Every finding on record at Canterbury Towers Inc

Based on observations, staff interviews, and facility record review, the facility failed to 1. Ensure staff completed hand hygiene between soiled dish handling and receiving of clean dishes when operating the dish washing machine, and 2. Ensure liquids such as milk were held at a temperature of 40 degrees Fahrenheit (F) and below prior to serving to residents.Findings included: 1.On 7/14/2025 at 10:25 a.m. the kitchen was toured with Staff A, Dietary Manager. He revealed he had a full complementary staff to support the thirty-three residents who resided at the facility and that all his Dietary Staff were trained and in-serviced on subject matters to include use and sanitation of food preparation equipment, personal hygiene, food sanitation, and kitchen cleaning operations. He revealed he, along with most of his staff are Serve Safe certified, which includes the knowledge of Kitchen/Food Sanitation. Staff A, Dietary Manager revealed the kitchen operates a High Temperature dish washing machine and revealed it is maintained by an outsourced maintenance company. He confirmed there had not been any recent concerns with the machine and he receives the proper soaps/detergents and supplies to run the machine effectively. Staff A, Dietary Manager revealed the machine, as a High Temperature dish washing machine, and per the machine's specifications, it should operate with a wash temperature of over 165 degrees Fahrenheit and above, and a rinse temperature of over 190 degrees Fahrenheit and above. Observations of the machine's metal specification plate attached to the undercarriage of the machine revealed a wash temperature to reach at least 150 degrees Fahrenheit and above, and a rinse temperature to reach 180 degrees Fahrenheit and above. A wash cycle demonstration was asked to be performed by staff. Staff A, Dietary Manager, revealed Staff D, [NAME] was the operator of the machine this morning. Staff D, [NAME] was asked how he operates the machine. Prior to Staff D, [NAME] being asked about the machine, he was observed to handle many soiled trays of eating ware with his bare hands, as well as touching soiled breakfast meal tray carts with his bare hands. Staff D, [NAME] was the only staff member who was observed in the dish machine room and had been observed operating the machine while Staff A, Dietary Manager, was interviewed just five minutes before. Staff D, [NAME] revealed the facility operates a High Temperature dish washing machine and he has been adequately trained on the use of the machine. He also denied any recent concerns with the machine, and he responded that the wash temperature should reach over 150 degrees Fahrenheit, and the final wash cycle should reach at least 180 degrees Fahrenheit. Staff D, [NAME] was then asked to perform a demonstration on how to operate the dish washing machine. Staff D, [NAME] then grabbed a metal sheet tray with his unwashed bare hands, pre rinsed the tray with a water spray down, then placed the tray in the dish washing machine. He then closed the door with his bare hands and the machine operated with both wash and rinse cycle. The machine's wash and rinse cycle met the machine's wash and rinse temperature criteria and then stopped. Staff D, [NAME] then opened the door of the machine and grabbed the metal sheet tray with his bare unwashed hands and placed it in a clean dry storage area. Staff D, [NAME] was the only staff member to utilize the machine during this observed tour time and he continued to handle soiled eating ware to include plates, eating utensils, pans, cups, and bowls with his soiled hands, pre rinsed said eating ware and placed in empty crates and then pushed the crates through the soiled side of the dish washing machine. Each time the machine was completed with its wash/rinse operation, he would then open the door with his soiled bare hands and pull the crate out and handle all the cleaned eating ware/cooking ware with his unwashed bare hands. Staff D, [NAME] was observed operating the machine by himself, feeding soiled eating ware in the machine and grabbing the cleaned eating ware with his unwashed bare hands for a period of at least ten minutes. Staff A, Dietary Manager, was in the vicinity and did not redirect or ask Staff D, Cook, to wash his hands after handing soiled eating ware and other soiled equipment, and prior to handling cleaned eating ware and other clean equipment. On 7/16/2025 at 1:55 p.m. during a second kitchen observation, Staff B, Dietary Aide was observed in the dish washing machine room and was performing dish washing tasks by himself. Staff B, Dietary Aide, was observed handling and touching soiled dishes, eating utensils, eating ware with his bare hands and scraping and rinsing those dishes and eating ware with his bare hands as well as doing a pre rinse at the sink next to the soiled side of the dish washing machine. He continued to take the pre rinsed eating dishes and eating ware with his bare hands and placed them in empty plastic crates. Staff B, Dietary Aide, was observed to push the soiled crates of eating ware, and other equipment through the soiled side of the machine and closed the machine's door. After the machine completed its wash and rinse cycle, Staff B, Dietary Aide then opened the machine's door with his unwashed bare hands and pulled the crate out and handled each individual piece and placed them in a drying or clean storage area. Staff B, Dietary Aide, was noted to do this same cycle of feeding soiled eating ware with his unwashed bare hands, placing them in the machine and grabbing all the cleaned eating ware with the same unwashed bare hands for at least five cycles or at least ten minutes. When Staff B, Dietary Aide, was asked if he knew what type of dishwashing machine he operates, he could not say whether it was a High Temperature or Low Temperature machine and, could only say the product name of the machine. On 7/17/2025 at 9:18 a.m. an interview with Staff A, Dietary Manager provided a verbal and physical demonstration of us of the dish washing machine. He revealed both Staff B, Dietary Aide and Staff D, Chef/Cook, were not in this morning and therefore those two staff members could not be interviewed related to the dish washing machine process. The Dietary Manager revealed the following process:Soiled dishes/eating utensils/eating ware are brought from the floor/unit and placed near the dish machine room. The soiled dishes are then placed on a metal trough and at a sink, where soiled dishes are scrapped and rinsed of food debris.The dishes/eating utensils/eating ware are then placed in a plastic crate rack and pushed through the dish washing machine. The door to the dish washing machine is then closed and by closing the door, the machine will start and operate both wash and rinse functions. After the machine is finished with both washing and rinsing, the machine's door is lifted up. At this time, staff operating the machine should be washing their hands prior to touching and receiving the washed items. Staff, after placing soiled rack of dishes/eating ware/eating utensils in the dish machine, should walk over to the nearest hand washing sink and wash their hands appropriately prior to touching cleaned dishes/eating ware/eating utensils. While Staff A, Dietary Manager was explaining the dish machine operations, Staff C, Dietary Aide was observed to place an empty tray rack on the floor, walked away from the dish machine room, handled other boxes and items, walked back to the dish machine room and then grabbed a crate of clean eating utensils and picked up individual forks, knives, spoons with her bare hands. She then placed them in another clean container. Staff C, Dietary Aide, left the dish machine room and pushed away soiled tray carts that were brought in from the unit/hallways. These carts had soiled trays that were brought back in from the breakfast meal service. She then walked back into the dish machine room and grabbed an already cleaned rack of dishes with her bare unwashed hands and then removed plates with her bare hands and placed them in another storage area. It was found Staff C, Dietary Aide, did not wash her hands after touching soiled eating ware and soiled equipment and before touching clean eating ware and eating equipment several times within a span of at least five minutes. Staff A, Dietary Manager, confirmed Staff C, Dietary Aide, should have washed her hands after touching the soiled eating ware/equipment and before touching newly cleaned eating ware/equipment. An interview with Staff C, Dietary Aide revealed she did not remember if she washed her hands before touching the washed eating ware/eating equipment. Staff C, Dietary Aide knew she should be washing her hands after handling soiled equipment or touching other things prior to receiving clean dishes from the dish washing machine. Staff A, Dietary Manager, confirmed all Dietary Staff are trained and in serviced on the proper use of the dish washing machine and also trained and in serviced on proper hand washing techniques while conducting operations in the kitchen. 2.During the first initial kitchen tour with Staff A, Dietary Manager on 7/14/2025 at 10:25 a.m. Staff A, Dietary Manager brought the state surveyor out from the main kitchen and into a food service Staging room, just outside the main kitchen space. Staff A, Dietary manager revealed this food service Staging room is used to store cooked and prepared foods from the kitchen and to plate and serve food items from the steam table. The Staging room was observed in a room between the main kitchen and the main dining room and had equipment to include 1. a handwashing sink, a counter space with cabinets and drawers, a small refrigerator with a freezer compartment, a steam table to hold food at appropriate food holding temperatures and a space to assemble trays of food. Also, the room was observed to store meal tray carts to place meal trays in. Staff A, Dietary Manger revealed they use this Staging room/space as means to serve the residents better and becomes a more homelike eating experience. Upon opening the small refrigerator, it was observed with various items to include many cartons of milk, cups of juices, plastic containers of other liquids, and other cold storage food items. Further observation revealed the refrigerator did not have a thermometer to see what the inside temperature was held at. There was a refrigerator temperature log at the door of the refrigerator, and it was documented with daily temperatures for the month of 7/2025. The temperatures were documented to include temperatures of 41 degrees Fahrenheit and below. However, there was no thermometer in the refrigerator or freezer compartment of this unit. Staff A, Dietary Manager, confirmed there was no thermometer in both compartments of the unit and did not know where they were or where they went. On 7/16/2025 at 12:27 p.m. Staff C, Dietary Aide was observed to prepare trays in the Staging room with cups, eating utensils, cartons of various milk types, cups of juices, cups of yogurt. She then placed the trays in various meal tray carts in preparation to receive plated food from the steam table area. Staff C, Dietary Aide prepared approximately fifteen to twenty of these trays with cold liquid items. They sat in the meal tray carts for at least fifteen minutes. An interview with Staff C, Dietary Aide revealed she prepares the trays with the liquids and stores the trays in the meal carts until she gets the plates of hot food items. She or other dietary staff will push the meal tray carts to various halls out in the unit. She revealed this was her normal process and she does this to save time. Staff D, [NAME] and Staff A, Dietary Manager, both confirmed Staff C, Dietary Aide's tray set up process. Staff C, Dietary Aide said she had removed the cold fluids including cartons of milk out from the main walk-in refrigerator from the kitchen about fifteen to twenty minutes prior to the observation/interview. Staff D, [NAME] was asked to pull a carton of milk at random from one of the tray carts to do a temperature demonstration. Prior to temping a random carton of milk, he and Staff A, Dietary Manager, revealed the holding temperature of cold fluids such as milk, should be at 40 degrees Fahrenheit or below. At 12:34 p.m. Staff D, [NAME] performed a random temperature demonstration with one of the random cartons of milk that were on a meal tray ready to go out to residents. He utilized his digital thermometer and revealed it was recently calibrated with a cup of ice and water. He then opened the carton of milk and positioned the stem of the thermometer in the milk. He held the thermometer in place in the milk for twenty seconds and the temperature read 63.2 degrees Fahrenheit. Staff A, Dietary Manager, Staff D, [NAME] and Staff C, Dietary Aide, confirmed the holding temperature for the milk, should have been below 40 degrees Fahrenheit or below. Staff A, Dietary Manager, said he would need to remove all the milks stored in the tray cart and replace them. He did confirm the milks would have gone out to residents during this observation, prior to checking the temperatures. On 7/17/2025 at 8:45 a.m. Staff A, Dietary Manager and Staff D, [NAME] were asked to revisit the Staging kitchen area where the small refrigerator/freezer was positioned. It was found on 7/14/2025 the unit did not have a thermometer in either the refrigerator or freezer compartment. Upon observing the refrigerator/freezer on 7/17/2025 at 8:45 a.m., the door was opened and there was a thermometer placed on the top shelf. The thermometer read 34 degrees Fahrenheit. There were cartons of milk placed on the shelving of the unit. Staff A, Dietary Manager, was asked to remove one of the milk cartons and test the milk for temperature. He confirmed the digital thermometer he had was calibrated via cup of ice and water. Staff A, Dietary Manager, pulled out a carton of milk, opened the pour spout and placed the digital thermometer in the milk and held it for twenty seconds. The thermometer read 49.4 degrees Fahrenheit. The Dietary Manger confirmed the milk was not being held or did not hold to a temperature below 41 degrees Fahrenheit. He could not say how long the cartons of milk were stored in the refrigerator but revealed the milks would have been served to residents. On 7/17/2025 at 1:00 p.m. Staff A, Dietary Manager provided the meal service Ware Washing in Meal Service Pantries policy and procedure with a revised date of 5/2023. The policy revealed; The community will follow established methods for the safe and effective use of dishwashers in the meal service pantries. The procedure revealed; #4 - Staff will use proper hand washing techniques prior to unloading and storing clean dishes. On 7/17/2025 at 1:00 p.m. Staff A, Dietary Manager provided the meal service Taste and Temperature Control policy and procedure with a last revised date of 5/2023 for review. The policy revealed; Food is maintained at palatable temperatures during service to meet resident expectations. The procedure revealed; #3 - Temperatures of hot and cold food will be taken again if food is delivered in bulk to service pantries to ensure temperature maintenance. #6 - Cold foods, such as milk, butter, ice cream, and juices should be refrigerated during service or held on ice or insulated bins to maintain proper temperature 40 degrees Fahrenheit or lower. On 7/17/2025 at 1:00 p.m. Staff A, Dietary Manager provided the Food Safety Management System policy and procedure with last revision date 5/31/2025, for review. The policy revealed; Hands must be washed frequently and correctly, including at the following times; After handling soiled equipment or utensils. The policy further revealed; Employees must clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands or arms for at least 20 seconds, using liquid soap in a dedicated handwashing sink:- Rinse under clean, running warm water;- Apply soap;- Rub together vigorously for at least 10-15 seconds while paying attention to removing soil from underneath the fingernails during the cleaning procedure and creating friction on the surfaces of the hands and arms or surrogate prosthetic devices for hands and arms; fingertips, and areas in between the fingers;- Thoroughly rinse under clean, running warm water;- Immediately follow the cleaning procedure with thorough drying using disposable towel or hand dryer;- To avoid re-contaminating their hands or surrogate prosthetic devices, employees may use a disposable paper towel or similar clean barriers when touching surfaces such as manually operated faucet handles on a handwashing sink or the handle of a restroom door.

Based on observations, and record reviews, the facility failed to maintain a safe, clean, comfortable homelike environment related to rusted bathroom equipment in three rooms (112,113, & 116) of thirty-three rooms toured.Findings included: On 07/14/2025 at 1:30 PM during a tour of the facility, it was observed that room [ROOM NUMBER], 113, & 116 had over the toilet, toilet seats which showed signs of rust. On 07/16/2025 at 2:46 PM during a tour of the facility, it was observed that room [ROOM NUMBER], 113, & 116 had over the toilet, toilet seats which showed signs of rust. During an interview on 07/17/2025 at 10:03 AM with the Director of Maintenance (DOM). She stated, “all the maintenance work orders are done on paper, and the employees will write up the work orders and then submit to myself.” The employees are directed to write up issues they observe daily. She also stated, “we use a maintenance inspection sheet to review the rooms as a preventative maintenance inspection to help guide our needs for each room. I have one full-time employee including myself to help with tasks. The room inspection sheet directs the personnel to do a room check, however that is not currently being done. I will provide you with an inspection policy if we have one and the room/weekly inspection sheet that we use for our surveys.” Review of the facility policy named, routine cleaning and disinfection, dated 1/16/25, unsigned, not dated, revealed, it is the policy of this facility to ensure the provisions of routine cleaning and disinfection in order to provide a safe, sanitary environment and the prevent the development and transmission of infections to the extent possible. Review of the facility policy named, skilled nursing facility (SNF) room inspection, dated 1/16/25, unsigned, revealed, it is the policy of this facility to utilize a maintenance inspection checklist in order to assure a safe, functional, sanitary and comfortable environment for residents, staff and the public. Review of a facility document named room inspection form, undated and unsigned. The document revealed a list of items to be cleaned in each room. (Photographic Evidence Provided)

Based on a review of resident records and interviews with staff, the facility failed to conduct timely comprehensive minimum data set (MDS) assessments and transmit assessments per the required timeframes for three residents (#2, #35, #21) out of six residents reviewed for MDS, out of a total of 20 residents in the sample. Findings included:A closed record review for Resident #2 revealed she was admitted to the facility on [DATE] and discharged [DATE]. Minimum data set (MDS) assessments were completed as required on 3/28/25 and 3/31/25; however, neither assessment reflected an accepted status. Resident #35 was admitted to the facility 2/12/25 and discharged [DATE]. The discharge MDS assessment was completed on 3/31/25 but was not submitted. Resident #21 was admitted on [DATE] and discharged on 3/10/25. The last MDS assessment completed for her was 3/4/25. There was no discharge assessment completed. An interview was conducted with the MDS Coordinator on 07/17/2025 at approximately 10:00 AM. She reviewed the MDS Management Center reports and confirmed Resident #2's discharge assessment was never submitted. She explained this resident's assessment dated [DATE] was an End of Stay Part A discharge MDS. It was submitted and uploaded to the electronic record keeping platform by the former MDS Coordinator, but she must have neglected to enter the accepted date into the system. She confirmed Resident #21's discharge assessment was never completed and submitted, nor was Resident #35's. (Photographic evidence obtained)

Based on interviews and record reviews, the facility failed to document revisions to the plan of care for one (Resident #18) of 18 sampled residents. Findings included: A review of Resident #18's medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses of dementia without behavioral disturbance and adjustment disorder with anxiety. A review of Resident #18's Interdisciplinary (ID) Notes dated 7/5/2023 at 4:50 PM revealed Resident #18 obtained a skin tear upon showering. A treatment for the skin tear was implemented and Resident #18's responsible party and physician were notified. A review of Resident #18's ID Notes dated 7/31/2023 at 1:27 PM revealed Resident #18 had new skin tears from a morning shower to the left hand, right hand, and right forearm. A treatment for the skin tears was implemented. A review of Resident #18's Minimum Data Set (MDS) assessment dated [DATE] revealed under Section C - Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Resident #18's MDS assessment also revealed under Section E - Behavior, Resident #18 displayed rejection of care behaviors 1 to 3 days in the 7 day assessment period. An interview was conducted on 8/10/2023 at 10:47 AM with Staff A, Licensed Practical Nurse (LPN). Staff A stated Resident #18 had skin tears on her hands and forearms which occurred in the shower on 7/31/2023. Staff A was not able to state how the skin tears developed but stated Resident #18 was typically combative with staff during showers and two staff members assisted Resident #18 with her showers. An interview was conducted on 8/10/2023 at 11:42 AM with Staff B, LPN. Staff B stated Resident #18 could sometimes be combative with staff while being provided care and hates showers. Staff B also stated Resident #18 developed a skin tear to her left arm on 7/5/2023 while being given a shower due to the resident swinging her arm and hitting the side of the shower chair. The skin tear was assessed and a treatment was initiated for the wound. A review of Resident #18's care plan revealed a problem, dated 8/10/2023, Resident #18 was at times physically abusive towards staff as evidence by resisting assistance and hitting staff during showers. Interventions included to monitor for danger to self and others, provide one to one assistance as needed and re-assurance, and if Resident #18's initial approach is abusive staff should stop and inform the nurse. Resident #18's care plan did not address physically abusive behaviors prior to 8/10/2023. An interview was conducted on 8/10/2023 at 1:21 PM with the facility's Director of Nursing (DON). The DON stated on 7/31/2023, Resident #18 developed skin tears on her bilateral arms and hands due to the resident becoming upset during a shower and flailed her arms. The DON addressed Resident #18's care plan did not address physically abusive behaviors prior to 8/10/2023 and stated interventions were initiated today [8/10/2023] because Resident #18's care plan was up for review. The DON stated Resident #18's behaviors probably should have been part of the resident's care plan prior to 8/10/2023 considering the resident had displayed the behaviors in the past. An interview was conducted on 8/10/2023 at 1:46 PM with Staff C, LPN/MDS. Staff C stated resident care plans were usually revised quarterly or when a medical or behavioral change is identified. Staff C also stated the care plan is revised as incidents occur, usually within 14 days, and Resident #18's care plan should have been revised upon discovery of her combative behaviors. A review of the facility policy titled Care Plans, dated January of 2023, revealed under the section titled Procedures each resident admitted to the nursing home facility shall have a plan of care. The assessment must be reviewed no less than once every 3 months and promptly after a significant change, which is a need to stop a form of treatment because of adverse consequences, or commence a new form of treatment to deal with a problem in the resident's physical or mental condition; and revised as appropriate to assure the continued accuracy of the assessment.

Based on observations, interviews, and record reviews, the facility failed to maintain accurate and complete medical records by failing to fully document occurrence of skin tears for one (Resident #18) of 18 sampled residents. Findings included: A review of Resident #18's medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses of dementia without behavioral disturbance and adjustment disorder with anxiety. A review of Resident #18's physician's orders revealed an order, dated 7/31/2023, to monitor steri strips to the left wrist, left forearm, right wrist, and right forearm every shift. A review of Resident #18's Interdisciplinary (ID) notes dated 7/5/2023 at 4:50 PM revealed Resident #18 obtained a skin tear upon showering. A treatment for the skin tear was implemented and Resident #18's responsible party and physician were notified. The ID note did not reveal how the skin tears to Resident #18 were obtained. A review of Resident #18's ID notes dated 7/31/2023 at 1:27 PM revealed Resident #18 had new skin tears to the left hand, right hand, and right forearm from a morning shower. A treatment for the skin tears was implemented. The ID note did not reveal how the skin tears to Resident #18 were obtained. A review of Resident #18's Minimum Data Set (MDS) assessment dated [DATE] revealed under Section C - Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Resident #18's MDS assessment also revealed under Section E - Behavior, Resident #18 displayed rejection of care behaviors 1 to 3 days in the 7 day assessment period. A review of Resident #18's care plan revealed a problem, dated 8/10/2023, Resident #18 was at times physically abusive towards staff as evidence by resisting assistance and hitting staff during showers. Interventions included to monitor for danger to self and others, provide one to one assistance as needed and re-assurance, and if Resident #18's initial approach is abusive staff should stop and inform the nurse. An observation was conducted on 8/8/2023 at 8:49 AM of Resident #18 during the breakfast meal. Resident #18 was sitting up in her bed and eating small amounts of food. Several skin tears dressed in steri strips were observed to Resident #18's bilateral hands and bilateral forearms. No bruising or bleeding was observed. Resident #18 was not able to state how the skin tears occurred and was not alert and oriented during conversation. An interview was conducted on 8/10/2023 at 9:40 AM with the facility's Risk Manager (RM) and Director of Nursing (DON). The RM stated Resident #18 developed skin tears while being given a shower on 7/31/2023 and was not able to state how the skin tears occurred during the shower. The RM was not able to find any documentation in Resident #18's medical record to detail how the skin tears occurred. An interview was conducted on 8/10/2023 at 10:47 AM with Staff A, Licensed Practical Nurse (LPN). Staff A stated Resident #18 had skin tears on her hands and forearms which occurred in the shower on 7/31/2023. Staff A was not able to state how the skin tears developed but stated Resident #18 was typically combative with staff during showers and two staff members assisted Resident #18 with her showers. Staff A, LPN stated she did not document how Resident #18 incurred skin tears during the shower and did not ask the nurse's aide how the skin tears occurred. Staff A stated she only treated the wounds. An interview was conducted on 8/10/2023 at 11:42 AM with Staff B, LPN. Staff B stated Resident #18 could sometimes be combative with staff while being provided care and hates showers. Staff B also stated Resident #18 developed a skin tear to her left arm on 7/5/2023 while being given a shower due to the resident swinging her arm and hitting the side of the shower chair. The skin tear was assessed and a treatment was initiated for the wound. Staff B stated skin tear incidents are documented by completing an incident report in the resident's record to document exactly what occurred. Staff B was not able to find an incident report for Resident #18's skin tears on 7/31/2023. An interview was conducted on 8/10/2023 at 1:21 PM with the facility's DON. The DON stated on 7/31/2023, Resident #18 developed skin tears on her bilateral arms and hands due to the resident becoming upset during a shower and flailed her arms. The DON addressed there was not an incident report documented related to the skin tears and stated she would expect the nurse to complete an incident report to document how the incident occurred. A review of the facility policy titled Incidents and Accidents, with no effective date, revealed under the section titled Policy Explanation the purpose of incident reporting can include: - Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care. - Conducting root cause analysis to ascertain causative/contributing factors as part of Quality Assurance Performance Improvement (QAPI) to avoid further occurrences. - Alert risk management and/or administration of occurrences that could result in claims or further reporting requirements. - Meeting regulatory requirements for analysis and reporting of incidents and accidents. A review of the facility policy titled Documentation in the Medical Record Policy, with no effective date, revealed each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. The policy also revealed under the section titled Policy Explanation and Compliance Guidelines licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. Documentation accurate, relevant, and complete, containing sufficient details about the resident's care and/or response to care.

Based on observations, interviews, and record reviews, the facility failed to implement an effective infection prevention and control program related to 1.) failing to ensure hand hygiene was performed during observation of medication administration for two (Resident #25, Resident #10) of six residents observed during medication administration, 2.) failing to administer eye drops in a manner to prevent cross contamination for one (Resident #10) of six residents observed during medication administration, and 3.) failing to ensure proper storage and usage of personal protective equipment (PPE) for one (Resident #6) of six residents observed during medication administration. Findings included: An observation of medication administration was conducted on 8/9/2023 at 8:39 AM for Resident #25 with Staff A, Licensed Practical Nurse (LPN). Staff A removed Resident #25's medications from the medication cart and dispensed them into a medication cup. Staff A crushed each medication to prepare them for administration to Resident #25. After preparing the medications, Staff A entered Resident #25's room and administered medications by mouth to the resident. During the administration, Resident #25 had a small emesis due to the taste of the crushed medications. Staff A assisted Resident #25 in cleaning the emesis and gathered paper towels for the resident to wipe her mouth off. After assisting Resident #25, Staff A exited the room and gathered medications for administration to Resident #10. Staff A did not perform hand hygiene during the observation of medication administration to Resident #25. An observation of medication administration was conducted on 8/9/2023 at 9:11 AM for Resident #10 with Staff A. Staff A removed Resident #10's medications from the medication cart and dispensed two medication pills into a medication cup. Staff A removed a vial of eye drops for administration to Resident #10 from the medication cart. After gathering the medications, Staff A removed a pair of gloves from the medication cart and entered Resident #10's room. Staff A explained to Resident #6 she was going to administer medications. Staff A administered Resident #10's medications by mouth before donning gloves to administer eye drop medication. Staff A held Resident #10's bottom eye lid and administered a drop of medication in the resident's right eye. Staff A then held Resident #10's bottom eye lid and administered a drop of medication in the resident's left eye. Staff A then removed her gloves and exited the room. Staff A did not change gloves in between administration of eye drops in the right and left eye and did not perform hand hygiene during the observation. An interview was conducted with Staff A following the observation. Staff A stated she would normally perform hand hygiene frequently throughout medication administration but addressed she did not and stated she was nervous. An observation of medication administration was conducted on 8/9/2023 at 9:16 AM for Resident #6 with Staff A. Staff A performed hand hygiene prior to pulling medications from the medication cart. Staff A removed three medications from the medication cart, including a capsule. Staff A removed a pair of gloves from her left side pocket and donned them. Staff A opened the medication capsule and emptied the contents into a medication cup. Staff A removed the gloves and crushed the other two remaining medications before adding it to the medication cup and mixing the medications with apple sauce. Staff A entered Resident #6's room and administered the medications before exiting the room. Staff A performed hand hygiene following the procedure. A follow up interview was conducted on 8/9/2023 at 11:03 AM with Staff A. Staff A stated she normally kept gloves in her pocket but she probably shouldn't store the gloves in her pocket. Staff A addressed she did not change gloves when administering eye drops to Resident #10 and stated she would not normally change gloves because she doesn't have pink eye or anything. Staff A stated she should have changed her gloves in between administration of Resident #10's eye drops. An interview was conducted on 8/10/2023 at 10:14 AM with the facility's Infection Control Preventionist (ICP) and the facility's Director of Nursing (DON). The DON stated daily rounding was conducted to ensure hand hygiene was being performed by staff. The ICP stated hand hygiene should be performed before and after meals, after using the bathroom, in between passing resident meal trays, before entering resident rooms, after leaving resident rooms, and before and after use of gloves. The ICP also stated she would not expect staff members to keep gloves inside of their pockets because other items could be inside the pocket and it would compromise the gloves. Gloves should be removed from the manufacturer's box before donning them. The ICP stated she would expect nursing staff to change gloves and perform hand hygiene when administering eye drops to a resident in both eyes to prevent spread of infection. A review of the facility policy titled Medication Administration, with no effective date, revealed under the section titled Policy Explanation and Compliance Guidelines nursing staff are to wash hands prior to administering medication per facility protocol and product. A review of the facility policy titled Hand Hygiene, with no effective date, revealed under the section titled Policy Explanation and Compliance Guidelines staff will perform hand hygiene when indicated using proper technique consistent with accepted standards of practice. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves.

Based on resident record reviews and staff interviews, the facility failed to ensure three of twenty-three sampled residents (#15, #11, #30), had care plans developed to include goals and interventions related to 1. anticoagulant use and routine oxygen therapy, and 2. accidents/falls. Findings included: 1. Review of Resident #15's electronic record revealed he was admitted to the facility for long term care on 10/1/2019. Review of the advance directives revealed Resident #15 was able to make his own decisions, but had a Health Care Surrogate in place. Review of the admission [DIAGNOSES REDACTED]. Review of the current Minimum Data Sheet (MDS) assessment Quarterly 11/4/2019 revealed, (Cognition/BIMS - Score 13 of 15), (Pain with Shortness of Breath), (Medications - Anticoagulant use 7 days a week),(Special treatment to include Oxygen therapy) Review of the Current POS dated for the month 11/2019 revealed resident was ordered and received the following: - Oxygen (O2) at 3 Liters Per Minute via Nasal Cannula continuously. 3 Liters Per Minute - Aspirin 81 mg delayed release 1 by mouth daily, routine for [MEDICAL CONDITION]. This medication is for Anticoagulant use. - Xarelto 20 mg 1 by mouth daily, routine for [MEDICAL CONDITION] Fibrillation. This medication was for Anticoagulant use. - Change nebulizer and or O2 tubing every Sunday if in use or every week. Review of the most current Medication Administration Record [REDACTED] 11/2019 revealed all above listed medications were documented as given. Review of the most current Care Plans with next review date 2/20/2020 revealed no problem areas with goals and interventions related to routine Oxygen therapy and routine Anticoagulant use. On 11/24/2019 at 10:00 a.m., the Director of Nursing (DON), who was also in training to take over as Minimum Data Set (MDS) coordinator duties, and acting as MDS coordinator, provided the current Care Plans for review. On 11/24/2019 at 10:40 a.m. interview with the DON, confirmed that Resident #15 is coded in the most current MDS assessment as continuous use of Anticoagulant and continuous use of O2 therapy. She further revealed that these areas should be care planned as problem areas with interventions. The DON confirmed that the current care plans did not reflect problem areas to include use of Anticoagulants and use of O2. She further confirmed that these areas should have been care planned. On 11/24/2019 at 10:50 a.m. Resident #15 was observed in his room and seated in his wheelchair. This observation revealed he was receiving oxygen therapy via an oxygen concentrator, located on the other opposite side of him. The oxygen tubing was observed coming from the concentrator and leading to his Nasal Cannula. Review of the concentrator oxygen gauge revealed a reading with the bubble gauge hovering at 2.5 liters per minute. On 11/26/2019 at 7:23 a.m. Resident #15 was observed in his room and seated in a wheelchair. Resident #15 was also observed receiving Oxygen therapy via cylinder oxygen tank at his side and tubing leading from the tank to his Nasal Cannula. Oxygen tank read resident #15 was receiving oxygen flow at a rate of 2.5 liters per minute. Resident #15 confirmed he uses the oxygen every day all day and he is supposed to have it at all times, including when he sleeps. On 11/26/2019 at 4:15 p.m. an interview with the 3-11 nurse Staff C, confirmed an observation of resident's oxygen tubing placement and oxygen flow rate. He indicated that the concentrator read 2.5 liters per minute and should be at 3 liters per minute continuously. Staff C was not aware if Resident #15 was care planned with interventions to include continual use of oxygen and routine use of Anticoagulants. 2. On 11/26/19 at 3:34 p.m., Resident #11 was observed in her room sitting in a chair next to the bed. The resident was well groomed and dressed for the day. The resident had a wanderguard on her right wrist. On 11/27/19 at 10:47 a.m., Resident #11 was observed in her room sitting in the chair next to her bed. The resident was wearing a wander guard on her right wrist. On 11/26/19 at 12:53 p.m., Staff G, Certified Nursing Assistant (CNA), reported that Resident #11 wanders. Staff G reported that Resident #11 was alert and oriented, but she thinks she can leave the facility. Staff G reported that Resident #11 thinks she still lives at home and can do everything independently. On 11/26/19 at 3:32 p.m., the Director of Nursing (DON) confirmed that Resident #11 had a wanderguard. She reported that the resident walked independently. She stated the wanderguard was in place for safety precautions only. A review of the Profile Face Sheet revealed that Resident #11 was initially admitted into the facility on [DATE] with a [DIAGNOSES REDACTED]. Section C of the Nursing Home Comprehensive Minimum Data Set ((MDS) dated [DATE] indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 09 out of 15 indicating moderately impaired. Section [NAME] of the MDS revealed that the resident did not display any wandering behavior. Section P indicated that the resident used a wander/elopement alarm daily. An At Risk For Elopement Assessment completed on 11/26/19 (during the survey) indicated the following: the resident was fully ambulatory, disoriented with no wandering, happy with placement, had no history of elopement attempts, no behavior modifications, had no orders for antipsychotics, and had a [DIAGNOSES REDACTED].#11 had a total score of 8 out of 10 on the elopement assessment. A score of 10 or more indicated that the resident was at risk for elopement. A review of the physician's orders [REDACTED]. Wander alarm to be worn at all times. Remove prior to leaving the facility Check placement for wanderguard bracelet A review of the Medication Record for 11/2019 revealed that the placement for the wanderguard was checked daily from (MONTH) 1st through (MONTH) 26th. A review of the care plans for Resident #11 revealed that she did not have a care plan initiated for the use of a wanderguard. On 11/27/19 at 10:55 a.m., the DON reported that Resident #11 does not try to leave the facility, but she would get up unassisted and walk down the hall to see the bird in therapy. The DON reported that the order for the wanderguard had been in place since (MONTH) 10, (YEAR). The DON reported that she would expect to see the use of the wanderguard on the care plan. The DON confirmed that there was no care plan in place for the use of a wanderguard. 3. On 11/26/19 at 9:43 a.m., Resident #30 was observed in bed sleeping. The resident's bed had full bolsters on both sides. On 11/27/2019 at 7:50 a.m., Resident #30 was observed in her room and still in bed. The resident was under the covers with the lights off and with her eyes closed. There were full bolsters on both sides of the bed. She was resting comfortably with the call light placed within reach. A review of the Profile Face Sheet revealed that Resident #30 was initially admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Section C of the Nursing Home Comprehensive Minimum Data Set ((MDS) dated [DATE] indicated that the resident had a BIMS (Brief Interview for Mental Status) score of 09 out of 15 indicating moderately impaired cognition. Section J indicated that the resident had had falls since admission. The resident had the following current order: Low air loss mattress on bed Resident #30 had care plans with interventions in place for falls and pressure ulcers that did not include interventions related to the use of an air mattress with bolsters. On 11/25/19 at 2:26 p.m., Staff A, Registered Nurse (RN) reported that Resident #30 had a few falls and now had bolsters on both sides of the bed. Staff A reported that there were no injuries from the falls. On 11/26/19 at 12:49 a.m., Staff G, CNA, reported that resident had the air mattress with bolsters because she had a fall. Staff G reported that Resident #30 had a fall last week. On 11/27/19 at 11:06 a.m., the DON reported that the bolsters come with the low air loss mattress. The DON reported that she would not expect to see the bolsters on the care plan, but she would expect to see the low air mattress on the care plan. The DON confirmed that the air mattress with bolsters was not on the care plan. The policy Comprehensive Care Plan revised on 02/2019 revealed the following: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment.

Based on record review, observation, interviews, and policy review the facility did not ensure appropriate pressure ulcer treatment and services were provided to promote healing of a pressure sore for one resident (#1) of one residents reviewed for pressure ulcers. Findings included: Resident #1 was admitted to the facility with a [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. every day for coccyx wound Review of the TARs (treatment administration records) indicated the following days the treatments were not completed: there were no signatures for the treatment to the pressure ulcer for (MONTH) 2019 on the 18th, 21st, and 23rd. The treatments were also not signed on the 11th and 14th of October. The treatments on the18th, 21st, and 23rd of (MONTH) were blank. An observation was conducted with Staff B, LPN, and Staff F, CNA on 11/26/19 at 2:43 p.m. Staff B, LPN and Staff F, CNA reentered Resident #1's bed room washed their hands in the bathroom sink and dried them with paper towels. Staff B, LPN explained the procedure to Resident #1. Staff F, CNA put on a pair of gloves and waited at the bed side while Staff B, LPN gathered the wound care supplies from the treatment cart. Staff B, LPN placed the barrier on the bed side table and prepared the wound care supplies. She opened the gauze 4x4's, calcium alginate, and the dressing. She removed a felt tipped pen from her pocket and dated the dressing. Then Staff B, LPN returned to the bathroom where she washed her hands in the sink and dried them with paper towels. When Staff B, LPN returned to the bed side she closed the privacy curtain. Then Staff B, LPN put on a pair of gloves, and assisted Staff F, CNA with removing Resident #1's brief. Staff B, LPN removed the dressing from Resident #1's sacral area and removed the packing of the wound. The wound was the size of quarter with tunneling present at 11:00. There was red, moderate drainage present on the wound packing. There was no odor. Staff B, LPN disposed of the dressing, gloves, and soiled packing in a red biohazard bag, performed hand hygiene with the hand gel and put on another pair of gloves. Then she opened the saline syringes and unrolled some gauze 4x4's and rolled them into a rope about 8 inches long. Next Staff B, LPN squeezed the saline syringe contents onto the rolled gauze rope she had made. Then Staff B, LPN used a cotton-tipped applicator to press the saline soaked gauze into the wound. Staff B, LPN placed the applicator and the soiled gauze on the barrier that Resident #1 was lying on. Then Staff B, LPN removed her gloves. She put the gloves on the barrier also and then pulled it from beneath Resident #1 and wrapped the contents in it. Next Staff B, LPN handed it to Staff F, CNA who placed it in a trash can at the bed side. Staff B, LPN removed the hand gel from the bedside table again, and performed hand hygiene. Then she put on another pair of gloves. Then Staff B, LPN used another cotton-tipped applicator to insert the calcium alginate into the wound. Staff B, LPN had difficulty getting it all in the wound. She packed as much as she could fit in the wound until the edges of the wound were bulging, leaving a one-inch strip hanging outside the wound. At this time Staff B, LPN used a gauze with saline and wiped the bottom area of the periwound (surrounding tissue) near the coccyx with it. Staff B, LPN did not clean any of the rest of the periwound area. She placed the gauze in the trash can. Then Staff B, LPN removed the gloves and placed them in the trash can. Next Staff B, LPN put on new pair of gloves. Staff B, LPN removed the barrier she had placed beneath resident. Then Staff B, LPN replaced it with a clean barrier. Next Staff B, LPN removed the gloves and put them in the trash can. Then she placed the red biohazard bag in the trash can. Then Staff B, LPN performed hand hygiene and put on a new pair of gloves. Staff B, LPN opened a skin prep wipe. Staff B, LPN applied the skin prep to the periwound. Staff B, LPN used her hand to fan the skin prep dry. Then Staff B, LPN removed the backing from the adhesive dressing she had opened and dated, and placed the dressing over the wound. Then Staff B, LPN wiped Resident #1's peri-anal area with some gauze. Staff B, LPN disposed of the gauze, barrier, and remaining supplies in the trash can, along with her gloves. Staff B, performed hand hygiene again using the hand gel. Staff B, LPN and Staff F, CNA used some pre-moistened cloths to finish peri care. Staff B, LPN and Staff F, CNA then applied a clean brief and barrier. Then Staff B, LPN washed her hands in the bathroom sink after removing her gloves. Next Staff B, LPN put on another pair of gloves and repositioned Resident #1. On 11/27/19 at 11:26 a.m. an interview was conducted with the DON (Director of Nursing). She said the appropriate way to pack a wound is loosely. When the surveyor asked what the outcome might be from overpacking the wound, she said she thinks there could be some discomfort. The DON also confirmed the periwound should have been cleaned. The DON also agreed that when gloves are removed there should be hand hygiene. In an interview with the wound care consultant physician on 1/27/19 at 1:26 p.m. he said usually you want to pack as much as you can but you don't want it too tight. You want it to reach to the bottom, you don't want to go further than that. Once you have hit the bottom you would hit the resistance, so you would not continue trying to push the packing in. But you do need to hit the bottom so the body recognizes there is a foreign object there. The policy, Hand Hygiene, dated 11/01/2019 was reviewed and the following information was found: Policy: It is the policy of the facility to perform hand hygiene in accordance with national standards from the Centers for Disease Control and Prevention and the World Health Organization. Procedure: 2. Alcohol-based hand rub may be used for all other hand hygiene opportunities (e.g. when soap and water is not indicated per # one). According to the World Health Organization, hand hygiene is to be performed: d. After caring for a resident including after removing gloves 3. The Centers for Medicare and Medicaid State Operations Manual indicates that hand hygiene should be performed: o. After removing gloves or aprons

Based on observations, staff and resident interview, and record review the facility failed to provide respiratory services according to orders for one of twenty-three sampled residents, during two of three days observed (11/25/2019 and 11/26/2019). It was determined through multiple observations, Resident #15's oxygen concentrator was running and providing the wrong oxygen flow rate. Findings included: On 11/25/2019 at 10:50 a.m. Resident #15 was observed in his room and seated in his wheelchair. This observation revealed he was receiving oxygen therapy via an oxygen concentrator, located on the other opposite side of him. The oxygen tubing was observed coming from the concentrator and leading to his Nasal Cannula. Review of the concentrator oxygen gauge revealed a reading with the bubble gauge hovering at 2.5 liters per minute. On 11/26/2019 at 7:23 a.m. Resident #15 was observed in his room and seated in a wheelchair. Resident #15 was also observed receiving Oxygen therapy via cylinder oxygen tank at his side and tubing leading from the tank to his Nasal Cannula. Oxygen tank read Resident #15 was receiving oxygen flow at a rate of 2.5 liters per minute. Resident #15 confirmed he uses the oxygen every day all day and he is supposed to have it at all times, including when he sleeps. On 11/26/2019 at 4:15 p.m. an interview with the 3-11 nurse Staff C, confirmed an observation of resident's oxygen tubing placement and oxygen flow rate. He indicated that the concentrator read 2.5 liters per minute and should be at 3 liters per minute continuously. Staff C was not aware if Resident #15 was care planned with interventions to include continual use of oxygen. Review of Resident #15's electronic record revealed he was admitted to the facility for long term care on 10/1/2019. Review of the advance directives revealed Resident #15 able to make his own decisions, but had a Health Care Surrogate in place. Review of the admission [DIAGNOSES REDACTED]. Review of the current Minimum Data Sheet (MDS) assessment Quarterly 11/4/2019 revealed, (Cognition/BIMS - Score 13 of 15), (Special treatment to include Oxygen therapy). Review of the Current Physician order [REDACTED]. - Oxygen (O2) at 3 Liters Per Minute via Nasal Cannula continuously. 3 Liters Per Minute Review of the current care plan with next review date to include 2/20/2020 did not reveal indication of continuous oxygen therapy use. Review of the ID notes from 10/2/2019 through to current 11/25/2019 revealed over five documented times indicating oxygen at 3 liters per minute continuously. On 11/26/2019 at 10:00 a.m. an interview with the Director of Nursing indicated that staff to include nurses and aides, when in the resident room, for those who receive oxygen therapy, should look at either the oxygen cylinder tank gauge or oxygen concentrator gauge flow rate, and ensure it is running at the ordered flow rate. She indicated that though Resident #15 did not have specific care plans for continuous oxygen use, there is an order that reflects continuous oxygen use with a flow rate of 3 liters per minute. She was made aware from her nursing staff that the oxygen flow rate had been running at the wrong flow rate at 2.5 liters per minute the past couple of days. The facility did not have a policy for oxygen use and flow rate.

Based on record review, observation, interviews, manufacturer's instructions, and policy review the facility did not ensure residents were free from significant medication errors for one resident (#183) of two residents observed during insulin administration. Findings included: Resident #183 was admitted to the facility with a [DIAGNOSES REDACTED]. A review of Resident #183's physician's orders [REDACTED]. 11/23/19 [MEDICATION NAME] 100 unit/ml subcutaneous solution (insulin [MEDICATION NAME]) - subcutaneous three times a day for DM: S/S (sliding scale) as follows: 300-349=4 units On 11/25/19 at 12:11 PM an observation was conducted with Staff A, RN during blood glucose testing and insulin administration. Staff A, RN removed a glucometer bag marked with Resident #183's name and room number from the medication cart. Staff A, RN removed test strips, and lancets from the bag as well. Staff A, RN also removed some alcohol preps, tissues, a [MEDICATION NAME]pen, and gloves from the medication cart. Then Staff A, RN knocked on Resident #183's bedroom door. After receiving permission to enter the room, Staff A, RN placed the supplies on top of a tissue on the bed side table. Staff A put on gloves. Next Staff A, RN put a test strip in the glucometer and turned the machine on. Then Staff A, RN cleansed Resident #183's right index finger with an alcohol prep. Then Staff A, RN used a lancet to prick the finger. Next, Staff A, RN applied the blood droplet to the test strip. The glucometer read 302. Then Staff A, RN wiped Resident #183's finger with a tissue. Staff A, RN disposed of the tissue and her gloves in the trash can at the bed side. Then Staff A, RN exited the room with the used test strip and lancet. She unlocked the medication cart with keys from her scrub top pocket. Then Staff A, RN disposed of the lancet and test strip in the sharps container in a drawer in the bottom of the medication cart. Then Staff A, RN retrieved an insulin needle from the medication cart. Next Staff A, RN returned to Resident #183's bedroom after knocking on the door. Then Staff A, RN said she forgot the alcohol preps. Staff A, RN exited the room, retrieved alcohol preps from the medication cart. Then Staff A, RN returned to Resident #183's bedroom again. Staff A, RN put on a pair of gloves. Staff A, RN removed the needle from the packaging and attached it to the top of the insulin pen. Next Staff A, RN dialed the [MEDICATION NAME]pen to 4 units. Staff A, RN did not prime the insulin pen with 2 units of insulin. Staff A, RN opened an alcohol prep and cleaned Resident #183's right lower abdomen with it. Then Staff A, RN injected the insulin. After disposing of her gloves in the trash can, Staff A, RN returned the insulin pen and glucometer to the bag in the medication cart. In an interview with the DON on 11/27/19 at 11:36 AM she said the insulin pen is set at two for them to get the two units of insulin. As you push the button for it to go in, the resident would be getting air first but she would get the two units. On 11/27/19 at 2:05 PM an interview was conducted with the Consultant Pharmacist, Manager of Operations. She said yes, insulin pens need to be primed. If the pen is not primed then the medication may not be delivered. Review of the manufacturer's instructions for [MEDICATION NAME], at www.[MEDICATION NAME].com revealed the following: Instructions: Step 2: Doing the airshot before each injection. Turn the dose selector to 2 units. Hold your [MEDICATION NAME] with the needle pointing up, and tap the cartridge gently a few times, which moves the air bubbles to the top. Press the push-button all the way in in until the dose selector is back to 0. A drop of insulin should appear at the tip of the needle. Step 3: Selecting your dose The dose selector should be set at 0. Turn the dose selector to the number of units you need to inject. The pointer should line up with your dose. A review of the Insulin Pen Policy, dated 8/1/19 was conducted and revealed the following information: Policy: It is the policy of this facility to use insulin pens in order to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare residents for self- administration of insulin therapy upon discharge. Policy explanation and compliance guidelines: 6. Insulin pens will be primed prior to each used to avoid collection of air in the insulin reservoir. 11. Procedure: g. Attach safety pen needle: i. Remove the pen cap from the insulin pen. ii. Wipe the rubber seal with an alcohol pad. iii. Twist open and remove outer cover from the safety pen needle. iv. Screw the pen safety needle onto the insulin pen. h. Prime the insulin pen: i. Dial two units by turning the dose selector clockwise. ii. With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears. i. Set the insulin dose: i. Turn the dose selector to ordered dose. A click will be heard for each unit dialed. If an incorrect dose has been set, dial the dose selector forward or backward until the correct number of units has been Set. ii. Check dose a second time.

Based on observations, interviews, record review, manufacturer's instructions, and policy review the facility did not ensure 1) appropriate hand hygiene during use of a glucometer and medication administration for one resident (#183) of two residents observed during blood glucose monitoring, 2) appropriate disposal of soiled wound care supplies and hand hygiene during wound care for one resident (#1) of one residents reviewed for pressure ulcer care, and 3) adequate hand hygiene during two of four meals observed dining services. Findings included: 1. Resident #183 was admitted to the facility with a [DIAGNOSES REDACTED]. A review of Resident #183's physician's orders revealed the following information: 11/23/19 [MEDICATION NAME] 100 unit/ml subcutaneous solution (insulin [MEDICATION NAME]) - subcutaneous three times a day for DM: S/S (sliding scale) as follows: 300-349=4 units On 11/25/19 at 12:11 PM an observation was conducted with Staff A, RN during blood glucose testing and insulin administration. Staff A, RN knocked on Resident #183's bedroom door. After receiving permission to enter the room, Staff A, RN placed the supplies on top of a tissue on the bed side table. Staff A put on gloves. Staff A, RN did not perform hand hygiene before putting on the gloves. Next Staff A, RN tested the resident's blood glucose with the glucometer, a lancet and a test strip. Staff A, RN disposed of her gloves in the trash can at the bed side. Then Staff A, RN exited the room with the test strip and lancet. She unlocked the medication cart with keys from her scrub top pocket. Then Staff A, RN disposed of the lancet and test strip in the sharps container in a drawer in the bottom of the medication cart. Staff A, RN did not perform any hand hygiene after removing the gloves, or disposing of the used supplies. Then Staff A, RN retrieved an insulin needle from the medication cart. Next Staff A, RN returned to Resident #183's bedroom after knocking on the door. Then Staff A, RN said she forgot the alcohol preps. Staff A, RN exited the room, retrieved alcohol preps from the medication cart. Then Staff A, RN returned to Resident #183's bedroom again. Staff A, RN put on a pair of gloves. Staff A, RN removed the needle from the packaging and attached it to the top of the insulin pen. Next Staff A, RN dialed the [MEDICATION NAME]pen to 4 units. Staff A, RN opened an alcohol prep and cleaned Resident #183's right lower abdomen with it. Then Staff A, RN injected the insulin. After disposing of her gloves in the trash can, Staff A, RN returned the insulin pen and glucometer to the bag in the medication cart . Staff A, RN did not clean the glucometer or perform hand hygiene. A review of the manufacturer's instructions for the[NAME]Smart Meter blood glucose monitoring system, undated, revealed the following: (page 21-22) Mitigate the risk of blood-borne pathogen transmission e.g. [MEDICAL CONDITIONS], the meter must be properly cleaned and disinfected. The life of the meter is five years for 18,250 cleaning and disinfection cycles. The validation testing was performed to simulate 10 cleaning and disinfection cycles per day over a five-year use life the meter for single patient home use, should be cleaned and disinfected once per week is recommended. Mitigate the risk of blood-borne pathogen transmission (e.g. [MEDICAL CONDITIONS]), the meter must be properly cleaned and disinfected. The life of the meter is five years for 18,250 cleaning and disinfection cycles. The validation testing was performed to simulate 10 cleaning and disinfection cycles per day over a five-year use life of the meter for single patient home use, should be cleaned and disinfected. Once per week is recommended. Cleaning is a general removal of debris, (food, feces, urates, blood, saliva, and other body secretions) which helps reduce the amount of organic matter that contributes to the proliferation of bacteria and disease. Disinfecting removes most of the organisms present on the surface which can cause infection or disease. It is useful against the number of bacterial and [MEDICAL CONDITION] microorganisms. The following disinfectant product (Clorox Germicidal Wipes) has been shown to be safe for use with the[NAME]Smart Meter, but any disinfectant product with the EPA registration number of -12 may be used on this device. If the meter is being operated by a second person who is providing testing assistance to the user, the meter should be disinfected prior to use by the second person. The user should wash hands thoroughly with soap and water after handling the meter, lancing device, or test strips. 1. Place device and wipes on a smooth surface. Be sure there is enough light. 2. Wash hands with soap and warm water and pat dry. 3. Put on a protective glove. 4. Take a piece of moistened wipe out of canister: 5. Wipe entire device until visibly clean. 6. Throw away the used wipe. Please do not reuse the wipe. Caution Always clean before disinfecting, all parts of devices are considered biohazard. Be sure to disinfect all parts thoroughly: Disinfect procedures 1. Prepare wipes in meter: 2. take a piece of premoistened wipes out of canister: 3. Put the moistened wipe on a smooth surface. 4. LCD side up. Wipe the device from left to right three times slowly. All other sides and surfaces should be wiped in this way. 5. Make sure the meter stays wet for one minute. Please do not get disinfectant liquid into the test strips slot. 6. Throw away the used wipes. Please do not reuse the wipe. A review of the facility policy, Infection Control- Point of Care Devices and Injection Safety Policy, dated 9/1/2019, showed the following: Intent: It is the policy of the facility to ensure that appropriate infection prevention and control measures are taken to prevent the spread of infection in accordance with state and federal regulations, and national guidelines. Procedure: 1. Shared point of care devices are to be cleaned and disinfected before and after each use with a disinfectant wipe included on Environmental Protection Agency (EPA) list D(https://www.epa.gov/pesticide-registration/list- D- EPAS-registered-antimicrobial-products-effective -against-human-hiv-1) If device is visibly soiled, it is to be wiped clean prior to using disinfectant wipe. 2. Point of care devices that are not shared are to be stored in plastic bags that are properly labeled with resident's name in order to prevent cross-contamination while device is not in use. Point of care devices are to be wiped clean/disinfected according to manufacturers instructions. In an interview with the DON on 11/27/19 at 11:36 AM she said her expectation is that there would be hand hygiene or soap and water during insulin administration and blood glucose monitoring. Each person that has a glucometer has their own. It is not used on other residents. The glucometers should be cleaned after use. They are for one resident only. On 11/27/19 at 1:15 PM an interview was conducted with the facility Risk Manager. He said you can't wash your hands enough. CDC put out guidelines saying you should use 70% alcohol. Anytime you have resident contact you should be washing or performing hand hygiene. He agreed there should be some hygiene going on during blood glucose monitoring and insulin administration. He said I think hand hygiene is always a good idea. If you take off a pair of gloves you should wash your hands or use hand sanitizer. In an interview with the Consultant Pharmacist, Manager of Operations on 11/27/19 at 2:05 PM she said all of the glucometers have instructions on them for how they should be cleaned after use. 2. Resident #1 was admitted to the facility with a [DIAGNOSES REDACTED]. Review of the physician's orders dated 11/6/19, revealed Pack wound (coccyx) with calcium alginate ag, skin prep periwound, cover with dry dressing and prn (as needed) soiling, dislodgment. every day for coccyx wound An observation was conducted with Staff B, LPN, and Staff F, CNA on 11/26/19 at 2:43 p.m. Staff B, LPN and Staff F, CNA reentered Resident #1's bed room after knocking on the door and requesting permission to enter. Staff B, LPN removed a bag of clean barriers from a drawer in Resident #1's dresser. Then Staff B, LPN placed the barrier on the bed side table. Next Staff B, LPN placed the wound care supplies, along with an open bottle of hand sanitizer that had been sitting on top of the treatment cart, on the bed side table. After Staff B, closed the bed room door, she returned to the bed side table and prepared the wound care supplies. She opened the gauze 4x4's, calcium alginate, and the dressing. She removed a felt tipped pen from her pocket and dated the dressing. Then Staff B, LPN returned to the bathroom where she washed her hands in the sink and dried them with paper towels. When Staff B, LPN returned to the bed side she closed the privacy curtain. Then Staff B, LPN put on a pair of gloves, and assisted Staff F, CNA with removing Resident #1's brief. After Staff B, LPN and Staff F, CNA turned Resident #1 to her left side, Staff B, LPN removed the dressing from Resident #1's sacral area. The dressing was appropriately dated. Then Staff B, LP removed the packing from the wound. The wound was the size of quarter with tunneling present at 11:00. There was red, moderate drainage present on the wound packing. There was no odor. Staff B, LPN disposed of the dressing, gloves, and soiled packing in a red biohazard bag. She tied the bag shut. Then Staff B, LPN performed hand hygiene with the hand gel that was sitting on the clean barrier. She returned the hand gel to the clean barrier. Then Staff B, LPN put on another pair of gloves. The she opened the saline syringes and unrolled some gauze 4x4's and rolled them into a rope about 8 inches long. Next Staff B, LPN squeezed the saline syringe contents onto the rolled gauze rope she had made. Then Staff B, LPN used a cotton-tipped applicator to press the saline soaked gauze into the wound. Staff B, LPN placed the applicator and the soiled gauze on the barrier that Resident #1 was lying on. Then Staff B, LPN removed her gloves. She put the gloves on the barrier also and then pulled it from beneath Resident #1 and wrapped the contents in it. Next Staff B, LPN handed it to Staff F, CNA who placed it in a trash can at the bed side. Staff B, LPN removed the hand gel from the bedside table again, and performed hand hygiene. Then she put on another pair of gloves. Then Staff B, LPN used another cotton-tipped applicator to insert the calcium alginate into the wound. Staff B, LPN had difficulty getting it all in the wound. She packed as much as she could fit in the wound until the edges of the wound were bulging, leaving a one-inch strip hanging outside the wound. At this time Staff B, LPN used a gauze with saline and wiped the bottom area of the periwound (surrounding tissue) near the coccyx with it. Staff B, LPN did not clean any of the rest of the periwound area. She placed the gauze in the trash can. Then Staff B, LPN removed the gloves and placed them in the trash can. Next Staff B, LPN put on new pair of gloves. Staff B, LPN removed the barrier she had placed beneath resident. Then Staff B, LPN replaced it with a clean barrier. Next Staff B, LPN removed the gloves and put them in the trash can. Then she placed the red biohazard bag in the trash can. Then Staff B, LPN performed hand hygiene using the hand gel that was sitting on the clean barrier. Then Staff B, LPN put on a new pair of gloves. Staff B, LPN opened a skin prep wipe. Staff B, LPN applied the skin prep to the periwound. Staff B, LPN used her hand to fan the skin prep dry. Then Staff B, LPN removed the backing from the adhesive dressing she had opened and dated, and placed the dressing over the wound. Then Staff B, LPN wiped Resident #1's peri-anal area with some gauze. Staff B, LPN disposed of the gauze, barrier, and remaining supplies in the trash can, along with her gloves. Staff B, performed hand hygiene again using the hand gel. Staff B, LPN and Staff F, CNA used some pre-moistened cloths to finish peri care. Staff B, LPN and Staff F, CNA then applied a clean brief and barrier. Then Staff B, LPN washed her hands in the bathroom sink after removing her gloves. Next Staff B, LPN put on another pair of gloves and repositioned Resident #1. On 11/27/19 at 11:26 a.m. an interview was conducted with the DON (Director of Nursing). The DON agreed that when gloves are removed there should be hand hygiene. The policy, Hand Hygiene, dated 11/01/2019 was reviewed and the following information was found: Policy: It is the policy of the facility to perform hand hygiene in accordance with national standards from the Centers for Disease Control and Prevention and the World Health Organization. Procedure: 2. Alcohol-based hand rub may be used for all other hand hygiene opportunities (e.g. when soap and water is not indicated per # one). According to the World Health Organization, hand hygiene is to be performed: a. Prior to caring for a resident. b. Prior to performing a procedure such as blood glucose monitoring or catheter care. c. When moving from a contaminated body site to a clean body site such as when changing a brief or wound dressing. d. After caring for a resident including after removing gloves. e. After contact with resident environment. 3. The Centers for Medicare and Medicaid State Operations Manual indicates that hand hygiene should be performed: d. Before after assisting with meals i. Upon and after coming in contact with a resident's intact skin o. After removing gloves or aprons 3. On 11/25/2019 at 12:15 p.m. the main dining room was observed for the lunch meal service. During that time an aide, Staff C was observed pushing a hydration cart throughout the main dining room and assisting residents with hydration pass. She went to each of the seven tables and assisted with preparing and serving drinks to residents. Staff C was observed touching various residents' shoulders and arms with her hand and continued to prepare and serve drinks without first washing or sanitizing her hands. She did not sanitize or wash hands at all during drink service, and passed hydration to over ten residents. At 12:44 p.m., Staff [NAME] was observed bringing bowls of soup to two residents. She placed them on the table, took a used napkin from a resident's hand and then pulled the waste can towards the table and then took the napkin and placed it in the waste can. Staff [NAME] then returned the waste can to next to the wall and went to the food service area to get two more bowls of soup. She did not wash or sanitize her hands between or after resident contact. After Staff [NAME] served the second set of bowls of soup to residents, she did go into the food service room and washed her hands at the sink. It was determined she did not wash her hands consistently between and after resident or trash contact. On 11/22/2019 at 10:00 a.m. an interview with the Dietary Manager and Registered Dietician revealed that their dietary staff have been trained and inserviced regularly with relation to hand hygiene. Both confirmed that staff should be sanitizing or hand washing between and after resident contact.

Based on observation, interview and record review, the facility failed to ensure dinnerware was clean and sanitized properly, due to the dishwashing machine's final rinse temperature was not at an adequate temperature of 180 degrees Fahrenheit, as per facility policy and manufacturer's recommendations. The facility reported that, of a current census of thirty-six residents, 100% received oral nourishment. Findings included: On 09/17/18 at 10:00 a. m., an initial brief tour of the kitchen was performed. During observation of the high temperature dishwasher, it was noted that the wash cycle reached 158 degrees Fahrenheit (F) but the rinse cycle only reached 173 degrees F. Per the label on the front of the dishwashing machine, the rinse cycle temperature was to reach 180 degrees F (as evidenced by photo documentation). Staff B, Certified Dietary Manager (CDM), stated that they had called a company to come and check the water booster. She stated that it was not working properly to get the rinse water up to 180 degrees (F). Record review of the (MONTH) Dishwashing Machine Temperature Log showed that the rinse cycle temperatures had only reached 180 degrees (F) 8 out of 49 opportunities, or 16%. Staff B, CDM, stated that she had not looked at the rinse temperatures from over the weekend. When asked if she had reviewed from the beginning of the month, she did not give an answer. Record review of the Dishwashing Machine Temperature Logs for both (MONTH) and (MONTH) (YEAR) was completed. The log for (MONTH) showed the rinse cycle had reached 180 degrees F only 23 out of 93 opportunities, or 25%. The log for (MONTH) showed the rinse cycle had reached 180 degrees F only 28 out of 93 opportunities, or 30%. Both Staff B, CDM and Staff C, CDM, verified the inadequate rinse temperatures on the logs. They stated that they would use the three sink compartment to wash the dishes and use paper and plastic dishware for the dishes until the company came to fix the dishwasher. On 09/17/18 at 11:00 a. m. ,the Nursing Home Administrator (NHA) visited the kitchen with the surveyors (2) regarding the dishwasher rinse temperatures. The dishwasher was started and she verified the rinse temperature was not reaching 180 degrees F. She also reviewed the label on the machine and stated that yes, the dishwasher was supposed to reach 180 degrees F for the rinse cycle. She stated that they had called the dishwasher company regarding the water booster but she was not aware the dishwasher was not getting up to the proper rinse temperature. The NHA stated that she had not looked at the logs regarding the rinse temperatures. The NHA reviewed the July, (MONTH) and (MONTH) temperature logs and confirmed there was a lack of 180 degrees rinse temperatures. She told the CDM staff that they would go to paper and plastic for lunch. When asked if there had been any outbreak of gastrointestinal issues with the residents, the NHA stated no, but she would check with the nursing staff. During an interview on 09/17/18 at 12:55 p.m., the NHA stated the electrician had come and fixed the dishwasher. It was reaching 180 degrees F for the rinse cycle. During observation on 09/17/18 at 1:00 p. m., the dishwasher machine rinse cycle was at 192 degrees F. Staff B, CDM, stated that she educated the daytime dishwashing person to let her know if the dishwasher was not up to the proper temperatures and would let the evening dishwashing person know also. On 09/18/18 at 9:49 a.m. the NHA stated that she was doing a QAPI related to dishwasher temperatures. She stated that she had in-serviced everybody and had worked with the CDM. She stated that the Registered Dietician was to be here today and will work with the CDMs today also. Record review of the facility's policy, Dishwasher Temperature, revision date of 09/19/18, reflected it is the policy of this facility to ensure dishes and utensils are cleaned under sanitary conditions through adequate dishwasher temperatures. All items cleaned in the dishwasher will be washed in water that is sufficient to sanitize any and all items. Manufacturer's instructions shall be followed for machine washing and sanitizing. For high temperature dishwashers (heat sanitization): the wash temperature shall be 150 to 166 degrees Fahrenheit. The final rinse temperature shall be 180 degrees Fahrenheit or above but not to exceed 194 degrees Fahrenheit. Water temperatures shall be measured and recorded morning, noon and evening. Corrective actions shall be taken for final temperatures below the required final rinse temperatures. These actions include informing the manager on duty and may also include use of 3-compartment sink and/or plastic dishware.

Based on observation, interview and record review, the facility failed to ensure the dishwashing machine was maintained in a safe operating condition as the final rinse temperature was not at an adequate temperature of 180 degrees Fahrenheit as per facility policy and manufacturer's recommendations. The facility reported a census of thirty-six with 100% of residents receiving oral nourishment. Findings included: On 09/17/18 at 10:00 a. m., an initial brief tour of the kitchen was completed. During observation of the high temperature dishwasher, it was noted that the wash cycle reached 158 degrees Fahrenheit (F), but the rinse cycle only reached 173 degrees F. Per the label on the front of the dishwashing machine, the rinse cycle temperature was to reach 180 degrees F (as evidenced by photo documentation). Staff B, Certified Dietary Manager (CDM), stated that they had called a company to come and check the water booster. She stated that it was not working properly to get the rinse water up to 180 degrees (F). Record review of the (MONTH) Dishwashing Machine Temperature Log showed that the rinse cycle temperatures had only reached 180 degrees (F) 8 out of 49 opportunities, or 16%. Staff B, CDM, stated that she had not looked at the rinse temperatures from over the weekend. When asked if she had reviewed from the beginning of the month, she did not give an answer. Record review of the Dishwashing Machine Temperature Logs for both (MONTH) and (MONTH) (YEAR) was completed. The log for (MONTH) showed the rinse cycle had reached 180 degrees F only 23 out of 93 opportunities, or 25%. The log for (MONTH) showed the rinse cycle had reached 180 degrees F only 28 out of 93 opportunities, or 30%. Both Staff B, CDM and Staff C, CDM, verified the inadequate rinse temperatures on the logs. They stated that they would use the three sink compartment to wash the dishes and use paper and plastic dishware for the dishes until the company came to fix the dishwasher. On 09/17/18 at 11:00 a. m. the Nursing Home Administrator (NHA) visited the kitchen with the surveyors (2) regarding the dishwasher rinse temperatures. The dishwasher was started and she verified the rinse temperature was not reaching 180 degrees F. She also reviewed the label on the machine and stated that yes, the dishwasher was supposed to reach 180 degrees F for the rinse cycle. She stated that they had called the dishwasher company regarding the water booster but she was not aware the dishwasher was not getting up to the proper rinse temperature. The NHA stated that she had not looked at the logs regarding the rinse temperatures. The NHA reviewed the July, (MONTH) and (MONTH) temperature logs and confirmed there was a lack of 180 degrees rinse temperatures. She told the CDM staff that they would go to paper and plastic for lunch. When asked if there had been any outbreak of gastrointestinal issues with the residents, the NHA stated no, but she would check with the nursing staff. During an interview on 09/17/18 at 12:55 p.m., the NHA stated the electrician had come and fixed the dishwasher. It was reaching 180 degrees F for the rinse cycle. During observation on 09/17/18 at 1:00 p. m., the dishwasher machine rinse cycle was at 192 degrees F. Staff B, CDM, stated that she educated the daytime dishwashing person to let her know if the dishwasher was not up to the proper temperatures and would let the evening dishwashing person know also. On 09/18/18 at 9:49 a.m. the NHA stated that she was doing a QAPI related to dishwasher temperatures. She stated that she had in-serviced everybody and had worked with the CDM. She stated that the Registered Dietician was to be here today and will work with the CDM's today also. Record review of the facility's policy, Dishwasher Temperature, revision date of 09/19/18 showed it is the policy of this facility to ensure dishes and utensils are cleaned under sanitary conditions through adequate dishwasher temperatures. All items cleaned in the dishwasher will be washed in water that is sufficient to sanitize any and all items. Manufacturer's instructions shall be followed for machine washing and sanitizing. For high temperature dishwashers (heat sanitization): the wash temperature shall be 150 to 166 degrees Fahrenheit. The final rinse temperature shall be 180 degrees Fahrenheit or above but not to exceed 194 degrees Fahrenheit. Water temperatures shall be measured and recorded morning, noon and evening. Corrective actions shall be taken for final temperatures below the required final rinse temperatures. These actions include informing the manager on duty and may also include use of 3-compartment sink and/or plastic dishware. Record review of the facility's policy, Kitchen Equipment, revised on 09/19/2018 showed it is the policy of this facility to ensure all kitchen equipment shall be maintained in good working order. All kitchen equipment shall be maintained in good working order, clean and free of debris. Manufacturer's instructions shall be followed for each individual equipment. Corrective action shall be taken for equipment not operating correctly. The action will be to inform the manager on duty. The manager will contact the maintenance department and/or maintenance service provider.

Based on observation, interview and record review, the facility failed to provide necessary nebulizer services for one of two respiratory residents (#22), of 6 medication administration sampled residents related to lung sounds, respiration rate and pulse rate, before and after nebulizer treatment. Findings included: Observation was conducted of medication administration on 09/19/18 at 9:55 a.m. to Resident #22 by Staff A, Licensed Practical Nurse (LPN), who administered [MEDICATION NAME] 15 mcg/2ml solution for nebulization every 12 hour for [MEDICAL CONDITIONS] and [MEDICATION NAME] / [MEDICATION NAME] 0.5 mg / 2 ml inhalation solution, every 12 hours for [MEDICAL CONDITION]. Staff A, LPN washed her hands and applied gloves. She placed the medications into the nebulizer cup. At approximately 10:06 a.m. she applied the mask and turned the nebulizer machine on. She talked to the resident throughout the nebulizer administration. At 10:12 a.m. she removed the mask from Resident #22's face and turned off the nebulizer machine. She dried her face with a tissue. She placed the nebulizer tubing back in the bag. Staff A, LPN rinsed out the mask and medication cup using gloves post washing of her hands. She laid the mask and cup on a barrier to dry. She washed her hands and left the room. During the nebulizer administration observation Staff A, LPN did not listen to lung sounds, check the respirations or pulse, before or after the nebulizer treatment. During an interview on 09/19/18 at 10:25 a.m. Staff A, LPN stated that she stays with the resident the whole time the nebulizer was being administered. She stated that Resident #22 hates the mask and will take it off. She stated that she will return and replace the mask and medication cup in the bag when they are dry. She stated that the resident was just getting over an Upper Respiratory Infection. She stated that she does not normally listen to lung sounds, check the respirations or pulse before or after the nebulizer treatment. During an interview on 09/19/18 at 2:15 p.m. the Director of Nursing (DON) stated the expectation regarding providing nebulizer medications is as follows: Prepare the medications, go to the room after you have knocked. Nurse should wash her hands. She should place medication in the nebulizer medicine cup. the nurse should listen to the lung sounds prior to treatment. Place the mask over the face and turn on the machine. the nurse should encourage the resident to take deep breaths. The nurse should stay with the resident until the treatment was complete. The nurse should reassess the resident by checking the lung sounds. She should clean the nebulizer medication cup and document. The DON reviewed the policy and procedure and verified that the procedure showed to obtain a baseline pulse, respiratory rate and lung sounds before and after and to instruct the resident to take a deep breath, pause briefly and then exhale normally. Repeat throughout the treatment. When informed that Staff A, LPN had not performed pulse, respirations and lung sounds before and after the treatment and stated that she did not normally perform them, the DON stated that she would have to educate her on the procedure. Resident #22 was admitted on [DATE] with a readmission on 01/04/2017. The face sheet showed [DIAGNOSES REDACTED]. Record review of the quarterly Minimum Data Set ((MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 99 (chooses not to participate or 4 or more items coded 0 because chose not to answer or gave nonsensical response. Resident had [MEDICAL CONDITIONS] listed in Section I, Active Diagnoses. Record review of Physician orders [REDACTED]. Record review of the facility's policy, Nebulizers (Updraft), dated 09/10 showed obtain baseline pulse, respiratory rate and lung sounds. Instruct the resident to take a deep breath, pause briefly and then exhale normally. Repeat pattern throughout treatment. Obtain post-treatment pulse, respiratory rate and lung sounds and document findings on the MAR indicated [REDACTED].

Based on observation, interview and policy review, the facility failed to post daily staffing data that was readily accessible to residents and visitors. Findings included: During an observation of the facility for 9/19/18, daily staffing data was not identified as posted. In an interview with the Nursing Home Administrator (NHA) on 9/19/18 at 2:10 p.m., she confirmed that staffing data information was not posted in a place that was accessible to residents and visitors. She further stated the data was calculated, and was on the back of the assignment sheet, which was kept in the charting room. The NHA confirmed staff/resident assignment information was posted, but not staffing data information. A review of a facility-provided policy titled, 'Nurse Staffing Posting Information' dated 1/2018 reflected: 1. The nurse staffing information will be posted on a daily basis and will contain the following information: a. Facility Name b. The current date. c. Facility current census d. The number of licensed and certified staff directly responsible for resident care per shift 2. The facility will post the nurse staffing data at the beginning of each shift. 3. The information posted will be: a. Presented in a clear and readable format b. In a prominent place readily accessible to residents and visitors

Based on observation, record review, and interview, the facility failed to ensure the drug regiment for one (#18) out of five sampled residents was free of unnecessary medications related to inadequate monitoring of blood pressure and pulse of resident prior to the administration of hypertensive medications and administering hypertensive medications outside of the ordered parameters. Findings included: The policy titled, Medication Administration - General Guidelines, dated 05/16, stated, Medications are administered as prescribed in accordance with manufacturer's specifications, good nursing principles and practices, and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. A review of policy section titled, Medication Administration, page 3, stated, Obtain and record any vital signs as necessary prior to medication administration. Resident #18 was admitted on [DATE] and 1/4/18, per the Profile Face Sheet. The facesheet included [DIAGNOSES REDACTED]. The Significant Change in Condition Minimum Data Set (MDS) revealed a Brief Interview of Mental Status (BIMS) 14, cognitively intact. The MDS identified hypertension as an active diagnosis. A review of (MONTH) (YEAR) physician orders [REDACTED]. Losartan 50mg (milligram) tablet. (Hold if systolic BP (blood pressure) <110 or if diastolic BP or pulse <60). By mouth every day [MEDICAL CONDITION](hypertension). The order and start date for Losartan was 7/8/18. [MEDICATION NAME] (Hold if systolic BP <110 or if diastolic BP or pulse <60) - by mouth [MEDICATION NAME] 12.5mg every 12 hours for HTN. The order and start date for [MEDICATION NAME] was 7/6/18. [MEDICATION NAME] 10mg tablet (Hold if systolic BP <110 or if diastolic BP or pulse <60) - 10mg by mouth hour of sleep for HTN. The order and start date for [MEDICATION NAME] was 4/23/18. The review of the (MONTH) (YEAR) Medication Administration Record [REDACTED] Blood pressure and pulse for Resident #18's 9:00a.m. [MEDICATION NAME] dose was not documented on 8/2, 8/3, 8/5 - 8/13, 8/24, and 8/27/18. The clinical record indicated a blood pressure for the 9:00 a.m. dose of [MEDICATION NAME] was obtained on 8/20 and 8/31, without record of pulse at that time. The MAR indicated [REDACTED]. A review of MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The clinical record did not identify documentation of blood pressures for the 9:00 p.m. administration of [MEDICATION NAME] or [MEDICATION NAME] on 8/10, 8/15-8/17, 8/19, 8/22, 8/25-8/26, 8/29-8/30. The clinical record did not include documentation of pulse for the 9:00 p.m. administration of [MEDICATION NAME] and [MEDICATION NAME] on 8/1, 8/3-8/5, 8/7-8/26, and 8/28 - 8/30/18. The clinical record revealed the 9:00 p.m. dose of [MEDICATION NAME] and [MEDICATION NAME] was administered outside the parameters on 8/27 (148/58), and 8/31/18 Resident #18's blood pressure was 148/55 at 7:19p.m., [MEDICATION NAME] was administered. A review of (MONTH) (YEAR) physician orders [REDACTED]. [MEDICATION NAME] 12.5mg (Hold if systolic BP <110 or if diastolic BP or pulse <50 - by mouth [MEDICATION NAME] 12.5mg every 12 hours for HTN. The order date was 9/5/18. Losartan 100mg tablet (Hold if systolic BP<110 or if diastolic BP or pulse <50) - by mouth every day for HTN, order date 9/4/18. [MEDICATION NAME] 10mg tablet (Hold is systolic BP <110 or if diastolic BP or pulse <50. - 10mg by mouth every day for HTN, order date 9/4/18. A review of the (MONTH) MAR, vital stats, and medication record for Resident #18 indicated a blood pressure and pulse was not documented for the 9:00 a.m. dose of [MEDICATION NAME] on 9/3, 9/5, 9/7-9/9, and 9/12-9/18. A pulse was not documented for the 9:00 a.m. dose of [MEDICATION NAME] on 9/11/18. The review of the (MONTH) administration of Losartan did not indicate documentation of pulse for Resident #18 on 9/5-9/14, 9/16-9/17, and 9/19. On 9/5/18, the administration time and dosage of Losartan changed to 100mg at 12:00 p.m. The clinical record did not identify a blood pressure on 9/16 at the time of Losartan administration. The (MONTH) MAR indicated [REDACTED]. The clinical record identified a pulse was not documented on 9/1-9/3, 9/5-9/10, 9/12, 9/14-9/15, and 9/17-9/18. A review of the clinical record indicated a blood pressure was not documented for the administration of [MEDICATION NAME] on 9/5-9/10, 9/12, 9/14-9/15, and 9/17-9/18. The clinical record revealed neither blood pressure nor pulse was documented for the 9:00 p.m. dose of [MEDICATION NAME] on 9/1-9/2, 9/4-9/6, 9/10, and 9/12-9/13. Further review of the clinical record identified a pulse was not documented at the time of [MEDICATION NAME] administration on 9/3, 9/7-9/9, 9/11, 9/14-9/16, and 9/18. During an interview on 9/19/18 at 12:12p.m., Staff D, Registered Nurse (RN), stated she documented Resident #18's blood pressure prior to the administration of 9:00 a.m. of [MEDICATION NAME]. She stated she documents blood pressures in the ancillary box of MAR. She reviewed the documentation for [MEDICATION NAME] and the ancillary box was empty. She indicated in the area for Losartan, a blood pressure was documented in ancillary box. She stated the order would have to be redone so the blood pressure box for [MEDICATION NAME] would show up. On 9/19/18 at 2:04 p.m. an interview with the DON was conducted, she stated if parameters were ordered, she would expect blood pressures and pulses to be taken, prior to administration and documented. She indicated blood pressures and pulses would be documented in the MAR indicated [REDACTED]. A review of nurse's notes did not identify additional documentation of blood pressures or pulses from 8/4 to 9/18/18. On 9/20/18 at 11:45 a.m., the DON stated her expectation would be that blood pressure was taken 15 minutes prior to administration of medications.

Based on observations, interview, and record review, the facility failed to take measures to prevent accidents and injuries for 1 of 1 (#10) residents reviewed for non-pressure related skin conditions. Resident #10 was found to have a hematoma resulting from an attempt to transfer the resident with a lift. Findings included: Observation of the resident on 10/03/17 at 9:30 a.m. during the initial tour revealed that the resident had a fist size hematoma that was blackish/purple in color on her lower right calf. Observations of the resident on 10/03/17 at 10:05 a.m. revealed that the resident had a fist size hematoma on the right lower outer extremity that was blackish/purple in color and swollen and oozing blood. The resident was observed to have her foot resting on a disposable chuck. Interview with the resident at this time revealed that the resident hit her leg against the lift during a transfer. Observation of the resident on 10/03/17 at 2:40 p.m. revealed the resident sitting in her wheelchair at her bedside, with her right lower leg noted to be purple/black in color, with no drainage noted. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed that Resident #10 was usually understood and understands others. This document reflected the resident's BIMS (Brief Interview for Mental Status) score of 13, (indicating intact cognition) and that the resident required extensive assistance from one person for bed mobility, and extensive assistance from two persons for transfers. Review of the Annual MDS dated [DATE], revealed that the resident was usually understood and understands others , had a BIMS score of 14 indicating intact cognition, required extensive assist of 1 person for bed mobility, and extensive assist of 2+ persons in transfers. Review of Resident #10's record revealed a Skin Evaluation Record dated 09/25/17. This document indicated that the date of origin was 9/24/17 and that the resident had a hematoma on the right shin. A description indicated, During transfer to SARA lift right lower leg (shin) rubbed against an unknown object and it was detected by a CNA (Certified Nursing Assistant) reported to RN. Review of the nurse's note dated 09/24/17 and written at 12:04 a.m. revealed that the nurse was notified by the CNA that the resident's leg was swollen. The note indicated that on inspection of the resident's right outer shin there was a hematoma the size of an egg and that measurements at that time of both legs were found to be 12.5 inches for the right leg and 12.0 inches for the left leg. Review of the nurse's note dated 09/25/17, written at 6:41 a.m. revealed that there was a Hematoma to the right shin 4in x 3in, with the circumference of the left leg 11 inches and the circumference of the right leg 12 inches. Review of the nurse's note dated 09/27/17, written at 10:10 p.m. (22:10) revealed that the hematoma measured 11.5cm length, 9.5cm width Review of the nurse's notes from 09/24/17 through 10/4/17 reflected the presence of a wound on the resident's right lower leg. Interview on 10/05/17 at 2:15 p.m. with the Risk Manager revealed that it was reported to her that Resident #10 had an injury to her right lower leg. She reported that during her investigation, while interviewing the staff involved in the incident, she was told that during the transfer while using the lift the resident had bumped her leg on the bed, which caused a hematoma. She reported that currently the resident is on Plavix 75 mg once a day, and Aspirin 81 mg once a day, and that on 9/24/17 the resident was on the same dosage of blood thinners. She reported that the resident had fragile skin, and [DIAGNOSES REDACTED]. Continued interview of the Risk Manager at this time revealed that she was told that two staff were assisting the resident with the transfer from the bed to the Sara Lift and that they were not sure what the resident's leg hit against, but that they did hear the bump at the time of the transfer. When asked by this surveyor about the staff's ability to use the lift appropriately, she reported that she did not have the staff demonstrate the ability of using the lift appropriately. Additionally, she reported that there was no in-service done with the staff at the time of the incident related to resident transfers. The Risk Manager reported, I will do an in-service now. Interview with staff H on 10/5/17 at 4:10 p.m. revealed that she, along with another aide were about to transfer the resident on the day in question. She reported that the resident was sitting on the bed and that the support belting was placed on the resident and clipped in place. She reported that the excess strap was hanging down the side of the resident and was rubbing on the resident's leg. She reported at that time she noted a red mark on the resident right lower leg and immediately notified the nurse. While in Resident #10's room on 10/5/17 at 4:20 p.m. with the permission and presence of Resident #10, Staff H demonstrated how the support belting worked along with the lift and showed this surveyor the belting that she believed rubbed against the resident's leg. The belting was noted to be a soft (seat belt like) material with no hard clips or metal on the excess length of the belt. The Sara lift was bought into the resident's room, and the resident initially indicated that she hit her leg on the leg rest located on the actual lift. An inspection of both the right and the left leg rest revealed that they were both made of a firm sponge like material and had no sharp, jagged, or hard surfaces. Review of the facility policy titled Incident and Accident Protocol dated 01/2017, with a revised date of 2/2017 revealed that The resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents.

Based on observation of the resident and interview with facility staff, the facility failed to ensure infection control practices were followed related to observation of a wound vac lying on the floor, with the tubing spilling out of the carrying tote, for one (#56) of 25 sampled residents observed in stage I. Findings included: On 10/03/2017 at 2:30 p.m., Resident # 56 was observed sitting in the activity room socializing. Under her chair was observed a small dark 'tote bag' lying on the floor with tubing extending out from the bag resting on the floor. Staff Nurse A confirmed, at the time of the observation, that the tote bag contained a wound vac, which was okay to be on the floor as it was in the tote bag. She confirmed that the tubing shouldn't be on the floor. During the observation, Nurse A realized the wound vac was beeping and commented that the beeping was probably due to a kink in the tubing. Once the nurse straightened the tubing and hung the tote bag on the back of the resident's chair, the beeping stopped. Observation of Resident #56 in the dining room at lunch on 10/04/2017 at approximately 1:15 p.m. revealed the tote bag with the wound vac inside, resting on the floor under her chair. The tubing extended out of the tote bag and was observed resting on the floor. Record review revealed Resident # 56 was admitted to the facility with a wound to her inner right thigh and back of her right calf. During wound care observation, on 10/04/2017 at 3:15 p.m., Staff Nurse C commented, the resident was scratched with something that was highly bacterial. Interview with Resident #56 on 10/05/17 at 9:00 a.m. in her room revealed that she was a gardener and she must have rubbed up against something that scratched her while she was out in the garden. She reported that the site quickly got hard, red and was oozing pus. She reported she went to the emergency room , where she was admitted to the hospital. Review of the initial note, dated 09/04/2017, from the Wound Care company, revealed under Assessment, the [DIAGNOSES REDACTED].

Based on interview and record review, the facility did not ensure that the representative for one (#6) of 18 sampled residents was notified of a change of condition after a skin tear was found and later after a toe injury was identified. Findings included: During a Stage 1 interview on 07/12/16 at 11:09 a.m., with a daughter of Resident #6, she said that the resident had sustained skin tears and the family had not been notified. At the end of the interview, another daughter, who was the resident ' s representative, arrived and said that she was disappointed that she had not been notified about the skin tears because she found the care to be very good. She said that the family came in and found the skin tears. The resident was admitted for therapy after surgery. She had a history of [REDACTED]. On 06/22/16 at 4:16 a.m., the nurse ' s note documented finding a skin tear on the resident ' s right upper arm. There was no documentation in the note that the resident ' s representative had been notified. Review of additional documentation also did not find that notification had been made. On 06/27/16 at 11:47 p.m., the Skin Evaluation Form documented a 2 and ¼ inch skin tear on the upper mid forearm. Again there were no notes that the resident ' s representative had been notified. In an interview with the Director of Nursing (DON) at 11:40 a.m. on 07/14/16, she said that the resident ' s care plan meeting was scheduled for the next day and she thought that was why the nurse didn ' t call the resident ' s representative that late. On 06/24/16 a toe injury was identified on the Skin Evaluation Form. There were no nurses' notes documenting that the representative was notified. In an interview with Nurse A on 07/14/16 at 9:26 a.m. she said that if an aide came to her to report a skin tear, she would look at the injury to assess and cover with a non-adherent gauze dressing to protect the wound. She would ask the resident if she knew what happened. She would notify the physician, the DON (Director of Nurses), and the family. She would fill out the report and get orders from the physician and start the treatment. Nurse A said that she would then document the injury, treatment provided and who was notified in the nurses' notes. She said that the aides are awesome about reporting everything. During the interview with the DON, on 07/14/16 at 11:40 a.m., she confirmed that the resident ' s representative should be notified when there is a change of condition unless the representative has signed a formed saying don't call for this problem or don't wake me until the morning. The facility policy for Change in a Resident's Condition or Status dated 2001 (Revised February , was reviewed. #3 Unless otherwise instructed by the resident, the Nurse Supervisor/Charge nurse will notify the resident ' s family or representative (sponsor) when: a. the resident is involved in any accident or incident that results in an injury including injuries of an unknown source. 4. Except in medical emergencies, notifications will be made within twenty four (24) hours of a change occurring in the resident ' s medical/mental condition or status. The policy was not followed for two of the three injuries sustained by the representative.

Based on observation, interview and policy review the facility failed to ensure that equipment was maintained in a sanitary manner for 1 (room 104) of 20 rooms sampled during the stage one assignments related to an elevated toilet chair with a rust colored uncleanable surface on the support bars located directly below the resident when utilized. Findings included: An observation made on 7/11/2016 at 2:13 p.m. of room #104's restroom revealed an elevated commode chair with metal support bars that were rust colored, rough and an uncleanable surface. Photographic evidence was obtained. An observation on 7/13/2016 at 10:25 a.m. of room #104's restroom was conducted revealing the elevated commode chair in the same condition, with rough, rust colored support bars that were an uncleanable surface. An interview and observation was conducted on 7/14/2016 at 11:27 a.m. with the nursing home administrator (NHA). The NHA confirmed the condition of the commode chair in room 104's restroom. The NHA responded that recently the facility purchased new assistive devices. The NHA believed they purchased 10 new devices. The NHA stated that rooms were checked weekly by housekeeping to complete a throughout cleaning. The NHA expected that staff who noticed a rust colored uncleanable surface would remove the device from resident use and replace it. The NHA also responded that staff were educated on what to do with equipment in this condition. The NHA responded that the assistive device would be removed from resident use and a new one would be placed in the room immediately. The NHA administrator provided a copy of the facility ' s policy for Maintaining a Safe, Clean, Comfortable and Homelike Environment (no date provided). The NHA confirmed that this was a current policy utilized by the facility. Policy: The facility will accommodate, to the extent possible. A personalized, homelike environment that recognizes the individuality and autonomy of each resident. Policy Explanation and Compliance Guidelines: 6. Report any furniture and/or equipment in disrepair to Maintenance promptly. The policy included a weekly Environmental Rounding sheet with expected observations: 1. Are resident care equipment clean and properly stored such as a IV, tube feeding, lifts, oxygen, nebulizers, vital sign machine, w/c (wheelchair)? 2. 3.