Every finding on record at Campion Health & Wellness, Inc

Based on observation and interview, the facility failed to properly store food items to prevent the risk of foodborne illness. Findings include: During the initial walk through of the kitchen on 4/11/23 at 7:14 A.M., the following observations were made: *An unlabeled container of a brown filling was observed with a date of 3/29 written on it in the walk-in refrigerator. *Two unlabeled containers resembling fruit cocktail with a date of 3/25 in the reach-in refrigerator. The Food Service Director (FSD) said that it was canned fruit cocktail put in a different container. *An unlabeled pan resembling pudding with no date written on it in the walk-in refrigerator. The FSD said it was tapioca pudding. During an interview on 4/11/23 at 7:22 A.M., the FSD said since the food items came from a can, they can be stored much longer than other food items even though they have been removed from the can. During an interview on 4/12/23 at 11:14 A.M. with the Registered Dietitian (RD) and FSD, the RD said she is not comfortable storing cooked food or opened food containers for more than 4 days. The FSD also said opened foods should not be stored for longer than 4 days. The RD and FSD both said the outdated food should have been thrown away. The RD continued to say that nursing and other staff members have been confused with the labeling and dating of food on the resident units. During the follow up visit to the kitchen on 4/12/23 at 11:42 A.M., the surveyor made the following observations: * An unlabeled container resembling fruit cocktail with a date of 3/25 in the reach in refrigerator.

Based on observation, record review and interview the facility failed to ensure services were provided for an external urinary catheter according to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of facility's policy titled, Care of Catheters and Drainage Bags, not dated, indicated the following: -Objective: to decrease growth of microorganisms while allowing increased resident mobility, comfort, and dignity. -Drainage bags should be replaced weekly or whenever there is a concern regarding proper completion of cleansing procedures. -Bags must be dated when changed. -Place drainage bag in plastic bag in bedside cabinet next to bed pan. Be sure plastic bag is labeled with resident's name and date. Resident #20 was admitted to the facility in March of 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set assessment dated [DATE] indicated that Resident #20 was cognitively intact and required extensive assistance from staff for bathing and dressing. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -To change drainage bag weekly, every evening shift, every 14 days for infection control with a start date of 11/23/21. During an interview on 1/19/22 at 8:30 A.M., the surveyors observed Resident #20 sitting up in his/her recliner, with his/her catheter drainage bag and tubing clipped to a rubbish bin with rubbish inside of it. The drainage bag was dated 12/31/21. Resident #20 said that he/she had the catheter for about a month and that the staff take care of it. Further interview with Resident #20 on 1/19/22 at 11:31 A.M., Resident #20 said that he/she only uses the catheter at night. The drainage bag was observed hanging on a towel rack in the resident's bathroom, the drainage bag was dated 12/31/21. On 1/20/22 at 7:45 A.M., the surveyors entered Resident # 20's room and observed the catheter drainage bag hanging on rubbish bin, dated 12/31/22. The drainage bag had not been changed for 20 days. During an interview on 1/20/22 at 10:09 A.M., Nurse #1 said that the drainage bag should be replaced every other week.

Based on interview and record review, the facility failed to address a significant weight loss, for 1 Resident (#8) out of a total sample of 12 residents, until 15 days after the weight loss was identified. Findings include: Review of the facility policy, titled Policy on Weight Monitoring, dated 12/28/21, indicated the following: To ensure nutritional and clinical standards are met, it is the policy of [NAME] Health & Wellness to obtain an accurate weight upon admission, readmission, and continue to be monitored weekly or by MD order throughout the stay in the facility. Procedure *Weekly weights are to be taken by CNA (certified nursing aide) and documented on weekly weight sheets, unless otherwise specified by MD, or per resident choice/ healthcare proxy. *The Dietitian will review weekly weight sheets, document weight in EMR (electronic medical record) and follow up if weight discrepancies are identified to be increased or decreased by 3 pounds or more from prior weekly weight. Confirmed significant weight changes are to be discussed at At Risk Meeting. Resident #8 was admitted in 11/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #8 scored a 15 out of 15 on the Brief Interview for Mental Status, which indicates intact cognition. Review of Resident #8 ' s care plan indicated the following: Focus: Potential nutrition problem on therapeutic diet Interventions: Provide and serve diet as ordered. Monitor intake and record each meal. (initiated 11/15/2021) Provide and serve supplements as ordered: monitor and record amount of supplement consumed (initiated 11/15/2021) Review of the Weight Record indicated the following: 11/3/2021 : 192.8 lbs (pounds) 11/29/2021: 187 lbs 12/2/21: 181.6 lbs 12/10/21: 177.8 lbs 12/15/21: 176.4 lbs 12/19/21: 176 lbs 12/22/21: 176.4 lbs Review of the Weight Record indicated that Resident #8 had a significant weight loss, 5.8 % loss, from 11/3/21 to 12/2/21 from 192.8 lbs to 181.6 lbs. Resident #8 had a further weight loss of 3.8 lbs from 12/2/21 to 12/10/21. Review of the Nutrition note, dated 12/17/21, 15 days after the initial significant weight loss was identified, indicated that Resident #8 was already receiving Super Cereal (a high calorie cereal to promote weight gain) and Ensure (a nutritional supplement). The Nutrition note indicated the following: Ongoing interventions include to Administer 8 oz Ensure if PO (by mouth) intake is less than 50% Daily weight monitoring NAS, Mechanically altered diet Super cereal with breakfast Updated interventions include that Resident #8 will now request ground meat when needed in the main dining room when soft entrees are not available. New monitoring and evaluation includes weekly meal rounds by Dietitian in addition to weekly weight review. During an interview on 1/20/22 at 9:32 A.M., the Dietitian said that she had recently started on 11/29/21 and was out on vacation and then was out sick for a few weeks since starting. The Dietitian said that in her absence the nurses should notify the doctor of any weight changes to be addressed.

Based on observation, record review and interview the facility failed to adhere to infection control practices for the care of a urinary catheter for 1 Resident (#20), out of a total sample of 12 residents. Findings include: Review of facility policy titled, Care of Catheters and Drainage Bags, not dated, indicated the following: -Objective: to decrease growth of microorganisms while allowing increased resident mobility, comfort, and dignity. -Replace cap on connection tip and place in plastic bag in bedside cabinet next to bedpan. -Be sure bag is labeled with resident's name and the date. Resident #20 was admitted to the facility in March of 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set assessment dated [DATE] indicated that Resident #20 was cognitively intact and required extensive assistance from staff for bathing and dressing. During an interview on 1/19/22 at 8:30 A.M., the surveyors observed Resident #20 sitting up in his/her recliner, with a catheter drainage bag dated 12/31/21 hanging on, and in contact with a rubbish bin with rubbish inside of it. Resident #20 said that he/she had had the catheter for about a month and that his/her nurse's aides help him/her with its maintenance. On 1/20/22 at 7:45 A.M., the surveyors entered Resident #20's room, the urinary catheter drainage bag, dated 12/31/21 was hanging and in direct contact with the rubbish bin which had trash in it. The surveyors entered Resident #20's room on 1/19/22 at 11:31 A.M. Resident #20 said that he/she only uses the catheter at night. The drainage bag was observed hanging on a bar and touching towels also hanging on the bar in Resident #20's bathroom. A paper towel was resting on top of the catheter tubing. The urinary drainage bag was not in a bag. On 1/20/22 at 9:32 A.M. the surveyors observed the catheter drainage bag dated 12/31/21 in Resident #20's bathroom, hanging from the towel bar and in direct contact with towels. The drainage bag was not bagged. During an interview on 1/20/22 at 10:09 A.M., Nurse #1 said the catheter drainage bag should be replaced every other week and that the CNA's clean and hang the drainage bag on the bar in the bathroom during the day. Nurse #1 said the tubing on the draining bag should be capped. The surveyors and Nurse #1 entered Resident #20's bathroom and observed that the catheter tube was not capped. During further interview with Nurse #1 she said the drainage bag should be placed on the walker next to Resident #20's recliner as the Resident prefers to sleep in the recliner at night. Nurse #1 said that she has seen it hung on the rubbish bin, but it should be on the walker. Nurse #1 and Nurse #2 said they were unaware of the facility policy to ensure that the drainage bag is placed in a plastic bag, labeled with resident's name and date when not in use.

Based on observations, interviews and facility policy review, the facility failed to implement infection control procedures to properly prevent the spread of COVID-19 by 1) failing to perform hand hygiene when indicated and by 2) failing to doff (take off) personal protective equipment (PPE) and by failing to perform hand hygiene when indicated on 1 of 2 resident units. Findings include: Review of the Centers for Disease Control and Prevention guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated, December 18, 2020 indicated the following: *HCP should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing personal protective equipment (PPE), including gloves. Hand hygiene after removing PPE and before and is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. *Put on clean, non-sterile gloves upon entry into the patient room or care area. *Remove and discard gloves before leaving the patient room or care area, and immediately perform hand hygiene. *Gowns: Put on a clean isolation gown upon entry into the patient room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. Disposable gowns should be discarded after use Review of the facility policy titled Coronavirus Disease 2019, updated December 2020, indicated the following: *Perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. *Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. *Remove and discard gloves when leaving the patient room or care area, and immediately perform hand hygiene. Review of the facility policy titled Coronavirus Disease 2019-Housekeeping Procedures, updated March 2020, indicated the following: *Don proper PPE: Gown, gloves, and mask. PPE should always include proper attire. PPE is not to be worn outside the room. PPE should be discarded, and associate should perform hand hygiene with soap and water if there is a need to leave the room for any reason. *Perform hand hygiene prior to entering the room, when removing PPE, and as required per policy. 1) On 12/14/20, at 9:00 A.M., on the first floor, (a unit with one positive COVID-19 resident and all other negative residents) the surveyor observed Certified Nurse's Aide (CNA) #1 walk out of a resident's room with her gloves still on, and then remove one glove in the hallway. The surveyor was standing with the Director of Nursing at this time, who also witnessed CNA #1 walk out of the room with her gloves on. The Director of Nursing stopped CNA #1 in the hall and asked her to wash her hands. During an interview on 12/14/20, at 9:02 A.M., the Director of Nursing said that the staff are supposed to remove their gloves and perform hand hygiene prior to leaving the room. During an interview on 12/14/20, at 9:04 A.M., CNA #1 said that she should have taken her gloves off in the room and performed hand hygiene before exiting. 2) On 12/14/20, at 9:06 A.M., on the first floor, (a unit with one positive COVID-19 resident and all other negative residents) the surveyor observed Housekeeper #1 in the COVID-19 positive Resident's room cleaning with full PPE on. A few minutes later, the surveyor observed Housekeeper #1 exit the COVID-19 positive Resident's room still wearing full PPE and carrying a bag of trash. The surveyor then observed Housekeeper #1 touch the door handle with her gloved hand and then close the Resident's door, Housekeeper #1 proceeded to walk down the hallway in the same PPE she had on in the COVID-19 positive Resident's room and then opened the dirty utility room door with her gloved hand. During an interview on 12/14/20, at 9:08 A.M., the Director of Nursing said that the housekeeping staff are supposed to remove their PPE and perform hand hygiene prior to leaving the room. During an interview on 12/14/20, at 9:09 A.M., the Housekeeping Supervisor said that she also observed Housekeeper #1 leave the COVID-19 positive Resident's room with full PPE on. She further said that she had already spoken to her and told her that she was to remove the PPE prior to exiting a room, then perform hand hygiene. During an interview on 12/14/20, at 9:10 A.M., Housekeeper #1 acknowledged that she should have removed her PPE and completed hand hygiene prior to leaving the Resident's room.

Based on interview the facility failed to ensure the designation of an Infection Preventionist who is responsible for the facility's infection prevention and control program. Findings include: During an interview on 12/14/20, at 8:12 A.M., the Director of Nursing said that the facility did not have an Infection Preventionist on staff. She said that she handles the facility COVID-19 testing but has not had the time to complete any specialized training in infection prevention and control. The Director of Nursing said that the facility hasn't had an Infection Preventionist since July . She further said that the facility has placed online advertisements but has not found anyone as of yet.

Based on observation, interview and policy review, the facility failed to ensure that dietary staff health care personal (HCP) wore a mask while in the facility to reduce the potential for asymptomatic spread of Covid 19 on 2 of 2 nursing units. Findings include: Review of the document provided by the facility, titled Personal Protective Equipment Guidance update, dated 8/23/20 indicated face masks should always be worn. Do not use homemade or cloth masks while in clinical area. Review of the Centers for Disease Control website (www.cdc.gov), page titled, Preparing for COVID-19 in Nursing Homes, updated June 25, 2020 indicated the following: - Healthcare Personnel (HCP): HCP include, but are not limited to, emergency medical service personnel, nurses, nursing assistants, physicians, technicians, therapists, phlebotomists, pharmacists, students and trainees, contractual staff not employed by the healthcare facility, and persons not directly involved in patient care, but who could be exposed to infectious agents that can be transmitted in the healthcare setting (e.g., clerical, dietary, environmental services, laundry, security, engineering and facilities management, administrative, billing, and volunteer personnel). - HCP should wear a facemask at all times while they are in the facility. When available, facemasks are generally preferred over cloth face coverings for HCP as facemasks offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others. Guidance on extended use and reuse of facemasks is available. Cloth face coverings should NOT be worn by HCP instead of a respirator or facemask if PPE is required. On 8/25/20 at 9:40 A.M., the surveyor observed Dietary Staff #1 in the 1st floor dining/activity room. She was wearing a cloth face covering. During an interview at that time she said that she had brought the cloth face covering from home and had not been told she should wear a face mask and not a cloth mask in a clinical area. On 8/25/20 at 10:01 A.M., the surveyor observed Dietary Staff #1 in the 2nd floor dining/activity room. She was wearing a cloth face covering. On 8/25/20 at 10:10 A.M., the surveyor observed Dietary Staff #1 exit the elevator on the 2nd floor nursing unit and walk through the clinical area towards the dining/activity room. During an interview with the Director of Nursing, on 8/25/20 at 10:30 A.M., she said that all staff, including dietary should be wearing a face mask, not a cloth face covering.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), the Facility failed to ensure staff implemented and followed the Facility's Abuse Policy, when on 10/02/19, Resident #1 told the Nurse Manager that Nurse #1 was verbally abusive toward him/her,and bullied him/her at night, the Adminstrator and Director of Nursing were not notified of the allegations until the following day, Nurse #1 was not asked to leave the premises and worked her full eight hours shift, placing other residents at risk for potential abuse, Findings include: The Facility's Abuse Policy, dated 05/02/17, indicated that: - any staff member who is told of or witnesses abuse, neglect, intimidation, and mistreatment must report immediately to the Administrator and Director of Nursing, - if abuse is being investigated, the accused staff member must be asked to leave the premises pending outcome of the investigation, -the Facility would report the incident to DPH and an initial report is to be sent with a follow-up report after completion of the investigation. Resident #1 was admitted to the Facility in (MONTH) (YEAR) and he/she was capable of making his/her own health care decisions. The Quarterly Minimum Data Set, dated dated [DATE], indicated Resident#1 was cognitively intact and he/she was able to communicate his/her needs. The Facility's Investigation, dated 10/03/19, indicated that it was alleged Nurse #1 verbally abused Resident #1. The Investigation indicated the Facility validated the allegations of verbal abuse, when on 10/03/19, the Nurse Manager told the Director of Nursing that Resident #1 told her that Nurse #1 had yelled at him/her, bullied him/her, and forced him/her to go to bed at night, against his/her desire to stay up. The Facility's Investigation included the Nurse Manager's Written Statement, dated 10/03/19, indicated that Resident #1 told her (on 10/02/19) about how he/she was being treated by Nurse #1. The Statement indicated that the Nurse Manager told Resident #1 that she would report the allegations to the Administrator. The Statement indicated Resident #1 told the Nurse Manager, he/she did not want to get anyone in trouble. The Surveyor interviewed the Nurse Manager at 10:50 [NAME]M. on 10/28/19, and reviewed her written witness statement with her, at the time of the interview. The Nurse Manager said although her Written Statement was dated 10/03/19, said that Resident #1 initially reported the allegations of verbal abuse involving Nurse #1 to her on 10/02/19, at approximately 2:30 P.M. The Nurse Manager said she spoke directly with Nurse #1 (on 10/02/19) about Resident #1's allegations while providing Nurse #1 the change of shift report, at approximately 3:00 P.M. The Nurse Manager said Nurse #1 responded to the allegations by saying Resident #1 was confused and denied the allegations. Nurse Manager #1 said she reported the allegations to the Director of Nursing, at approximately 1:30 P.M. on 10/03/19 (almost 24 hours after the allegations were made). The Surveyor interviewed the Director of Nursing (DON) at 1:15 P.M. on 10/28/19. The DON said the Nurse Manager reported the allegations regarding Nurse #1 to her on 10/03/19. Review of the Facility's Staffing Schedule, indicated Nurse #1 worked at the Facility on 10/02/19 from 3:00 P.M. to 11:00 P.M., and continued to interact with Resident #1 and other residents, placing residents at risk for further abuse. The Surveyor interviewed the Administrator at 1:40 P.M. on 10/28/19. The Administrator said he was unaware that Resident #1 initially reported the allegations of abuse to the Nurse Manager on 10/02/19. The Administrator said he was notified about the allegations of abuse on 10/03/19, which was when the Facility suspended Nurse #1 pending the investigation.

Based on interview and record review, the Facility staff failed to develop a water management infection control program to include a Facility risk assessment, a water management team, and to develop a written water management policy and procedure. Findings include: The Surveyor interviewed the Facility Management Director and Facility's licensed plumber on 5/16/19 at 9:47 A.M. The Facility Management Director said that the Facility did not develop a water management infection control facility risk assessment. The Facility Management Director said that the Facility contracted with a outside company to test its water supply for infectious agents and that staff had identified and corrected areas in the Facility, such as shower heads, to minimize infection. The Facility Management Director said that the Facility did not have a water management team, and that staff did not have team meetings to review water management risks and processes. The Facility Management Director said that the Facility did not have a policy and procedure for water management infection control. Review of the Facility's infection control plan, dated (YEAR), indicated there was no reference to water management infection control.

Base on observation, record review and interview the Facility failed to ensure that food is stored prepared and distributed in accordance with professional standards for food safety and sanitization to prevent the spread of pathogens which could result in food borne illness for the Residents. Findings include: During a tour of the kitchen conducted on [DATE] at 2:20 P.M., with the Dietary Aide, the following were observed: 1. The Ph test strip used to check the concentration of the sanitizing solution had expired as of ,[DATE]. 2. The pans of jello, seafood salad rolls, prunes, fruit cups, cranberry juice and open almond milk in the refrigerator were not labeled and dated. 3. The exhaust fan in the window blowing outward was dusty. 4. A pan of unidentified food was not labeled and sitting on top of the stove area without being covered with clear plastic wrap. The Dietary Aide said it was risotto that was served for lunch. Lunch was served approximately 1 to 2 hours earlier prior to the time of the observation, so the food was not promptly refrigerated. 5. Observed in the refrigerator were a tub that contained multiple types of dressing from the salad bar and a pan of cut lettuce that were not dated. 6. A box of raw bacon had a pan of hard boiled eggs sitting on top of it and a box of cooked bacon was stored behind it. Raw and cooked food items must be properly separated. 7. Three trash barrels containing discarded food items did not have a cover on them. 8. Three red buckets did not contain enough sanitizer to cover several scrubbing pads, a pair of gloves and a scrub brush. The Dietary Aide was made aware of the items and explained to a worker that it need to have enough sanitizing solution in the buckets to cover the items for proper disinfection to occur. 9. A milk crate of dirty rags was observed hanging on the wall. 10. Three large, open bags of clam fry, panco and brown rice were observed in the food storage area with no secure closure of the bags.

Based on observation, interview, and record review, the Facility failed to provide activities of daily living (ADL) to a resident requiring extensive assistance with care (#18) out of a total sample of 12 residents. Findings include: For Resident #18 the Facility failed to identify the need for an intervention to keep Resident #18's shoes clean and free of food debris. Resident #18 was admitted to the facility in 4/2014 with [DIAGNOSES REDACTED]. He/she requires extensive assist for bathing, dressing, and personal hygiene and is dependent for locomotion on unit. He/she has a fluctuating eating status from independent to physical assist because of his/her [MEDICAL CONDITION]. Observations made by the Surveyor were as follows: a. 6/07/18 at 8:14 A.M., Resident # 18, he/she was in the unit bistro eating breakfast. Staff was assisting him/her with the food. It was observed that Resident #18 shoes were dirty with food debris. b. 6/08/18 at 1:12 P.M., Resident #18 was in the unit bistro eating lunch. He/she was independently eating his/her meal Surveyor observed that Resident #18 shoes dirty with food debris. c. 6/8/18 at 3:00 P.M., Resident #1 was in his bed covered with a sheet, he/she had his shoes on and they remained dirty with food debris. d. 6/11/18 8:06 A.M., Resident #18 was observation by Surveyor sitting in the wheelchair in bistro eating breakfast. A certified nursing assistant was assisting him/her with the entire meal. Shoes remained dirty with food debris. 06/11/18 1:23 P.M., Resident #18 laying on top of bed with his/her shoes on his feet. Unit Manager #1 observed the shoes and agreed they were dirty with food debris. She said that if Resident #18 could see, he/she would be upset with having dirty shoes. She further said the shoes should be cleaned as part of Resident #18's daily dressing and grooming.

Based on observations and interviews, the Facility failed to ensure that expired medications were not available for administration in 2 of 2 medication rooms inspected. Findings include: 1. During observation of the second floor medication room with Unit Manager #2 on 06/07/18 at 1:20 P.M., the following expired medications were noted: * the insulin kit in the refrigerator had expired as of 5/31/18. * One bottle of [MEDICATION NAME] 100 tabs (taken to rapidly relieve chest pain) had expired 7/2016. *9 [MEDICATION NAME]-scop packets (taken to relieve post-operative nausea and vomiting or motion sickness) had expired 3/18. * 6 [MEDICATION NAME] scop packets had expired 12/17. *3 bottles senna-S. 60 tabs (a stool softener). Two bottles had expired 1/18 and one bottle 5/18. Unit Manager #2 removed the expired medications for disposal. 2. During observation of the first floor medication room with Unit Manager #1 on 6/07/18 at 01:50 P.M., one bottle of [MEDICATION NAME] 100 tablets (a stool softener) had expired 3/2018. Unit Manager #1 removed the expired medications for disposal.

Based on record review and interview, the facility failed to conduct a complete screening for 1 of 2 newly hired employees (A) prior to the date of hire. For one newly hired employee (A), the facility failed to conduct a timely check of the appropriate out of state Nurse Aide Registry prior to employment as required. According to the facility's Resident Abuse policy, dated 11/16/16, operational standards for the screening of employees indicated that all employees at the facility are screened after preplacement offer of employment by obtaining criminal offender record information ( CORI) authorized by the Massachusetts Department of Criminal Justice Information Services. Efforts are made to secure either written or verbal references from either previous employers or current employers. Information from the Nurse Aide Registry in Massachusetts is also verified for all applicants under final consideration for any position. Employee files were reviewed on 4/10/17 . Review of the facility's screening documentation indicated that Employee A, a Certified Nursing Assistant,(CNA) was hired 1/2/17 and had been employed in New Jersey a few years prior to employment at the facility. The facility was unable to provide evidence that the New Jersey Nurse Aide Registry check was obtained prior to employment. During interview on 4/10/17 at 11:05 A.M., the Administrator said that the Massachusetts Certified Nursing Assistant (CNA) registry was checked but the out of state ( New Jersey ) Nurse Aid Registry was missed and was completed on 4/10/17.

Based on observations and staff interviews, the facility staff failed to ensure that medications and biologicals were of current date to provide reliability of strength and accuracy on 1 of 2 units observed. In addition, the Facility failed to ensure that the medication cart was locked and that medications were not left unsupervised on top of the medication cart. Findings include: 1) During observation of the medication pass on [DATE] at 7:35 A.M., Nurse #3 prepared all of the medications for Non-Sampled Resident #1, pushed the lock of the medication cart in, but not completely, so that it was not locked, and entered the Resident's room. Upon retuning to the medication cart, the Surveyor pointed out the lock, which Nurse #3 confirmed by testing it, that it had not completely locked. Nurse #3 said the medication cart should be securely locked before leaving the cart unattended in the hallway. 2) During observation of the medication pass on [DATE] at 7:50 A.M. Nurse #3 left a medication card containing Allopurinol (used to treat gout or kidney stones) on top of the medication cart unattended while she entered the Resident's room to make sure he was available to take medications. The Surveyor remained at the medication cart while Nurse #3 was in the Resident's room and pointed to the medication card on top of the medication cart when Nurse #3 returned. Nurse #3 said she should not have left the medication on top of the cart, unattended. 3) During observation of the medication room on the first floor on [DATE] at 10:50 A.M., with Nurse #1 and the Director of Nursing, the following observations were made: *One tube of Clobetasol Propionate (topical steroid cream used to treat skin conditions)that expired ,[DATE]. *One tube of artificial tears ointment that expired ,[DATE]. *One tube of Tobradex (used to treat eye infections) eye ointment that expired [DATE]. *One large tackle box labeled IV Kit that had expired [DATE]. *One large jar of Hydrolatum cream (skin cream for dry skin) with several large cracks on the bottom that allowed the cream to ooze out on the shelf. *One multi-use vial of Tuberculin with no label documenting the date opened and date expired.

Based on observations and staff interviews, the facility staff failed to follow proper infection control practices regarding a dressing change for 1 sampled resident (#5) and during a medication pass with 1 Non-Sampled Resident (NS#1), to prevent infections in a total of 10 sampled residents and 2 Non-Sampled Residents. Findings include: 1) For Resident #5, the facility staff failed to conduct a dressing change observing proper infection control practices to prevent infection and ensure there was no cross contamination. Resident #5 was admitted to the Facility in 10/2014 with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] indicated the Resident had a brief inventory of metal status (BIMS) score of 15 which indicated the Resident had no cognitive impairment. The Resident required the assistance of one for activities for daily living. The Resident was non-ambulatory and moved about his/her room and facility with a motorized wheelchair that had customized supports for the head and neck. Nurse #1 was observed performing a dressing change on Resident #5 on 4/6/17 at 10:25 A.M. Observations were as follows: *Donning gloves without first performing hand hygiene Nurse #1 removed the Resident's soiled dressing from the Resident's left thigh. *Without removing the gloves from a dirty procedure, Nurse #1 used a wooden tongue depressor as an applicator to remove some [MEDICATION NAME] cream (a cream to treat burns), from the jar. Nurse #1 used the tongue depressor to apply the [MEDICATION NAME] onto the burn on the Resident's left thigh. Nurse #1 then placed the used applicator on the lid of the jar, contaminating the lid. * Nurse #1 changed her gloves without first performing hand hygiene. Nurse #1 removed the dirty dressing on the right thigh and then used the same applicator to dip into the [MEDICATION NAME] cream again, contaminating the cream with debris from the wound, and applied the cream to the Resident's right leg. Nurse #1 then placed the applicator on the lid again. *Nurse #1 changed her gloves again without first using hand hygiene and used the same applicator to dip into the [MEDICATION NAME] cream again, applied cream to the Resident's peri area, and placed the applicator on the lid again. By using one applicator on all three wound sites, this technique resulted in cross-contamination with any source of bacteria located in any of the three wound sites. It also contaminated the cream in the jar by repeatedly dipping the applicator in the cream after it touched multiple open wound that creates a medium in which the bacteria could grow and places the Resident at risk of infection from future use of the [MEDICATION NAME] cream. *After applying the [MEDICATION NAME] to each thigh, Nurse #1 used scissors, without first wiping them clean with an alcohol wipe, to cut the telpha dressing that applied over the [MEDICATION NAME] cream and cutting the Kling gauze that was wrapped over the final dressing. When the dressing was completed, Nurse #1 began collecting the Resident's left over dressing supplies with the same dirty gloves and placed the items on the chest of drawers. *Nurse #1 then removed her gloves, and without performing hand hygiene first, donned another pair of gloves and then cleaned the Resident's overbed table with purell and then collected items for the Resident to apply another condom catheter for urine collection. Throughout the dressing change, Nurse #1 placed the soiled dressing materials, gloves and other trash items in the Resident's trash can. Nurse #1 then removed her gloves and did not perform hand hygiene before leaving the Resident's room. As Nurse #1 approached the nursing station, another resident requested assistance and she left to attend to that Resident without performing hand hygiene. Nurse #1 was interviewed on 4/6/17 at 11:00 A.M. after she returned from the other Resident's room. The Surveyor discussed the infection control breeches with the Nurse who did acknowledge the areas in which infection control practices were not correctly applied. 2) During observation of the medication pass on 4/6/17 at 3:40 P.M. Nurse #2 was administering eye drops to Non-Sampled Resident #1. Nurse #2 was observed placing one drop in each eye and using one tissue for both eyes to dry some of the liquid which was on the Resident's cheeks. Following the administration of the eye drops, the Surveyor discussed the infection control breech of using the same tissue to dry both eyes. Nurse #2 acknowledged that she should have used one tissue for each eye to avoid cross contamination with any organisms between the two eyes.

Based on record review and interview, for 1 of 3 sampled residents (Resident #1). the Facility failed to report or investigate an allegation of abuse by CNA #1. On 11/24/12 Resident #1 told Nurse #1 that CNA #1 assaulted him. Nurse #1 allowed CNA #1 to continue to work directly with Resident #1. On 11/25/12 CNA #1 again worked directly with Resident #1. On 11/26/12 Resident #1 repeated the allegation to staff and at this time the Facility reported to the public authority and initiated an investigation. Findings included: The Facility's abuse policy, dated 2/06/12, indicated residents will be protected from harm during the investigation process. The abuse policy indicated after an initial report of abuse an incident report is to be completed and licensed nursing staff were required to immediately notify the Administrator and Director of Nursing. The abuse policy indicated suspected incidents of abuse will be reported to the state agency within 24 hours. The abuse policy indicated suspected abuse will result in immediate job suspension. Resident #1's quarterly minimum data set (MDS) report, dated 11/01/12, indicated the following conditions: no significant cognitive deficits; no behavioral symptoms; required extensive staff assistance for transfers and walking and a [DIAGNOSES REDACTED]. The Surveyor interviewed Nurse #1 on 12/18/12 at 2:00 P.M. Nurse #1 said on 11/24/12 , at approximately 8:00 P.M., Nurse #1 entered Resident #1's bedroom and observed Resident #1 appeared upset and anxious. Nurse #1 said Resident #1 told her a man matching the physical description of CNA #1, "really forced me to go to bed", or words to that effect. Nurse #1 said Resident #1 told her he/she did not want to go to bed. Nurse #1 said Resident #1 told her this man, "assaulted" him/her, or words to that effect. Nurse #1 said she told Resident #1 she did not think anybody did anything "bad to him", or words to that effect. Nurse #1 said CNA #1 was assigned to care for Resident #1 and that he had just been in Resident #1's bedroom to provide evening care. Nurse #1 said she did not report the alleged incident to management, or remove CNA #1 from the schedule, or complete an incident report. The Surveyor interviewed the Director of Nurses (DON) on 12/18/12 at 8:30 A.M. The DON said on 11/26/12 Resident #1 told management that on approximately 11/24/12 a person matching the description of CNA #1 forced Resident #1 to go to bed. The DON said she interviewed Nurse #1 about the alleged incident and Nurse #1 told her Resident #1 reported on 11/24/12 CNA #1 assaulted him/her. The DON said CNA #1 worked on Resident #1's unit for full shifts on 11/24/12 and again on 11/25/12. The DON said CNA #1 worked in the Facility on 11/26 (11:00 P.M. to 7:00 A.M. shift), but not on Resident #1's unit. Resident #1's unit staff schedule, dated 11/24/12 and 11/25/12, indicated CNA #1 worked on Resident #1's unit during the 3:00 P.M. to 11:00 P.M. shifts. Resident #1's activities of daily living flow sheets, dated 11/24/12 and 11/25/12, indicated CNA #1 provided direct care to him/her during the 3:00 P.M. to 11:00 P.M. shifts.

Based on record review and staff interview the facility failed to ensure the resident exercised his/her rights as a resident of the facility to make his/her own advanced directive decisions for 1 resident (# 2) in a total sample of 10. Findings include. 1. For Resident #2 the facility failed to ensure the resident had a written consent for an advanced directive decision. Review of the clinical record on 11/14/11 revealed the resident had [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] indicated the resident was alert, oriented, and cognitively intact. Review of the physician's orders [REDACTED]. The clinical record revealed a lack of any written consent for an end of life decision by the Resident. Interview with the charge nurse on 11/14/11 at 11:30 A.M. confirmed there was no written consent for the Do Not Resuscitate, Do Not Intubate order. The nurse notified the physician and the order was discontinued on 11/15/11.

Based on record review and staff interview, the facility failed to ensure that two resident's rights (#3, and #4), out of a sample of 10 residents, were assured and protected. Findings included: 1. For Resident #3 the facility failed to ensure that the resident's rights of formulating advanced directives were protected. Record review on 11/14/11 revealed that Resident #3 was admitted ,[DATE]. [DIAGNOSES REDACTED]. Record review revealed a that on 8/3/11 the resident signed a Comfort Care/Do Not Resuscitate ("DNR") Order Verification form. Record review revealed the physician progress notes [REDACTED]. Record review revealed an order written [REDACTED]. There is no documentation of any health status change between 8/3 and 8/4/11that could have impacted the resident's cognitive condition. . The Resident's capacity for decision making on 8/3/11 is in question given the determination by the physician the next day, on 8/4/1, that the Resident lacked capacity for medical decision making. The resident was unable to consent to the DNR. There was no order to activate the HCP found in the record. The physician failed to activate the HCP on 8/4/11 after the determination of lack of capacity. The physician order [REDACTED]. During interview on 11/14/11at approximately 11:00 A.M. the unit manager said that there was no order for the activation of the HCP in the record. 2. For Resident #4 the facility failed to ensure the Resident's rights for medical decision making. Record review on 11/15/11 revealed that Resident #4 was admitted ,[DATE]. [DIAGNOSES REDACTED]. Record review revealed a physician progress notes [REDACTED]. The patient is confident in this course of action and reiterated their decision multiple times". Review of the medical record revealed an order written [REDACTED]. Activate Health Care Proxy when appropriate". Review of the order for activation of the HCP "when appropriate" is in conflict with the progress note that determined the Resident was cognitively intact. It is the physician or designated mental health consultant who determines capacity and thus the need for activation of the HCP. The progress notes reflect that the physician determined the resident had medical decision making capacity therefore activation of the HCP was not necessary. See F 514

Based on record review and staff interview, the facility failed to develop a comprehensive care plan for 2 residents (#4 and #2) in a total sample of 10. Findings include: 1. For Resident #4 the facility failed to develop a comprehensive plan of care addressing the Resident's pacemaker including interventions for monitoring function of the device and the resident's assessment needs. Record review on 11/15/11 revealed that Resident #4 was admitted ,[DATE]. [DIAGNOSES REDACTED]. Although the facility had documents from the hospital with the serial number and type of device stored in the medical record, there was no information regarding the rate the pacemaker was set at. There were no parameters identified for nursing to notify the physician in the event of pacemaker malfunction nor were there orders for the monitoring of the pacemaker function. Review of the physician orders [REDACTED]. The order was for a date that had already passed. A notation on the 10/1/11-10/31/11 Treatment Administration Record noted "Pacemaker Checks due [DATE] at 10:30 AM". There was no order for the December pacemaker check or checks at any interval. During interview with the unit manager on 11/15/11 at 11:00 A.M., the unit manager said that she did not know the parameters for the pacemaker. The unit manager said during the interview that there was no care plan for the monitoring of the pacemaker. At the exit conference, the Director of Nursing provided the surveyor with a document from the cardiology consult with information regarding the type, model and rate for the pacemaker. The DON said that the unit manager found the information in the record. See F 514 2. For Resident #2 the facility failed to develop a comprehensive plan of care addressing the Resident's pacemaker that included interventions for monitoring function of the device. Clinical record review on 11/14/11 revealed Resident #2 was admitted on ,[DATE]. [DIAGNOSES REDACTED]. Review of the clinical record revealed a nurses note dated 11/10/11 that indicated a pacemaker check had been completed. Review of the physician's orders [REDACTED]. Record review revealed no care plan for the pacemaker. There were no parameters identified for nursing to notify the physician in the event of pacemaker malfunction nor were there orders for the monitoring of the pacemaker function. During interview on 11/15/11 the staff nurse said there was no plan of care for monitoring the resident's pacemaker.

Based on record review and staff interview, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurate for 1 of 10 residents (# 4). The findings include: For Resident #4 the facility failed to: 1. ensure that medication ordered for coverage for elevated blood sugars as determined by the fingerstick blood tests were recorded as given and 2. failed to ensure the physician orders [REDACTED]. 1. Record review on 11/15/11 revealed that Resident #4 was admitted ,[DATE]. [DIAGNOSES REDACTED]. Record review revealed signed physician orders, dated 11/4/11, for blood sugar monitoring twice a day with sliding scale coverage. The original date on the orders was 5/8/11. The order specified Finger Stick Blood sugars (FSBS) twice a day, at 6:00 A.M. and 4:00 P.M. The order specified a sliding scale for insulin coverage: [MEDICATION NAME] R Insulin-100/ml (units per milliliter) Dose according to sliding scale: 200 - 250 6 units Sub Q (subcutaneously) 251 - 300 8 units Sub Q (subcutaneously) 301 - 350 10 units Sub Q (subcutaneously) 351 - 400 12 units Sub Q (subcutaneously) 401 - 450 14 units Sub Q (subcutaneously) 451 - 500 16 units Sub Q (subcutaneously) BS> 500 Call MD Review of the facility Blood Sugar Records from 5/8/11 to 11/15/11 revealed that there was missing documentation of testing and administration of the [MEDICATION NAME] R insulin as ordered by the physician as follows: 6/3/11 4:00 PM no documentation of the blood sugar testing and no documentation of any insulin administered. 6/13/11 4:00 PM result = 314 no documentation of insulin administration. 6/27/11 4:00 PM result = 336 no documentation of insulin administration. 8/31/11 4:00 PM result = 307 no documentation of insulin administration. 9/2/11 4:00 PM result = 349 no documentation of insulin administration. 9/19/11 4:00 PM result = 221 no documentation of insulin administration. 9/29/11 4:00 PM result = 202 no documentation of insulin administration. 9/30/11 4:00 PM result = 210 no documentation of insulin administration. 10/14/11 4:00 PM result = 211 no documentation of insulin administration. 10/18/11 4:00 PM result = 245 no documentation of insulin administration. 10/23/11 4:00 PM result = 430 no documentation of insulin administration. 10/24/11 4:00 PM result = 348 no documentation of insulin administration. 10/26/11 4:00 PM result = 337 no documentation of insulin administration. 2. .For Resident #4 the facility failed to ensure that the transcription of the physician orders [REDACTED]. Record review revealed an order dated 9/30/11 "Code Status DNR/DNI (do not intubate)/DNH (do not hospitalize). Activate Health Care Proxy when appropriate". Record review on 11/15/11 revealed a physician progress notes [REDACTED]. The patient is confident in this course of action and reiterated their decision multiple times". Review of the order for activation of the HCP "when appropriate" is in conflict with the progress note that determined the Resident was cognitively intact. It is the physician or designated mental health consultant who determines capacity and thus activation of the HCP. The physician progress notes [REDACTED]. 3. For Resident #4 the facility failed to ensure that the transcription of the physician orders [REDACTED]. a. Review of the physician orders [REDACTED]. The order was for a date that had already passed. A notation on the 10/1/11-10/31/11 Treatment Administration Record noted "Pacemaker Checks due [DATE] at 10:30 AM". There was no order for the December pacemaker check or checks at any interval. b. Record review revealed physician orders, last signed off as complete on 11/4/11, for "Change C-Pap mask and tubing every 6 months" and "clean [MEDICAL CONDITION] mask every morning at 6:00 AM" and "[MEDICAL CONDITION] at 14 CM water at bedtime". Record review revealed that the order for use of the [MEDICAL CONDITION] had been discontinued 10/7/11. During interview on 11/14/11 at approximately 2:00 P.M. the unit manager said that the documentation was missing for the FSBS and sliding scale medication administration, the pacemaker check order for the 9/16/11 should have been edited off , that there was no order for the 12/16/11 pacer check and that the order for the C-Pap mask and tubing should have been edited off the orders.