented in the (electronic) chart. She stated there were no other places behaviors would be documented. An interview with EI #21, a Registered Nurse (RN), on 03/16/22 at 3:39 PM, revealed side effect monitoring was completed for 72 hours after a new medication was ordered. She stated the nurses did not document or track side effects or behaviors of residents on [CONDITION(S)] medications after the initial 72-hour window, but she documented behaviors in her weekly notes. She stated RI #27 would yell and wander. She revealed the resident was taking a [CONDITION(S)] medication and should be monitored for behaviors and side effects, but the facility did not track behaviors or side effects. She stated she began working at the facility two weeks ago. An interview with EI #20, an LPN, on 03/17/2022 at 10:58 AM, revealed side effect monitoring was supposed to be attached to the physician orders and there should be a place to document side effects of the medication. She stated RI #27 was taking [MEDICATION(S)] for mood, [MEDICATION(S)] for Alzheimer's, and [MEDICATION(S)] as a mood stabilizer. She indicated these medications should include behavior and side effect tracking. She stated behavior and side effect tracking was important to monitor for change of condition, notify the physician of changes, and medication review. A telephone interview was conducted with EI #19, a Pharmacist, on 03/17/2022 at 1:22 PM in the presence of EI #1. EI #19 stated [CONDITION(S)] medications requiring behavior monitoring included [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)]. She stated when she reviewed behavior tracking documentation, she looked at behavior nursing notes to see if there was an increase in behaviors and in the MAR. She stated behavior monitoring and side effect tracking would be specific to the resident. She indicated each facility did side effect monitoring differently and some would just indicate monitor for changes. She indicated [CONDITION(S)] medications needed to be monitored for effectiveness and to determine if adjustments were needed. She revealed she recalled RI #27 and that the resident was taking [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] related to Depression or Dementia. She stated the behavior monitoring depended on why a medication was added; if the medication was ordered due to depression, the monitored behavior would be related to that. She stated behavior monitoring should be associated with these medications. Side effect monitoring should include falls and [CONDITION(S)]. An interview with EI #1, the Administrator, on 03/17/2022 at 1:36 PM revealed [CONDITION(S)] medications should be monitored, and side effects tracked. He stated if everything was going alright with the medication after a few weeks, daily monitoring would not be needed. He stated if something changed with the resident, it should be noted, and any developments reported to the contracted behavioral team. He stated he was not sure how the orders for side effects and behavior monitoring were received. He indicated behaviors and side-effects were communicated in writing and verbally from staff. He stated behaviors and side-effects should be included in the resident's care plan. He also indicated behaviors should be documented in the CNAs' behavior tracking or behavior notes. An interview with EI #2, the Director of Nursing, on 03/17/2022 at 2:53 PM revealed [CONDITION(S)] medications should have orders for behavior and side effect monitoring. EI #2 stated the behavior and side effect monitoring should be documented and believed the facility's MAR did not have a place to document that information.

Based on interviews and record review, the facility failed to ensure a baseline care plan was developed within 48 hours of admission for Resident Identifier (RI) #89, one of nine sampled residents reviewed for a baseline care plan. Findings include: A review of the Admission Record for RI #89 indicated the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of RI #89's Order Summary Report and Clinical Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] - Hospice services (order date of 02/17/2022) - Regular diet, dysphagia (difficulty swallowing foods) mechanical soft texture, with thin consistency liquids (start date of 02/17/2022); and - Wound care to the left hip (start date of 02/25/2022). On 3/14/2022 at 1:20 PM, RI #89's electronic medical record was reviewed. There was no baseline care plan available for review in the resident's medical record. On 03/15/2022 at 10:30 AM, an interview was conducted with EI #6, a Licensed Practical Nurse (LPN). EI #6 indicated she was the admitting nurse for RI #89 on 02/17/2022. She stated she did not start a baseline care plan. EI #6 said she did not even know how to do it, because it was not part of the admission process. On 03/15/2022 at 11:21 AM, an interview was conducted with EI #5, the Treatment Nurse. She stated EI #4, the Minimum Data Set (MDS) Coordinator, was responsible for starting the baseline care plan and the MDS Coordinator was the only one that did care plans. The care plan should have been initiated on 02/17/2022 (the date of admission) and should have included RI #89's skin/wound interventions, hospice information, and diet information. On 03/15/2022 at 12:28 PM, an interview was conducted with EI #4. She stated the initiation of the baseline care plan was a team effort and was not one certain person's responsibility. She stated RI #89 should have had a baseline care plan within 72 hours of admission. She said she had reviewed the resident's electronic medical record and was not able to locate a baseline care plan. EI #4 indicated the baseline care plan would have information such as pressure ulcers/skin conditions, hospice, and diet. On 03/17/2022 at 1:52 PM, an interview was conducted with EI #2, the Director of Nursing (DON). He stated the baseline care plan should be initiated when a resident was first admitted to the facility and could be completed by any of the licensed nurses. He stated hospice and pressure ulcers would be included in the baseline care plan. He stated his expectation was that the nurses get it done and the facility followed the rules. On 03/17/2021 at 2:52 PM, an interview was conducted with EI #1, Administrator. He stated his expectation was that the baseline care plan be completed timely, thoroughly, and in a detailed manner.

Based on record review and interviews, the facility failed to ensure comprehensive care plans were developed and implemented for Resident Identifier (RI) #89 within seven days of the completion of RI #89's admission Minimum Data Set (MDS) assessment. This affected one of 24 sampled residents for whom care plans were reviewed. Findings include: A review of the Admission Record for RI #89 indicated the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #89's admission MDS assessment was signed as completed by the Registered Nurse (RN) on 03/03/2022. On 03/14/2022 at 1:20 PM, RI #89's electronic medical record was reviewed. It was noted RI #89's comprehensive care plans were not initiated until 03/14/2022. On 03/15/2022 at 11:21 AM, an interview was completed with Employee Identifier (EI) #5, the Treatment Nurse. She stated the Minimum Data Set (MDS) Coordinator, EI #4, was responsible for initiating care plans. EI #5 confirmed RI #89's care plans were initiated on 03/14/2022. On 03/15/2022 at 12:28 PM, an interview was completed with EI #4. She stated the resident did not have comprehensive care plans until 03/14/2022. EI #4 stated the resident should have had a comprehensive care plan by 03/09/2022 (seven days after the admission MDS was completed). On 03/17/2022 at 1:52 PM, an interview was conducted with EI #2, the Director of Nursing. He stated his expectation was the facility should be following the MDS guidelines regarding comprehensive care plan completion timing. On 03/17/2021 at 2:52 PM, an interview was conducted with EI #1, the Administrator. He stated his expectation was that the comprehensive care plan be completed timely, thoroughly, and in a detailed manner.

Based on record review and interviews, the facility failed to ensure a comprehensive care plan was developed to address Resident Identifier (RI) #93's use of an antidepressant medication. This affected one of 24 sampled residents for whom care plans were reviewed. Findings include: RI #93 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #93's significant change Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 12/07/2021, indicated RI #93 received an antidepressant medication on seven out of seven days of the seven day assessment look-back period. The Care Area Assessment (CAA) Summary for this MDS assessment was signed by Employee Identifier (EI) #13, the Licensed Practical Nurse (LPN) MDS Coordinator, on 12/13/2021. The summary indicated [CONDITION(S)] drug use was a triggered care area for further assessment and was to be addressed in the care plan. A review of the Order Summary Report for active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the February and March 2022 Medication Administration Records (MARs) indicated RI #93 had received [MEDICATION(S)] daily from 02/05/2022 through the current date of 03/16/2022. A review of RI #93's current care plan, printed 03/16/2022, revealed there was no care planned focus area, goal, or interventions related to antidepressant use. In an interview on 03/17/2022 at 9:08 AM, EI #4, the Registered Nurse (RN) MDS Coordinator, confirmed there was no care plan for [MEDICATION(S)] use for RI #93. EI #4 stated there should have been a care plan for the antidepressant. In an interview on 03/17/2022 at 2:55 PM, EI #1, the Administrator, stated he expected comprehensive care plans to be completed by all team members who were responsible and completed timely and in a thorough manner. EI #1 would expect that RI #93's care plan should address their antidepressant. In an interview on 03/17/2022 at 3:22 PM, EI #2 stated his expectation was that the comprehensive care plan was done on time and that RI #93 would have a care plan for an antidepressant.

Based on observations, staff interviews, record reviews and review of the facility's policy entitled COVID-19 Education, Prevention & Response Guide, the facility failed to ensure all staff be screened for COVID-19 symptoms and/or exposures prior to entering one (1) of six (6) resident halls. This failure increased the risk of transmission of COVID-19 to residents and staff. The findings include: During the entrance conference on 01/05/21 at 8:45 AM with the Administrator and the Director of Nursing (DON), the DON stated that all staff are screened at the front entrance prior to reporting to their department for their work assignment. On 01/06/21 at 8:25 AM observations were made of staff entering the facility through the exit door off of the service hall. On 01/06/21 at 8:25 AM, Housekeeper (HSK) 3 was observed entering the facility through the exit door on the service hall. During an interview on 01/06/21 at 8:25 AM, HSK3 stated she enters the facility through the service hall exit door and walk through the service hallway to the front entrance desk to get a temperature check and to answer the screening questions before starting her daily assignment. Review of the screening log dated 01/06/21 revealed HSK3 was screened at the front entrance. During an interview on 01/06/21 at 8:27 AM, Dietary Aide (DA) 1, revealed she entered the building at 5:00 AM through the service hall exit door and walked through the facility to be screened at the North Hall nurses' station. Review of the screening log for 01/06/21 revealed DA1 had her temperature taken at the North Hall nurses' station but no screening questions were documented. During an interview on 01/06 at 8:30 AM, DA2 revealed she enters the building through the service hall exit door and walk through the facility to be screened at the North Hall nurses' station. Review of the 01/06/21 screening log verified DA2 had her temperature taken at the North Hall nurses' station, but no screening questions were documented. During an interview on 01/06/21 at 8:34 AM, DA3 revealed she enters the building through the service hall exit door and walk through the facility to be screened at the North Hall nurses' station. Review of the 01/06/21 screening log verified DA3 had her temperature taken at the North Hall nurses' station, but no screening questions were documented. During an interview on 01/06/21 at 8:36 AM, DA4 revealed she enters the building through the service hall exit door and walk through the facility to be screened at the front entrance. Review of the 01/06/21 screening log verified DA4 had her temperature taken and answered the screening questions at the front entrance. During an interview on 01/06/21 at 8:38 AM, HSK2 revealed she enters the building through the service hall exit door and walk through the facility to be screened at the front entrance. Review of the 01/06/21 screening log verified HSK2 had her temperature taken and answered the screening questions at the front entrance. During an interview on 01/06/21 at 8:40 AM, the Director of Maintenance revealed that he and his morning staff enter the building through the service hall exit door and walk through the facility to be screened at the front entrance. When asked the reason for using the service hall exit door, the Director of Maintenance stated that the front door was locked at the time he and his staff arrive in the morning. Review of the screening log for 01/06/21verified the Director of Maintenance had his temperature taken and answered the screening questions at the front entrance. During an interview on 01/06/21 at 8:44 AM, the Director of Activities revealed she enters the building through the service hall exit door and walk to be screened at the front entrance. Review of the 01/06/21 screening log verified the Director of Activities had her temperature taken and answered the screening questions at the front entrance. During an interview on 01/06/21 at 10:30 AM, the Certified Dietary Manager (CDM) stated she was aware that her staff enters the building through service hall exit door and walks to either the front entrance or to North Hall nurses' station to be screened. When asked the reason for using the service hall exit door, the CDM stated that the front door is locked at the time her morning shift comes to work. The CDM stated the second shift of dietary staff enter and are screened at the front entrance. Observations on 01/06/21 at 9:00 AM revealed the service and front entrance hallways intersected a resident hallway that housed new admissions/ readmissions under 14-day quarantine to monitor for signs and symptoms of COVID-19. It was also observed that residents in rooms 101, 102, 104, and 105 were on isolation precautions for unknown COVID status; residents in rooms [ROOM NUMBERS] were not on isolation and all resident doors on the hallway were open. Review of the facility policy, COVID-19 Education, Prevention & Response Guide, revised December 2020, revealed Guidance for Limiting the Transmission of COVID-19 1. Team Member & Essential Caregiver Testing and Screening: . Screen all healthcare professionals at the beginning of their shift utilizing the essential caregiver logs . During an interview on 01/06/21, the DON revealed she is aware that staff is entering the service hall exit door and being screened at the front desk or the North hall nurses' station. When asked the rationale for allowing early morning staff to enter through the service hall exit door and walk through the facility to a screening area, the DON stated that the decision was made because the front door is locked and unmanned at the time the dietary, housekeeping, and maintenance staff arrive for work in the morning. During an interview on 01/06/21 at 3:45 PM, the Administrator and the DON verified that the facility's county positivity rate was 18.7% and the staff was at risk of being exposed to COVID-19 while away from the facility. The Administrator and DON also acknowledged that allowing the staff to walk through the service hallway and the hallway to the North Hall nurses' station for screening increases the risk of transmission of COVID-19 to the residents and other staff.

Based on observation, interviews, record review, and review of a facility document titled, SKILL 7-1 Hand Hygiene, the facility failed to ensure a licensed nurse washed their hands after removing gloves and prior to administering Resident Identifier (RI) #10's eye drop medication. Further, the licensed nurse left RI #10's room after administering medications and returned to the medication cart without first washing hands. This affected one of two residents observed during medication administration pass receiving an eye drop medication and one of four nurses observed during medication administration pass. Findings Include: Review of a facility document titled SKILL 7-1 Hand Hygiene, undated, revealed the following: . The most important and basic technique in preventing and controlling transmission of infection is hand hygiene. 3 . a. Before and after having direct contact with patients. c. After contact with body fluids or excretions, mucous membranes . e. When moving from a contaminated body site to a clean body site during patient care . g. After removing gloves . RI #10 was admitted to the facility on [DATE] and readmitted on [DATE]. On 5/19/19 at 8:34 a.m., Employee Identifier (EI) #2, Licensed Practical Nurse (LPN), was observed administering medications to RI #10. After giving RI #10's medications by mouth, EI #2 did not wash hands prior to putting on gloves to administer RI #10's eye drops. EI #2 then left RI #10's room and returned to the medication cart to sign the medications off on the Medication Administration Record, [REDACTED] On 5/19/19 at 3:39 p.m., EI #2, LPN, was interviewed. When asked what was done after administering RI #10's medications by mouth, EI #2 said he put on gloves without washing hands. EI #2 further stated after he administered RI #10's eye drops, he removed gloves and returned to the medication cart without washing hands. When asked what should have been done, EI #2 said wash hands before putting on gloves and after removing them for infection control reasons. EI #3, the Infection Control Preventionist, was interviewed on 5/19/19 at 3:45 p.m When asked what the facility's policy was on hand hygiene during medication administration, including by mouth medications and eye drops. EI #3 said wash hands, dry hands, and put on gloves. EI #3 said if a nurse did not wash hands after removing gloves, the concern would be infection control and it could cause an infection to a resident.

Based on record review, interview and review of a policy tilted Abuse Policy the facility failed to ensure an allegation of verbal abuse was reported to the State Agency within 2 hours. This affected one of five abuse records reviewed during the survey and Resident Identifier (RI) #165 and RI #25. Findings Include: Review of a policy tilted Abuse Policy, with an effective date of (MONTH) (YEAR), documented: .Reporting . 1. Any allegation of abuse within two hours . On 5/20/19 at 12:00 p.m., the surveyor reviewed an online incident report involving an allegation of verbal abuse concerning RI #165 and RI #25. The facility became aware of the incident on 8/14/18 at 6:00 p.m. and did not report the incident until 8/15/18 at 6:18 p.m. On 5/20/19 at 12:42 p.m., an interview was completed with Employee Identifier (EI) #1, Registered Nurse (RN)/Director of Nursing (DON). EI # 1 stated the allegation of abuse concerning RI #165 and RI #25 occurred on 8/14/18 and was reported to the State Agency on 8/15/18. When asked when the allegation should have been reported to the State Agency, EI #1 stated she thought it was 24 hours, but it should have been reported within 2 hours.

Based on observation, interviews and record review the facility failed to ensure a care plan was developed for Resident Identifier (RI) #84's indwelling catheter. This deficient practice affected RI #84, one of four sampled residents with an indwelling catheter. Findings Include: RI #84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review RI #84's Admission Minimal Data Set, (MDS) with an Assessment Reference Date (ARD) of 4/28/2018 revealed RI #84 had an indwelling catheter. RI #84 was observed on 5/24/18 at 7:49 a.m. in wheelchair in hallway with foley catheter below level of bladder in a privacy bag. A review of RI #84's 2/27/2018 physician's orders [REDACTED].Foley Catheter Care every shift . A review of RI #84 's medical record revealed there was no care plan for RI #84 indwelling urinary catheter. The surveyor conducted an interview with Employee Identifier (EI) # 3, the MDS Coordinator on 5/24/18 at 2:40 p.m. The surveyor asked EI # 3's did RI #84 have a care plan for an indwelling catheter. EI # 3 replied no it was resolved by accident because she knew he had one (referring to indwelling catheter). EI # 3 was asked what was the significance of not having a care plan for an Indwelling Catheter. EI # 3 replied the care would not be given and potential infection. On 5/24/18 an interview was conducted with EI # 4 at 4:25 p.m., RN, (Registered Nurse). EI # 4 was asked if RI #84 had a care plan for an Indwelling Catheter. EI # 4 stated that RI #84 had one but it looked like it was resolved. EI # 84 was then asked what would be the significance of not having a care plan for an Indwelling Catheter. EI # 4 replied a care plan would ensure patient safety, prevent complications and infection.

Based on observation, interview, and review of facility policy the facility failed to ensure Resident Identifier (RI) #7 was provided privacy during incontinent care on 03/16/2017. This deficient practice affected RI #7, one of one resident observed during incontinent care. Findings Include: The facility's policy titled Resident's Rights and Quality of Life with an effective date of May 1, 2012 revealed: POLICY STATEMENT It is the policy . that all residents have the right to a dignified existence, self determination and communication . A resident has the right: .To personal privacy . RI #7 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 3/16/2017 at 10:02 a.m., an observation was made of incontinent care provided by Employee Identifier's (EI) #3 and #4, both Certified Nursing Assistants (CNA). The door was closed and the privacy curtain was partially pulled to conceal RI #7 but remained open at the foot of RI #7's bed. RI #7's roommate, wheeling herself in a wheelchair towards the room's door, paused at the end of RI #7's bed and looking at RI #7, whose buttocks were exposed, before leaving the room. On 3/17/2017 at 11:28 a.m., an interview was conducted with EI #2, Director of Nursing (DON). It was asked of EI #2 if a nurse should ever leave the door/curtain open providing incontinent care and EI #2 replied no.

Based on observations, a review of Potter and Perry's FUNDAMENTALS OF NURSING NINTH EDITION, and interviews the facility failed to ensure the medication (med) pass error rate was not greater than 5% (percent). A medication was omitted and a gastrostomy tube ([DEVICE]) error was made related to inadequate flushes between each medication resulting in a 7.1 percent medication error rate. This affected Resident Identifier (RI) #18, one of five residents and one of three nurses observed during med pass. Findings Include: A review of Potter and Perry's, FUNDAMENTALS OF NURSING NINTH EDITION, copyright 2017, page 624 revealed: . Medication Errors . Medication errors include . failing to administer a medication . Also, page 636 revealed: . PROCEDURAL GUIDELINES .Steps .17. Flush the tube with 15 -30 ml (Milliters) of water between each medication . RI #18 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of RI #18's March 2017 physician orders [REDACTED]. There was also an order [REDACTED]. On 3/15/2017 at 9:30 a.m., Employee Identifier (EI) #1 LPN (Licensed Practical Nurse), administered ten medications to RI #18 per [DEVICE], and one inhaled medication. EI #1 pushed each medication with the syringe and used extra water added to residual medication from each cup as a flush. EI #1 did not flush with water between each medication as ordered. On 3/16/2017 at 8:30 a.m., EI #1 was asked if the flush should contain medications. EI #1 stated, she did not think so. On 3/17/2017 at 11:28 a.m. EI #2 DON (Director of Nursing) was asked if the flush between medications should contain any medication, EI #2 responded no, just water.

Based on observation, interview and review of facility policy titled Resident's Rights and Quality of Life, the facility failed to ensure Resident Identifier (RI) #3 was not served milk in the eight ounce waxed cardboard cartons. This deficient practice affected RI #3, one of twelve sampled residents observed during meals. Findings include: The facility's policy titled Resident's Rights and Quality of Life with an effective date of May 1, 2012 revealed: POLICY STATEMENT It is the policy .that all residents have the right to a dignified existence . RI #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #3's tray card dated 3/15/2017, revealed the breakfast meal beverages were to include skim milk and juice. On 3/15/2017 at 7:38 a.m., RI #3 ate breakfast in the dining room. Juice was served in a glass and RI #3 drank all the juice. Milk was served in the paper carton with a straw. When RI #3 had not drank any of the milk from the carton, the surveyor asked if RI #3 would like a glass for the milk. RI #3 said yes. On 3/15/2017 at 8:15 a.m.,when RI #3 had finished eating all of the breakfast, the facility staff asked if RI #3 would like a glass for the milk. RI #3 said, yes. RI #3 drank half of the milk after it was poured from the carton into a clean glass. On 3/17/2017 at 10:30 a.m., EI (Employee Identifier) #5, CDM (Certified Dietary Manager) was asked how food and beverages were served on RI #3's hall. EI #5 said, cartons of milk were served. When asked why glasses were not served with milk cartons, EI #5 replied, milk had always been served in cartons. EI #3 said, the use of drinking glasses with resident's milk had not been discussed. When asked if anyone had discussed with her RI #3 wanting a glass for milk on 3/15/2017 at breakfast, EI #5 said, no one had discussed that with her and it could have been resolved.

Based on observation, interview, record review, and a review of resident's tray cards, the facility failed to honor preferences as indicated on RI (Resident Identifier) #5's tray card. This was observed on 3/15/17 and 3/16/17, two of four days of survey. This deficient practice affected RI #5, one of twelve sampled residents whose meals were observed. Findings include: RI #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #5's quarterly MDS (Minimum Data Set) with an Assessment Reference Date of 3/3/2017 revealed RI #5 was independent for meals and required only setup help. RI #5's breakfast tray cards dated 3/15/2017 and 3/16/2017, documented orange juice was a dislike. On 3/15/2017 at 8:20 a.m. RI #5 was served six ounces of orange juice on the breakfast tray. On 3/16/2017 at 8:10 a.m. RI #5 was again, served orange juice on the breakfast tray. On 3/17/2017 at 10:20 a.m. EI (Employee Identifier) #5/Certified Dietary Manager was asked what happened in regard to RI #5 receiving orange juice, which was a dislike. EI #5 replied, they messed up, and servers get confused by interruptions in the dining room. EI #5 said, she encourages the staff to read the diet cards.

Based on record review, observation, interview, and review of Potter and Perry's Nursing Standards, Physicians Orders and interviews, the facility failed to ensure Resident Indentifer (RI) #18 was allowed to rinse his/her mouth out with water after inhaling a steroid medication on 3/15/17 and failed to administer RI #18's water flushes between medications, as ordered by the physician, when administered through a gastrostomy tube ([DEVICE]) on 3/15/17. These deficient practices affected RI #18, one of five residents observed during medication administration on 3/15/17 and 3/16/17. Findings Include: A review of Potter and Perry's, FUNDAMENTALS OF NURSING NINTH EDITION, copyright 2017, Chapter 32, Medication Administration, Page 665 revealed: . CLINICAL DECISION: .corticosteroid, .rinse mouth out with water . after inhalation to reduce risk of fungal infection . Also on Page 636 revealed: .PROCEDURAL GUIDELINES .Steps .17. Flush the tube . between each medication . RI #18 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The March 2017 Physician order [REDACTED]. [MEDICATION NAME] 250-50 DISKUS 1 PUFF BY INHALATION DAILY RINSE MOUTH WITH WATER AFTER USE DO NOT SWALLOW . RI #18's Physician order [REDACTED]. FLUSH G TUBE WITH 5-10 ML (milliliters) WATER BETWEEN EACH MEDICATION On 3/15/2017 at 10:10 a.m. EI (Employee Indentifer) #1 administered 10 medications through a [DEVICE] to RI #18 without flushing between medications as ordered. EI #1 added water to each medication cup to use as a flush, however, the cups all contained residual medication. EI #1 pushed the residual medication mixed with the water into the [DEVICE] by syringe. EI #1 then administered [MEDICATION NAME] 250-50 Diskus to RI #18 without providing an opportunity for RI #18 to rinse and spit afterwards. An interview with EI #1 was completed on 3/16/2017 at 8:30 a.m. EI #1 was asked if RI #18 was allowed to rinse and spit after administration of the [MEDICATION NAME] 250-50 Inhaler. EI #1 responded, no. EI #1 stated, the potential negative outcome of not rinsing and spitting after using a steroid inhaler was mouth irritation. EI #1 was asked if the flush between medications should contain any medication. EI #1 stated I do not think so. An interview with EI #2 DON (Director of Nursing) was completed on 3/17/2017 at 11:27 a.m. EI #2 was questioned why it was important to rinse and spit after using a steroid inhaler. EI #2 responded that it could cause yeast/thrush in the mouth. EI #2 was asked if a flush for a [DEVICE] should contain any medications. EI #2 responded no, just water.

Based on observation, review of Potter and Perry's, FUNDAMENTALS OF NURSING, and interview, the facility failed to ensure RI (Resident Identifier) #18's gastrostomy tube ([DEVICE]) was flushed by a licensed nursed according to proper procedure and fluids and medications were allowed to infuse by gravity. This affected RI, #18, one of one residents observed for tube feeding during medication pass on 3/15/17. Findings include: A review of Potter and Perry's, FUNDAMENTALS OF NURSING NINTH EDITION, copyright 2017, Page 636 revealed: PROCEDURAL GUIDELINES .Steps .16. Administer medication . b. Gravity . reinsert syringe into tip of feeding tube . Pour liquid medication or dissolved mixture of crushed medicine into feeding tube .allow it to flow . freely using gravity. Do not mix medications together; administer each separately . 17. Flush tube with 15 - 30 ml (milliters) . between each medication . RI #18 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 3/15/2017 at 9:30 a.m., EI (Employee Identifier) #1 LPN (Licensed Practical Nurse) was observed pushing 30 milliliters (ml) of water to flush RI #18's tube. The tube was clogged and the flush caused ballooning of the feeding tube. EI #1 then forced water into the feeding tube with the plunger and the rest of the clog was advanced. Each medication was placed in water, drawn up into the syringe with air, and was pushed into the tube and not allowed to flow by gravity. On 3/16/2017 at 8:30 a.m., EI #1 was asked how she was trained to administer medications per [DEVICE]. EI #1 said, check placement, residual, and flush. When asked how she administered the medications to RI #18, EI #1 said, she had pushed. When asked why she pushed, EI #1 replied, she usually uses gravity but had pushed with RI #18. When asked what the potential negative outcome was of pushing medications in the [DEVICE], EI #1 replied, pressure in the abdomen. On 3/17/2017 at 11:28 a.m., EI #2 DON (Director of Nursing) was asked if it was an appropriate measure for a licensed nurse to push a flush and medications via a [DEVICE]. EI #2 stated, no it is not; it flows in by gravity. EI #2 was asked what was the potential negative outcome if medications and flushes were pushed with a syringe via feeding tube. EI #2 stated it would introduce air into the stomach, causing discomfort.

Based on observations, review of Potter and Perry's FUNDAMENTALS OF NURSING Ninth Edition and interviews, the facility failed to ensure a licensed nurse washed hands during medication (med) pass and did not place her soiled ungloved finger in a pill crush pouch to administer medications to Resident Identifier (RI) #18. This deficient practice affected RI #18, one of five residents and one of three nurses observed during med pass on 3/15/17. Findings Include: A review of Potter and Perry's, FUNDAMENTALS OF NURSING NINTH EDITION, copyright 2017, Page 458 revealed: . Hand Hygiene.hand hygiene guidelines: 1. When hands are visibly dirty . 3. If hands are not visibly soiled . use an alcohol-base, waterless antiseptic . After contact with surfaces or objects . After removing gloves . RI #18 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 3/15/2017 at 9:30 a.m., EI #1 LPN (Licensed Practical Nurse) was observed crushing each medication in crush pouches and dropped a pill on the floor. EI #1 picked the medication up from the floor, removed her gloves, retrieved a replacement pill from med cart, then disposed of the dropped pill in the sharps container. Then without washing her hands, EI #1 placed an ungloved finger into the crush pouch to open the bottom to get the residual medication out. On 3/16/2017 at 8:30 a.m., EI #1 was asked if she use hand sanitizer, washed her hands, or changed gloves after dropping the medication on the floor. EI #1 replied, I guess not. EI #1 was then asked about the negative outcome of not using hand sanitizer, washing hands or changing gloves after picking up an item from the floor, and putting a finger in a pouch of medication. EI #1 replied, the spread of bacteria and infection. On 3/17/2017 at 11:28 a.m., EI #2 DON (Director of Nursing) was asked what the potential negative outcome was for not washing hands after picking up an item off the floor and putting an ungloved finger inside a medication pouch. EI #2 replied, it could spread infection.

Based on observation, interview, and review of RI (Resident Identifier) #18's Medication Administration Record [REDACTED]. This deficient practice affected RI #18, one of five residents observed receiving medications on 3/15/17 and 3/16/17, and one of three nurses observed during medication (med) pass. Findings include: Potter and Perry, FUNDAMENTALS OF NURSING, Ninth Edition, copyright 2017, Chapter 32, Medication Administration, page 628, documented: . Right Documentation. Nurses . use accurate documentation to communicate with one another. Many Medication errors result from inaccurate documentation. Therefore always document medications accurately at the time of administration and verify any inaccurate documentation before giving medications. RI #18 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #18's Controlled Drug Record for PRN (as needed) pain medication revealed EI #1 LPN, signed the med out as being administered on 3/15/2017 at 8:00 a.m., however, it was observed EI #1 administered one tablet of [MEDICATION NAME]/ [MEDICATION NAME] 7.5 /325 milligrams (mg) at 9:30 a.m. to RI #18. On 3/17/2017 at 12:25 p.m. EI #1 was asked about the entry in the narcotic record on 3/15/2017 at 8 a.m. being signed out before entering RI #18's room. EI #1 stated, RI #18 asked for it every four hours, so she went ahead and signed it out.

Based on observation, interview, and review of the 2013 Food Code, the facility failed to ensure one of two dumpsters were completely enclosed and maintained in good condition with intact lids. This deficient practice was observed on 3/14/17 and 3/15/17, two of four days of the survey. Findings include: A review of the FDA (Food and Drug Administration) Food Code 2013, pages 167 through 170, revealed the following: . 5-5 REFUSE, RECYCLABLES, AND RETURNABLES . 5-501.13 Receptacles. (A) . receptacles and waste handling units for REFUSE, recyclables, and returnables and for use with materials containing FOOD residue shall be durable, cleanable, insect- and rodent-resistant, leakproof, and nonabsorbent . 5-501.15 Outside Receptacles. (A) Receptacles and waste handling units for REFUSE, recyclables, and returnables used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers . 5-501.111 Areas, Enclosures, and receptacles, Good Repair. Storage areas, enclosures, and receptacles for REFUSE, recyclables, and returnables shall be maintained in good repair . On 3/14/2017 at 1:55 p.m. two facility dumpsters were observed. One dumpster was open, having a collapsed lid. A rodent was observed in the dumpster area. On 3/15/2017 at 9:30 a.m. EI (Employee Identifier) #6 Maintenance Supervisor, was asked to describe the dumpster. EI #6 said, the lid was messed up and the door handle was missing, leaving a hole in the side. When asked what could be done to correct the problem, EI #6 said, he could call and have the dumpster replaced. On 3/15/2017 at 9:37 a.m., the facility dumpsters were observed. One dumpster was not in good repair, having a collapsed lid and a rusted hole in the side door.

Based on observation, interview and record review the facility failed to ensure licensed staff did not physically touch Resident Identifier (RI) #15, then proceed and administer RI#16's medication on 3/1/16 without washing her hands. This affected one of five residents for medication administration observation. Findings Include: A review of Potter and Perry's FUNDAMENTALS OF NURSING EIGHTH EDITION, Copyright 2013 Chapter 31 Medication Administration page 612 revealed: .Implementation 1. Prepare medications: a. perform hand hygiene .2 Administer medications .l. Dispose of soiled supplies and perform hand hygiene . RI #15 was readmitted to the facility on [DATE], [DIAGNOSES REDACTED]. RI # 16 was readmitted to the facility on [DATE], [DIAGNOSES REDACTED]. On 3/1/16 at 8:20 AM Employee Identifier (EI) #3 Licensed Practical Nurse was observed during medication pass to give RI #15's medication. She then sanitized her hands and started preparing RI #16's medication. RI #15 asked EI #3 to look at a dressing on the chest, EI #3 touched RI #15's clothing to view the dressing. EI #3 then got another medication cup and continued to prepared RI #16's remaining medications and went in to administer them, without sanitizing or washing her hands. On 3/1/16 at 8:45 AM an interview was conducted with EI #3, she was asked when was she supposed to sanitize her hands. EI #3 replied sanitize between each resident then after three wash hands. EI #3 was asked if she touched RI #15's clothing then prepared and gave RI #16's medication without sanitizing her hands. EI #3 replied yes. When EI #3 was asked if she should have washed or sanitized her hands between residents if there was resident contact. EI #3 replied yes. EI #3 was asked what was the potential for harm in not washing or sanitizing hands between residents. EI #3 replied cross contamination.

Based on observation, record review and interview the facility failed to ensure Employee Identifier (EI) #1 Licensed Practical Nurse followed RI #17's Physician orders [REDACTED].#1 administered RI #17's insulin by the medication label instead of following the documentation on the Medication Administration Record [REDACTED]. Findings include: Documentation from POTTER PERRY . FUNDAMENTALS OF NURSING EIGHTH EDITION .CHAPTER 31 Medication Administration page 611 .SAFETY GUIDELINES FOR NURSING SKILLS .Clarify all unclear orders and ask for help whenever you are uncertain about a medication order or calculation Resolve all your concerns related to medication administration before preparing and giving medications use technology ( .electronic MARs) that is available to you when preparing and administering medications .pg 612 .STEP RATIONALE ASSESSMENT 1. Check accuracy and completeness of each Medication Administration Record [REDACTED]. Compare name of medication on the label with the MAR (Reading labels and comparing them with the transcribed order reduces error is the first accuracy check.) RI #17 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 03/01/16, at 4:00 PM EI #1 was observed during a medication administration of insulin for RI #17. EI #1 obtained RI #17's Humalog Insulin bottle from the medication cart. The label documentation included: Humalog 100 units/ (per) ml (milliters) inject 4 units subcutaneously three times a day. EI #1 was observed to obtain 4 units in a syringe and administer 4 units of insulin to RI #17. A review on 03/01/16, at 4:10 PM of RI #17's current Physician orders, revealed an order for [REDACTED]. On 03/01/16, at 4:15 PM EI #1 was asked what dose of insulin he had given RI #17. EI #1 stated, 4 units. He was then asked to tell the surveyor what the Physician order [REDACTED].#1 replied Humalog 100 units/ml cartridge 6 units. EI #1 was asked why the dose on RI #17's bottle was different from the documented order. EI #1 stated, I do not know. EI #1 was asked what the potential for harm was if the Physician order [REDACTED]. He replied it would not be the proper dose and may not be effective and the label should have coincided with the order on the computer medication administration record. EI #1 stated the label documented 4 units and the order documented 6 units. On 03/01/16, at 5:15 PM an interview was conducted with EI #2 Director of Nursing. She was asked if she was aware RI #17's Humalog Insulin label was wrong. She replied no. EI #2 was asked who was responsible for reconciling the medication label documentation with the same dose as the Physician order. She replied the nurses. She was asked what the potential for harm was if the label documented the wrong dose. She replied the patient might not get the right dose. EI #2 reviewed RI #17's Physician orders [REDACTED].#1 had given the correct dose of insulin if he gave 4 units instead of 6 units. EI #2 stated, No. EI #2 was asked when the order was changed. She stated 12/28/2015.