Every finding on record at Clinch Valley Medical Center

Based on resident interview, family interview, staff interview, clinical record review, and facility document review, the facility staff failed to accurately document education for the flu and pneumococcal vaccines for 5 of 5 current resident reviews, Residents #2, #3, #7, #9, and #16. The findings included: 1. For Resident #2 (R2), the facility failed to provide documented evidence of education regarding risks verses benefits for the flu and pneumococcal vaccines. R2's diagnosis list indicated diagnoses, which included, but not limited to hip fracture, hypertension, and diabetes.The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 3/6/26 assigned R2 a brief interview for mental status (BIMS) summary score of 11 out of 15 for cognitive abilities, indicating the resident was moderately impaired. Interview with R2 on 3/25/2026 at 11:50 am, resident was somewhat groggy and confused. When asked about the flu vaccine resident stated he had received it, when asked about pneumonia vaccine he was unsure, stated he had received all his vaccines at his local pharmacy. On 3/25/25, the MDS Coordinator/RN, provided paperwork from the paper chart to indicate the resident had refused their flu vaccine upon admit and that he had not received the pneumovax and the patient and family were unsure/unable to determine but the patient does not want. No documentation on if the resident received education on the influenza or pneumococcal vaccine located in the paper chart or electronic record at the start of the survey. 2. For Resident #3 (R3), the facility failed to provide documented evidence of education regarding risks verses benefits for the flu and pneumococcal vaccines. R3's diagnosis list indicated diagnoses, which included, but not limited to CVA with left sided weakness. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 2/4/26 assigned R3 a brief interview for mental status (BIMS) summary score of 11 out of 15 for cognitive abilities, indicating the resident was moderately impaired. Interview with R3 on 3/25/26 at 11:45 am revealed that R3 reports having his Covid 19 and Influenza vaccine every year in the month of October but was unable to do so this year because he was incapacitated and in the hospital. He feels he has had a pneumococcal vaccination over the last few years. He thinks his daughter may be able to verify. He reports using a local pharmacy.Interview with R3's daughter on 3/25/2026 at 12:35 pm, she stated she was sure they were asked about vaccination upon admission and remembers answering questions about timelines on vaccines. R3 generally receives his vaccinations at his pharmacy or doctor's office.On 3/25/26, the MDS Coordinator/RN provided paperwork to indicate the resident had refused their flu vaccine and pneumovax vaccine upon admit, per family R3 had been vaccinated for pneumonia in the last five years. She also provided a faxed copy of vaccinations for R3 indicating he had been vaccinated for the flu on 10/10/24 but no record of the pneumovax. No documentation on if the resident received education on the influenza or pneumococcal vaccine located in the paper chart or electronic record at the start of the survey. 3. For Resident #7 (R7), the facility failed to provide documented evidence of education regarding risks verses benefits for the flu and pneumococcal vaccines. R7's diagnosis list indicated diagnoses, which included, but not limited to renal cell carcinoma with metastatic, CHF, acute cholecystitis, stage III sacral ulcer. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 2/2/26 assigned R3 a brief interview for mental status (BIMS) summary score of 15 out of 15 for cognitive abilities, indicating the resident was cognitively intact. Interview with R7 on 3/25/2026 at 11:30am, revealed R7 in his room, in bed. He reports being up to date on his Influenza shot, had the Covid 19 shot and booster, and feels positive he has taken the pneumococcal vaccine within the last two or three years. He does not remember if he spoke to anyone upon admission as he was very sick when he came in the facility and had been transferred from another state.On 3/25/2026, the MDS Coordinator/RN, provided paperwork to indicate that upon admit, the resident had refused their flu vaccine and refused the pneumococcal vaccine due to being on immune therapy. No documentation on if the resident received education on the influenza or pneumococcal vaccine located in the paper chart or electronic record at the start of the survey.4. For Resident #9 (R9), the facility failed to provide documented evidence of education regarding risks verses benefits for the flu and pneumococcal vaccines. R9's diagnosis list indicated diagnoses, which included, but not limited to UTI, hypertension, diabetes. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 3/18/26 assigned R9 a brief interview for mental status (BIMS) summary score of 13 out of 15 for cognitive abilities, indicating the resident was cognitively intact. Interview with R9 on 3/25/2026 at 11:25am, resident in her room and sitting in her chair, reports she had the last flu vaccine, Covid as well and knowns she has had all the last ones regarding the pneumococcal vaccine. She could not remember the year/s she had a pneumococcal vaccine but feels it was after 2020. On 3/25/2026, the MDS Coordinator/RN, provided paperwork to indicate that upon admit, the resident had received the flu vaccine prior to coming to the facility (current) and had previous doses of the pneumococcal vaccine, but dates where not documented in the electronic record. She also provided a vaccination record from R9's physician. No documentation on if the resident received education on the influenza or pneumococcal vaccine located in the paper chart or electronic record at the start of the survey.5. For Resident #16 (R16), the facility failed to provide documented evidence of education regarding risks verses benefits for the flu and pneumococcal vaccines. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 3/26/26 assigned R16 a brief interview for mental status (BIMS) summary score of 14 out of 15 for cognitive abilities, indicating the resident was cognitively intact. Interview with Resident #16 (R16) on 3/25/2026 at 12:15 PM revealed, R16 sitting up in a chair in her room, alert and oriented. R16 stated that she took the 1st COVID vaccine, and it messed her up, she has had the pneumonia vaccine not sure which one it was or when, has had pneumonia twice and stated the pneumonia shot is not going to help me. Asked if they offered her the vaccines here (FLU, Pneumonia and Covid), she stated they did but again stated she wasn't taking any more vaccines the COVID vaccine really messed her up. When asked if education of how either taking a vaccine or not taking one would hurt or help her, she responded, yes, and I still don't want it. No documentation located in the electronic record or paper copy provided regarding documentation of education and acceptance or refusal, at the time of the interview. Requested and reviewed a facility policy titled, Inpatient Influenza and Pneumococcal Screening and Vaccination with a revision date of 10/2017, section: Procedure, which read in part, . 2. The screenings for pneumococcal disease will be done 365 days a year. The screening for influenza will be done form October 1st through March 31st. 3. At the end of the screening process, the most current versions of the applicable Vaccine Information Statements ([NAME]) will be given to the patient and will be used to assist in educating the patient regarding vaccines . On 3/25/2026, the MDS Coordinator/RN, provided paperwork to indicate that upon admit, the resident had refused all vaccinations and does not want the Influenza or pneumococcal vaccination. No documentation on if the resident received education on the influenza or pneumococcal vaccine located in the paper chart or electronic record at the start of the survey. Requested and reviewed a facility policy titled, Documentation with a revision date of 2/2024, section: Patient Care Notes, which read in part, .Patient care Notes are sufficiently detailed to contribute to the comprehensive survey of the patient, which the entire clinical record is designed to provide An Interview with Infection Preventionist on 3/24/2026 at 3:00 pm revealed they do not keep a record of educating the residents about the flu or pneumonia vaccines and only ask if they have been vaccinated. Interview with the MDS Coordinator/RN on 3/25/2026 at 1:05pm, she provided verbal confirmation of flu vaccination documentation she had just entered in the electronic chart regarding the current residents. She stated it was supposed to have been done previously but had not been done. She discussed the Education Provided tab in the electronic record that asks questions about influenza and pneumococcal vaccines. She reports it is not being utilized as it should be by staff. When completing her MDS assessments she provides handouts for vaccine recommendations for flu, Covid and pneumococcal. while she does discuss vaccines and provide handouts, she will make sure there is documentation of the resident accepting or declining the educational materials going forward and that staff are educated on documentation.Interview with Registered Nurse (RN) #4 (RN4) on 03/25/2026 at 2:25 PM, RN4 states on admission we ask about vaccines, RSV, pneumonia, FLU, and COVID we also include the Flu vaccination status on the bedside shift report (blank copy given), I've honestly never had anyone tell me they hadn't got the vaccine that wanted it. When asked what would you do if they do want the vaccine, she reports she would call infection control.Interview with RN#1 (RN1) on 3/25/2026 at 2:25 PM, when asked if they educated the residents about vaccines, if they hadn't gotten them or refused to get them, RN1 stated they would and they would put it in a note. When asked the question regarding vaccines on the admission assessment, RN1 stated, no we just know to ask. Interview with the MDS Coordinator/RN on 3/25/2026 at 1:05pm, she provided verbal confirmation of flu vaccination documentation she had just entered in the electronic chart regarding the current residents. She stated it was supposed to have been done previously but had not been done. She discussed the Education Provided tab in the electronic record that asks questions about influenza and pneumococcal vaccines. She reports it is not being utilized as it should be by staff. When completing her MDS assessments she provides handouts for vaccine recommendations for flu, Covid and pneumococcal. while she does discuss vaccines and provide handouts, she will make sure there is documentation of the resident accepting or declining the educational materials going forward and that staff are educated on documentation.Interview with the Infection Preventionist on 3/25/2026 at 4:30 PM, when asked about the pneumonia policy, she reports they don't have a policy on the pneumonia vaccine and don't have one specific for skilled patients but have one for the medical center. When asked if they were following the one for the medical center in regards to the skilled nursing unit, she replied, we are in the process of updating the current to include the skilled residents. The policies are not specific to LTC residents, but policies do include the skilled and hospital together, being organizational wide. The IP had a copy of the Infection Control requirements for documenting education on vaccines per CMS Appendix PP. On 03/25/26 at 4:30 p.m., an end of the day meeting with the Chief Nursing Officer, Assistant Administrator, Infection Preventionist (IP), RN/MDS Coordinator, Administrator, and Quality Risk Manager held. Discussed at the meeting was the inability to locate documentation on vaccination education, with the resident declining or accepting the educational materials. The facility does not have a separate procedure for skilled nursing at this time regarding vaccinations or documentation of education. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to follow establish infection control guidelines for 1 of 5 current residents in the survey sample, Resident #9.The findings included: The facility nursing staff failed to wear gloves when accessing a peripheral IV site.Per the Cleveland Clinic a peripheral IV is a thin, flexible tube that healthcare providers use to draw blood and administer treatments, IV fluids, and medications.Resident #9's diagnoses included urinary tract infection, hypertension, and diabetes.Section C (cognitive patterns) of Resident #9's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 03/18/26 included a brief interview for mental status (BIMS) score of 13 out of a possible 15 points, indicating Resident #9 was cognitively intact.Resident #9's comprehensive care plan included the focus area IV therapy. Interventions included routine site care.Resident #9's provider orders included Furosemide (Lasix) IV 40 mg and normal saline flush IV 10 milliliters (mls) as needed for IV-line flush.On 03/24/26 at approximately 12:00 p.m., Registered Nurse (RN) #1 was observed accessing Resident #9's peripheral IV. RN #1 removed the swab cap, flushed the IV line with 5 ml's of saline, slowly injected the medication Furosemide, flushed the IV line with 5 ml's of saline and replaced the swab cap. RN #1 did not apply any gloves prior to completing this procedure.On 03/24/26 at 1:05 p.m., during an interview with RN #1 this staff verbalized that they did not wear any gloves during the IV procedure and stated if the resident had been on contact isolation she would have.On 03/24/26 at 4:35 p.m. during an end of the day meeting with the Chief Nursing Officer, Assistant Administrator, Infection Preventionist (IP), RN/MDS Coordinator, Administrator, and Quality Risk Manager the issue with RN #1 not applying gloves when accessing a peripheral IV was reviewed. The IP acknowledged RN #1 should have applied gloves before accessing the IV.On 03/24/26 the IP provided the surveyor with a copy of their policy titled, Bloodborne Pathogen Exposure Control Plan. This policy read in part, .Tasks and Procedures That Are Performed By Employees In Which Occupational Exposure May Occur.Intravenous/intra-arterial therapy.Gloves will be worn in the following situations.when performing vascular access procedures.No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on interviews and document reviews, the facility staff failed to provide NOMNC notifications for two (2) of three (3) residents selected for SNF (Skilled Nursing Facility) Beneficiary Notification Review (BNR). (These two (2) residents will be identified as BNR Resident-B and BNR Resident-C.) The findings include: Three (3) residents were selected for SNF Beneficiary Notification Review. These three (3) residents were selected from the list of Medicare beneficiaries who were discharged from a Medicare covered Part A stay with benefit days remaining in the past 6 months prior to the survey; this list was provided by facility staff members. Two (2) of the three (3) residents were reported to not have been provided the NOMNC (CMS 10123) (Notice of Medicare Non-Coverage). Information provided by the facility's Interim Unit Manager (IUM) indicated: 1. BNR Resident-B had coverage still effective upon discharge . BNR Resident-B was discharged after the completion of intravenous antibiotic therapy. BNR Resident-B was discharged to their home with home health services. 2. BNR Resident-C was discharged with remaining days of coverage after the completion of intravenous antibiotic therapy. BNR Resident-C was discharged to home; BNR Resident-C was documented as refusing home health services. On 1/10/23 at 1:38 p.m., the facilitys' IUM reported that neither BNR Resident-B's nor BNR Resident-C's discharge was resident initiated, but that both residents were involved in the discharge planning and were agreeable to the discharge. The IUM reported that due to both residents agreeing with the discharge that neither were provided NOMNC notification. The IUM reported the facility did not have a written policy and procedure to guide the use of NOMNC notifications. On 1/10/23 at 4:44 p.m., the survey team met with the facility's IUM and Chief Nursing Officer (CNO). The failure of facility staff to provide BNR Resident-B and BNR Resident-C with NOMNC notification when discharged with benefit days remaining was discussed. The absence of a written policy and procedure to address the use of the NOMNC notification was discussed.

Based on observation, staff interview, and facility document review the facility staff failed to ensure food was properly stored for one of one unit. The findings were: 1. The facility staff failed to consistently document refrigerator and freezer temperatures and failed to document what action was taken when temperatures fell outside the acceptable range. In the afternoon of [DATE], the chief nursing officer (CNO) accompanied the surveyor to the clean utility room to observe the unit's only patient refrigerator. The refrigerator and freezer's temperature logs were reviewed for the months of [DATE] and February 2021. · [DATE] Nourishment Temperature Log for the Refrigerator: For the 31 days in [DATE], there were eight (8) days refrigerator temperatures were not documented. On the Freezer Temperature Log, there were ten (10) days freezer temperatures were not documented. · February 2021 Nourishment Temperature Log for the Refrigerator: For the 16 days prior to the survey, there were nine (9) days refrigerator temperatures were not documented. There was one (1) day the temperature fell below the acceptable range which was noted on the log as 33 degrees to less than 40 degrees. (February 9th: temperature = 28 degrees). There was no documented action taken to correct the refrigerator temperatures. On the Freezer Temperature Log, there were nine (9) days freezer temperatures were not documented. · The logs' instructions read to plot temperatures daily with initials, if the temperature was out of range notify dietary services and adjust the temperature control, re-check temperature in 30 minutes, plot 2nd temperature, and if temperature remains out of range send work order to Plant Operations for repair. 2. The facility staff failed to dispose of orange juice that had expired. On [DATE] at 5:55 p.m., the interim unit manager accompanied the surveyor to the same patient refrigerator in the clean utility room. Items observed in the refrigerator: whole milk, 2% milk, Ensure, grape juice, apple juice, soft drinks, and applesauce. There were five (5) cartons of orange juice found with a sticker on it dated [DATE]. The interim nursing manager spoke with someone in the dietary department on the phone and then reported to the surveyor the date on the sticker was the expiration date. The interim nurse manager acknowledged the orange juice was therefore expired and should be removed. She removed the expired orange juice from the refrigerator. The interim nurse manager reported it was the night shift nurses' responsibility to document the refrigerator and freezer temperatures and dispose of expired food/drink items. On [DATE] at 4:18 p.m., the CNO reported the unit had not been closed at any time during the calendar year 2021 and provided the facility's policy titled, Temperature Logs: Refrigerators, Freezers, and Warmers. The policy read in part, Patient Nourishment Refrigerators A. Daily logs will be maintained to monitor temperature of each refrigerator used for patient food and drinks. B. Temperatures are to be maintained between 33 to 40 degrees Fahrenheit. C. Any temperature out of recommended range will have the temperature readjusted. A recheck of the temperature will be obtained in 30 minutes. If the temperature is still out of range, Plant Operations will be notified of need for repair. Dietary will be notified to remove food items. D. Nourishment refrigerators will be cleaned weekly. And, Nourishment Freezers A. Daily logs will be maintained to monitor the temperature of each freezer used for food or drinks. B. Temperatures are to be maintained at or below 0 degrees Fahrenheit. C. Any temperature out of recommended range will have the temperature readjusted. A recheck of the temperature will be obtained in 30 minutes. If the temperature is still out of range, Plant Operations will be notified of need for repair. Dietary will be notified. D. Nourishment freezers are to be cleaned weekly, defrosted as needed. On [DATE] at 7:15 p.m., the facility's chief executive officer (CEO), chief operating officer (COO), chief nursing officer (CNO), and interim nurse manager were informed of the above described findings.

Based on staff interview and clinical record review the facility staff failed to ensure 2 of 10 residents were free from unnecessary medications, Resident #8 and Resident #14. The findings included: 1. For Resident #8 the facility staff failed to provide a diagnoses/indication for use for the [CONDITION(S)] medication [MEDICATION(S)] ([MEDICATION(S)]). Resident #8's admission H and P (history and physical) listed diagnoses that included, but not limited to septic right lower extremity joint present on admission, hx of [CONDITION(S)], history of [CONDITION(S)] ([CONDITION(S)]), hypertension, history of sleep apnea, and history of [CONDITION(S)]. Resident #8's admission MDS (minimum data set) assessment had not been completed, however resident is alert and oriented to person, place, time and situation. Resident #8's clinical record was reviewed on 02/17/21 and contained a physician's order summary, which read in part [MEDICATION(S)] Tab ([MEDICATION(S)] Tab) PO (by mouth) 0.5 mg HS (bedtime) This order did not have a diagnosis or indication for use. Surveyor spoke with the interim nurse manager on 02/17/21 at approximately 4:00 pm regarding resident's [MEDICATION(S)] and the reason for receiving it. Interim nurse manager stated that it was a home med and that resident took it because he gets anxious at night and it helps him sleep. Pharmacy manager was present while surveyor was discussing the residents medication with the interim nurse manager, and stated that resident had a [CONDITION(S)] that caused his anxiety. Surveyor asked the pharmacy manager if the physician's order summary should list a diagnosis or indication for use for the medication and they stated, yeah, it probably should. The concern of the medication, [MEDICATION(S)], being used without a diagnosis/indication for use was discussed with the administrative team (administrator, chief nursing officer, interim nurse manager) during a meeting on 02/17/21 at approximately 7:15 pm. No further information was provided prior to exit. 2. The facility staff failed to ensure there was in indication for use/diagnosed condition for a [MEDICATION(S)] ([MEDICATION(S)], an anti-depressant) order for Resident #14. Resident #14's clinical record was reviewed with the facility's interim nurse manager on 02/17/21. The admission history and physical (H&P) noted the resident's diagnoses included, but were not limited to, dehydration with acute kidney injury, weakness and conditioning with multiple falls, urinary tract infection positive for E-coli requiring IV (intravenous) antibiotics, [CONDITION(S)] (low platelet level), [CONDITION(S)] ([CONDITION(S)]), Type 2 diabetes, [CONDITION(S)], and mild [CONDITION(S)] of left lower extremity. The minimum data set (MDS) had an assessment reference date (ARD) of 02/09/21. Section C (Cognitive Patterns) of the MDS documented Resident #14's BIMS (brief interview for mental status) score was 12 out of 15. The Patient's Order List included an active order dated 02/04/21 at 9:00 a.m. for [MEDICATION(S)] Tab ([MEDICATION(S)]) by mouth 25 mg every morning. The order list showed the medication was last administered on 02/17/21 at 9:32 a.m. The surveyor was unable to locate an indication for use or diagnosis for [MEDICATION(S)]. On 02/17/21 at approximately 6:30 p.m., the interim nurse manager was asked and she acknowledged there was no indication for use listed within the order for [MEDICATION(S)] and no diagnosis related to the order for [MEDICATION(S)] located within the medical record. She reported that since [MEDICATION(S)] was a home medication when the doctor wrote the order, the indication for use would not be addressed. The interim nurse manager attempted to call the facility's director of pharmacy but there was no answer. On 02/17/21 at 7:15 p.m., the facility's chief executive officer (CEO), chief operating officer (COO), chief nursing officer (CNO), and interim nurse manager were informed of the above described findings. No further information was provided prior to the exit conference on 02/17/21 at 7:45 p.m. with the facility's CEO, COO, CNO, and interim nurse manager.

Based on staff interview, facility document review, and during a medication pass and pour observation facility staff failed to store drugs in locked compartments for 1 of 1 nursing units. The findings included: The facility staff failed to secure the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN (licensed practical nurse) #1 left the medications out on top of the medication cart and out of their view during a medication pass. On 2/17/21 at 4:11pm LPN #1 opened a single dose package of lactobacillus and placed the tablet in a medication cup on top of the medication cart. LPN #1 left the medication cart to retrieve required PPE (personal protective equipment) leaving the cart and the medication cup with the lactobacillus tablet on top of the cart and out of their view. LPN #1 returned to the medication cart with isolation gowns and stated I only left it because you were here. On 2/17/21 at 4:48pm LPN #1 retrieved a resident's individual medication drawer from a medication cart and placed it on top of another medication cart that they were using to pass medication. LPN #1 placed the medication cart with the individual open medication drawer on top at the doorway of Resident #12's room. LPN #1 turned their back to the medication cart with the open drawer of medications on top and out of view, went in the room and administered a subcutaneous injection in the resident's arm and dialed the resident's phone at their request prior to returning to the medication cart. Surveyor asked LPN #1 about leaving the drawer of medications on top of the medication cart, LPN #1 stated it was in the doorway and don't ding me for that. The medications left unattended and out of view in the open drawer on top of the medication cart included individual dose packages of [MEDICATION(S)] sodium, [MEDICATION(S)] 40mg, [MEDICATION(S)] 75mcg, [MEDICATION(S)] 10mg, [MEDICATION(S)] 10mg, and a vial of [MEDICATION(S)] insulin. On 2/17/21 at approximately 6:10pm, surveyor notified the interim nurse manager of the issue regarding the medications being left on top of the medication cart unattended and out of view by LPN #1 during the medication pass and pour observation. Surveyor requested and received the facility policy entitled Medication Security which states in part: Purpose: All areas in the hospital are required to meet federal and state regulations regarding the safe and secure storage of medications. Policy: All areas of the hospital that store and utilize medications, as defined by the Centers for Medicare and Medicaid Services (CMS), will at a minimum maintain all ordered and floor stock medications in either a locked-secure container (such as an Acudose System) or under constant surveillance. On 2/17/21 at 7:13pm, surveyor notified the CNO (Chief Nursing Officer), CEO (Chief Executive Officer), and the COO (Chief Operational Officer) of the issue regarding medications being left unattended on top of the medication cart and out of view by LPN #1. No further information regarding this issue was presented to the survey team prior to the exit conference on 2/17/21.

Based on staff interview, clinical record review, facility document review, and during a medication pass and pour observation facility staff failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections for 1 of 11 residents in the survey sample, Resident #13. The findings included: For Resident #13, the facility staff failed to sanitize a hand held scanning device following taking it into the resident's room, who is on transmission based precautions, and laying it on the bed sheet covering the resident. Resident #13's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #13 did not have a completed admission MDS (minimum data set) at the time of the survey. The H&P Hospitalist note dated 2/12/21 states in part, patient is conscious, oriented x 3. On 2/17/21 at 4:53pm during a medication pass and pour observation, surveyor observed LPN (licensed practical nurse) #1 don a disposable gown and gloves and enter Resident #13's room carrying a hand held scanning device from the medication cart. LPN #1 scanned Resident #13's identification band and then placed the scanning device between Resident #13's upper thighs on the sheet covering the resident. After administering Resident #13's medications, LPN #1 picked up the scanning device on returned it directly to the medication cart without disinfecting and removed their disposable gown and gloves. Surveyor observed a Contact Isolation sign and PPE (personal protective equipment) supplies on the outside of Resident #13's door. Surveyor asked LPN #1 if the scanning devices are cleaned, LPN #1 stated I guess if you sit it down in a room and probably in a perfect world. LPN #1 then disinfected the scanning device prior to entering the next resident's room to administer medications. On 2/17/21 at approximately 6:10pm surveyor notified the Interim Nurse Manager of the observation of LPN #1 laying the scanning device on Resident #13 and carrying the device out of the room and returning it to the medication cart without disinfecting the device. On 2/17/21 at 7:13pm surveyor notified the CNO (Chief Nursing Officer), CEO (Chief Executive Officer), and the COO (Chief Organizational Officer) of the observation regarding LPN #1 returning the hand held scanning device to the medication cart without disinfecting after laying it on Resident #13 who is on contact precautions for ESBL in the urine. No further information regarding this issue was presented to the survey team prior to the exit conference on 2/17/21.

Based on observation, staff interview and facility document review, the facility staff failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The findings included: The facility staff failed store, prepare, distribute and serve food in accordance with professional standards for food service safety. The surveyor surveyed the kitchen on 1/28/19 at 5:15 p.m. The food services director accompanied the surveyor. The surveyor observed one reach-in refrigerator. On the bottom shelf, the surveyor observed an opened bag of hash browns. The bag did not have a label or a date when opened. A box of apple pie was also observed that had been opened. There was not a date when opened or a label. A bag of potato wedges and sweet potato fries were also observed in the refrigerator. Both had been opened. There was not a label or a date on either bag. The surveyor and the food services director checked the cook's refrigerator. The temperature gauge on the outside of the refrigerator did not record a temperature and the food services director was unable to locate a thermometer on the inside of the refrigerator. The food services director stated she would get one. The surveyor observed a rack of seasonings and spices. A container of poultry seasoning dated 05/08/17 was observed. The food services director removed the poultry seasoning and stated she would discard. An almost full container of garlic powder dated 11/23/17 was also observed. The food services director stated she couldn't believe there was that much garlic left. The food services manager stated it was used a lot. A second reach in refrigerator was observed. The food services director was unable to locate an inside thermometer. The thermometer on the outside read 36.5 degrees. The surveyor observed the assistant food service director obtain the tray lime temperatures on 1/29/19 at 11:30 a.m. The temperature of the turkey sandwiches was obtained. The turkey sandwich temperature was 42.5 degrees. The assistant director of food services checked a second turkey sandwich and the temperature was found to be 41.3 degrees. The surveyor asked what should be done and the assistant food services director stated remove the sandwiches and return to the refrigerator/freezer for cooling. The food services director was informed of the above concerns on 1/28/19 at 5:30 p.m. and stated the opened bags of food items should be labeled and dated and the refrigerators should have a thermometer. The food services manager stated the refrigerators usually have thermometers. The food services director informed the surveyor on 1/29/19 at 11:45 a.m. that thermometers had been found or placed in the reach-in refrigerators. The food services director was made aware of the tray line temperature concerns. The surveyor requested the facility policy on food storage and labeling/dating food items. The surveyor reviewed the facility policy titled Diet Kitchens on 1/29/19. The policy read in part Policy 2. Each diet kitchen refrigerator has an operating thermometer to enable proper food storage temperature monitoring. Procedure: 3. All food items placed by the Food Services Department into diet kitchen refrigerators are clearly labeled as to contents and dated when appropriate. The surveyor informed the nurse manager of the above concern on 1/29/19 at 5:46 p.m. and the administrator/chief executive officer of the above concern on 1/29/19. No further information was provided prior to the exit conference on 1/30/19.

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to provide the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 11 residents (Resident #1). The findings included: The facility staff failed to ensure infection control practices were maintained during wound care to Resident #1. Resident #1 was admitted to the facility 1/14/19 with [DIAGNOSES REDACTED]. The admission minimum data set (MDS) assessment had not been completed. Resident #1's initial care plan included a skin assessment risk dated 1/14/19 and read the patient will remain free from pressure ulcers. Interventions read: Skin assessment risk: moderate; skin care: prevent breakdown. Additional interventions: Wound care clean wound with saline/pat dry/apply silversorb/cover with kling bid (twice a day). The surveyor observed wound care on 1/29/19 at 2:37 p.m. with registered nurse #2. Resident #1 was on contact isolation for an infected right heel ulcer. Resident #1 was asked if the surveyor could observe wound care. Resident #1 stated yes. Registered nurse #2 donned gown and gloves at entrance to Resident #1's room. R.N. #2 obtained Resident #1's dressing supplies from a drawer in the room. R.N. #2 placed a barrier under the resident's feet and removed the sock on the right foot. R.N. #2 removed the old dressing and discarded. R.N. #2 donned a new pair of gloves. The ulcer was cleaned with sterile water. R.N. #2 poured the sterile water from the top of the ulcer and let it dribble down over the wound. The ulcer was then dabbed with a dry 4x4 gauze. Silversorb gel was applied on a gauze and the gauze was placed over the ulcer. R.N. #2 then wrapped the right foot in kerlix and dated the dressing after the dressing had been applied and taped. R.N. #2 removed the gloves and hands were sanitized. The surveyor reviewed the wound care orders dated 1/14/19. The physician's orders [REDACTED]. BID. The surveyor interviewed R.N. #2 upon completion of the wound care on 1/29/19 at 4:51 p.m. R.N. #2 stated she thought she should wash her hands or use hand sanitizer after removing the soiled dressing but didn't. R.N. #2 stated she wasn't aware about the dating and initialing of the wound dressing after the dressing had been applied to the resident and to clean the wound in a circular manner starting from the inner part of the wound and moving outward. The surveyor informed R.N. #2 that the sterile water needed to be dated when opened and the order was for saline. The surveyor informed the nurse manager of the above concern on 1/29/19 at 5:46 p.m. and requested the facility policy on dressing changes. The surveyor interviewed the director of infection control (other #5) and the quality assurance director (other #3) on 1/30/19 at 11:52 a.m. The infection control director stated anytime one goes from dirty to clean, wash hands. The quality assurance director stated the dressing procedures were in Lippincott, the procedure manual. The surveyor reviewed the facility policy titled Wound debridement on 1/30/19. The procedure read in part Perform hand hygiene Put on clean gloves and other personal protective equipment, as needed Remove the existing dressing gently, irrigating it with normal saline solution, as needed, to ease removal Discard the soiled dressing in a waterproof trash container Remove and discard your gloves Perform hand hygiene Put on clean gloves Clean the wound with sterile saline solution and sterile gauze The surveyor informed the nurse manager of the above concern on 1/30/19 at 1:05 p.m. No further information was provided prior to the exit conference on 1/30/19.

Based on staff interview and clinical record review, the facility staff failed to ensure one of 11 residents was free of an unnecessary [MEDICAL CONDITION] medication (Resident #64). The findings included: The facility staff failed to ensure there was an indication for use/diagnosed condition for which [MEDICATION NAME] was prescribed; failed to identify behavioral interventions to include non-pharmacological interventions, and failed to identify specific target behaviors and monitor for effectiveness associated with the use of [MEDICATION NAME] for Resident #64. The clinical record of Resident #64 was reviewed 1/28/19 through 1/30/19. Resident #64 was admitted to the skilled nursing unit on 1/25/19 with [DIAGNOSES REDACTED]. An admission minimum data set (MDS) assessment had not been completed. Resident #64's care plan initiated 1/25/19 identified skilled nursing unit standard of care that included for the resident to demonstrate appropriate feelings and decreased fear. The (MONTH) 2019 physician's orders [REDACTED]. The surveyor was unable to locate an indication for use, any target behaviors for [MEDICATION NAME], or monitoring of the effects/side effects of [MEDICATION NAME] (an antidepressant). The care plan had not been developed. The surveyor informed the nurse manager on 1/30/19 at 10:30 a.m. The nurse manager stated he would notify the pharmacy of the above concern. The surveyor interviewed the pharmacy director on 1/30/19 at 10:37 a.m. The pharmacy director stated she was unable to locate an indication for [MEDICATION NAME] use, no targeted behaviors or any monitoring of the effects/side effects. The pharmacy director stated she needed to brush up on the regulations and needed to separate acute care from skilled care. No further information was provided prior to the exit conference on 1/30/19.

Based on observation, staff interview, and facility document review, the facility staff failed to ensure a hazard free environment for Residents on the unit. The findings included: The facility hydrocollator unit was not secured and was accessible to Residents of the facility. The unit is used to heat hot packs for use in therapy. The temperatures of the hydrocollator unit were documented to be as high as 162 degrees Fahrenheit. On 01/21/15 at approximately 3:15 PM, the surveyor observed the hydrocollator unit, located in the therapy room. The unit was unsecured, and the surveyor was able to open the hydrocollator and visualize the heated water and pads inside the unit. There was no one in attendance in the therapy room at this time. On 0/21/15 at approximately 3:30 PM the surveyor asked the nurse manager to accompany her to the therapy room to observe the hydrocollator. The nurse manager asked the COTA (certified occupational therapy assistant) about the hydrocollator unit. The COTA stated that the therapy room was locked at 4:30 PM each day and unlocked upon the arrival of therapy staff and remained unlocked during the day. The COTA also stated that no Residents were in the therapy room unless accompanied by therapy staff. The nurse manager had the COTA remove the hydrocollator unit into a secure locked office, unless being used by therapy staff. On 1/22/15 at approximately 10:30 AM, the nurse manager and physical therapist spoke with survey team regarding the hydrocollator unit. They stated that the unit would remain locked in a secure area unless being utilized by therapy staff. No further information regarding this issue was provided prior to exit.

Based on observation, staff interview, facility document review, and clinical record review the facility staff failed to maintain effective infection control measures during a wound care observation for 1 of 5 residents (Resident #1). The findings included: The facility staff failed to wash their hands or perform any hand hygiene prior to wound care and failed to perform any hand hygiene when going from a dirty area to a clean area. Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. There was no MDS (minimum data set) assessment completed on this resident. However, Resident #1 was alert and orientated to person, place, and time. Resident #1's clinical record included a form titled "Decubitus-Pressure Ulcer Care Protocol." This form was coded to indicate the resident had an unstageable wound at the time of admission. The facility staff had transcribed the following onto this pressure ulcer protocol form "Center is different color, black area, no broken...unstageable area...(Rt) buttock." This form had been signed by the physician on 01/25/14. The residents care plan included an intervention for decubitus care. On 01/29/14 beginning at approximately 8:40 a.m., the surveyor observed LPN (licensed practical nurse) #1 prepare and administer Resident #1's morning medications. Prior to administering these medications LPN #1 used hand sanitizer to sanitize her hands and placed clean gloves on both hands. Immediately after administering Resident #1's medications, LPN #1 lowered the residents bed, pulled the residents covers back, rolled the resident onto her right side, took her gloved hands and removed the old dressing from the residents right buttock area, cleaned the wound with normal saline using clean 4X4 dressings, discarded the used 4X4's, patted the wound using clean 4X4 dressings, measured the wound, and applied a new predated [MEDICATION NAME] dressing. During this observation the wound was noted to be clean in appearance and measured 2 cm in diameter. After rolling the resident onto her back and replacing the residents covers. LPN #1 removed her gloves and used hand gel to sanitize her hands. LPN #1 did not perform any hand hygiene after administering the resident's morning medications, prior to beginning wound care or during the wound care observation. On 01/29/14 at approximately 10:45 a.m., during a meeting with administrative staff #3, administrative staff #3 was notified that LPN #1 had not performed any hand hygiene or changed her gloves after administering Resident #1's morning medications and prior to or during a wound care observation. A copy of the facility policy and procedure on infection control was requested. On 01/29/14 at approximately 11:00 a.m., the surveyor interviewed LPN #1, during this interview LPN #1 was asked if she had washed her hands or performed any hand hygiene after administering Resident #1's morning medications, prior to performing wound care, or during wound care. LPN #1 verbalized to the surveyor that she had not but that she usually did. On 01/29/14 at approximately 12:30 p.m., administrative staff #3 provided the surveyor with a copy of an updated "Decubitus-Pressure Ulcer Care Protocol" form that had been updated to indicate this area was now staged at a stage II. The physician had signed this protocol sheet on 01/29/14 and had transcribed "healing stage 2" onto this form. Administrative staff #3 also gave to the surveyor a copy of a document titled "Lippincott Procedures" and stated the facility followed Lippincott procedures for infection control. This policy/procedure read in part. "Implementation...Gather and prepare the necessary equipment at the patients bedside, perform hand hygiene...put on gloves and other personal protective equipment, if needed, to remove the existing dressing and expose the wound...Discard the soiled dressing...Inspect the wound...Measure the wound size, irrigate the wound with normal saline solution...Remove and discard your soiled gloves, perform hand hygiene, and put on a new pair of sterile or clean gloves...Blot the surrounding skin dry with a sterile 4"X4" gauze pad...Gently place the dressing over the surface of a shallow wound...Discard or clean and disinfect supplies and equipment. Remove and discard your gloves. Perform hand hygiene." Administrative staff #3 also verbalized to the surveyor that she would have expected LPN #1 to change her gloves and perform hand hygiene during the wound care procedure. Administrative staff #3 stated that she had spoken with the wound care department and the facility staff would be receiving an inservice on wound care that would include hand washing. No further information regarding this issue was provided to the surveyor prior to the exit conference.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to follow physician orders [REDACTED].#4). The findings include: For Resident #4, the facility staff failed to follow the physician order [REDACTED].#4's blood sugar in 2 hours after a blood sugar obtained at 1805 was 487. Resident #4 was admitted to the facility 1/3/13 with [DIAGNOSES REDACTED]. The initial minimum data set (MDS) had yet to be completed. The surveyor reviewed the clinical record of Resident #4 on 1/8/13. The physician orders [REDACTED]. Continue regular insulin sliding scale @ (at) AC & HS (before meals and bedtime)." The initial physician orders [REDACTED]. Dose Inst (instructions): BS (blood sugar) < (less than) 60: 25 ml (milliliters) of D50 (fluids with [MEDICATION NAME]) IVP (intravenous piggy back) stat (immediately); Repeat BS (blood sugar) in 15 min (minutes) and Contact MD (medical doctor) stat with results: 60-139: 0 units 140-180: 2 units 181-220: 4 units 221-260: 6 units 261-300: 8 units 301-340: 10 units 341-380: 12 units > (greater than) 380: 16 units For any BS (blood sugar) of 261 or > (greater), Give Insulin and Repeat BS (blood sugar) In 2 hrs (hours); If still 261 or > (greater than), Contact MD (medical doctor) for new orders!! The electronic Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The next blood sugar obtained was documented at 2141 (9: 41 p.m.). The electronic Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The surveyor reviewed the electronic clinical record for 1/4/13. There were no entries in the electronic clinical record that the blood sugar was rechecked two hours (2) after Resident #4 received 16 units of regular sliding scale insulin at 1805. The clinical record did reveal an entry dated 1/5/13 0053 that read "Patients FS (finger stick) at 2141 (9:41 p.m.) was 343, gave 12 units of regular insulin and 25 units of [MEDICATION NAME] as ordered. Finger stick recheck at 0045 was 261, notified ______ (name of physician), no new orders." Resident #4's blood sugar was not rechecked for 3 hours and 36 minutes after the blood sugar result of 487 at 1805 (6:05 p.m.) was recorded. Resident #4's dietary intake for each meal on 1/4/13 was recorded as 25% eaten. There were no percentages recorded for snacks. The surveyor interviewed the nurse manager registered nurse #1 on 1/8/13 at 10:15 a.m. She researched the blood sugar concern and stated originally Resident #4 had orders for blood sugars every 6 hours but the orders for blood sugars were changed to before meals and at bedtime on 1/3/13. She stated she spoke with the nurse who changed the order in their data entry system and there were issues with their system. The nurse manager registered nurse #1 stated that she had interviewed the nurse that obtained the blood sugar at 1805. The nurse manager stated that Resident #4's blood sugar elevation was reported to the oncoming shift (facility does 12 hour shifts) but the blood sugar was not rechecked as ordered by the physician. "We didn't do the blood sugar monitoring. It was shift change. That's not an excuse. Not done." The surveyor requested the facility policy on diabetic management on 1/8/13. The policy titled "Insulin Routine Sliding Scale Orders" read in part "4. All sliding scale insulin is human regular and administered SUBCU; Please document all values of insulin administered on eMAR: Blood Glucose ValueOrders ([MEDICATION NAME] R or [MEDICATION NAME] R Insulins Only)< (less than) 60 D5025mls IVP STAT; Repeat Blood Glucose in 15 minutes Contact Physician STAT with repeat Blood Glucose results60-1390 units of regular Insulin SUBCU140-1802 units of regular Insulin SUBCU181-2204 units of regular Insulin SUBCU221-2606 units of regular Insulin SUBCU261-3008 units if regular Insulin SUBCU301- units of regular Insulin SUBCU341- units of regular Insulin SUBCU> (greater than) units of regular Insulin SUBCUBlood Glucoses=> (greater than) 261 mg/dl, administer appropriate insulin as ordered by scale; REPEAT BLOOD GLUSOSE in 2 HOURS; IF REPEAT Blood Glucose is still=> (greater than) 261 mg/dl contact Physician for new orders." The surveyor informed the nurse manager registered nurse #1 and the chief nursing officer of the above finding on 1/8/13 at 12:45 p.m. prior to the exit conference. No further information was provided prior to the exit conference on 1/8/13. Reference: Potter and Perry. Fundamentals of Nursing. 6th ed. St. Louis: Mosby. 2005. Fundamentals of Nursing. "Insulin is ordered by a specific dose at select times or by a sliding scale. A sliding scale dictates a certain dose based on the client's blood glucose level." (880). Mosby's Drug Guide for Nurses, 2011, 9th edition, Skidmore-Roth, pages 535-538 was used as a reference for [MEDICATION NAME] insulin. [MEDICATION NAME] Insulin is short acting, used to control [MEDICAL CONDITION] (elevated blood sugar) in patients with diabetes, and onset of action is 30 minutes with peak effect 2.5-5 hours and duration up to 6 hours.

Based on staff interview, facility document review and clinical record review, the facility staff failed to ensure 1 of 7 residents (Resident #7) in the survey sample were free of significant medication errors. Resident #7 did not receive regular sliding scale insulin on 12/13/12 at 3:55 p.m. The findings include: Reference: Potter and Perry. Fundamentals of Nursing. 6th ed. St. Louis: Mosby. 2005. Fundamentals of Nursing. "Insulin is ordered by a specific dose at select times or by a sliding scale. A sliding scale dictates a certain dose based on the client's blood glucose level." (880). Mosby's Drug Guide for Nurses, 2011, 9th edition, Skidmore-Roth, pages 535-538 was used as a reference for [MEDICATION NAME] insulin. [MEDICATION NAME] Insulin is short acting, used to control [MEDICAL CONDITION] (elevated blood sugar) in patients with diabetes, and onset of action is 30 minutes with peak effect 2.5-5 hours and duration up to 6 hours. Resident #7 was admitted to the facility 12/3/12 with [DIAGNOSES REDACTED]. Resident #7's initial minimum data set (MDS) with an assessment reference date (ARD) of 12/10/12 assessed the resident with a cognitive summary score of 12 out of 15 in section C Cognitive Patterns (C0500). Section I Active [DIAGNOSES REDACTED]. Resident #7's clinical record was reviewed 1/8/13. The physician order [REDACTED]." The surveyor received the facility diabetic protocol from the nurse manager registered nurse #1 on 1/8/13. The policy titled "Insulin Routine Sliding Scale Orders" read in part "4. All sliding scale insulin is human regular and administered SUBCU; Please document all values of insulin administered on eMAR: Blood Glucose ValueOrders ([MEDICATION NAME] R or [MEDICATION NAME] R Insulins Only)< (less than) 60 D5025mls IVP STAT; Repeat Blood Glucose in 15 minutes Contact Physician STAT with repeat Blood Glucose results60-1390 units of regular Insulin SUBCU140-1802 units of regular Insulin SUBCU181-2204 units of regular Insulin SUBCU221-2606 units of regular Insulin SUBCU261-3008 units if regular Insulin SUBCU301- units of regular Insulin SUBCU341- units of regular Insulin SUBCU> (greater than) units of regular Insulin SUBCUBlood Glucoses=> (greater than) 261 mg/dl, administer appropriate insulin as ordered by scale; REPEAT BLOOD GLUSOSE in 2 HOURS; IF REPEAT Blood Glucose is still=> (greater than) 261 mg/dl contact Physician for new orders." The 12/13/12 electronic medication administration record (eMAR) revealed a blood sugar result of 147 at 1555 (3:55 p.m.). The eMAR did not provide evidence that, based on the sliding scale protocol, the required 2 units of regular insulin was administered. The surveyor reviewed the nurse's notes and the rehab notes for 12/13/12 and found no evidence that the sliding scale insulin was administered. The occupational therapy note 12/13/12 1524 (3:24 p.m.) read in part "Location of pain: no reports of pain/did report "feel shaky." Nursing alerted and reported they would alert lab for follow through. Patient she felt like she did when her "sugar was low." The surveyor requested the assistance of the nurse manager registered nurse #1 on 1/8/13 at 11:00 a.m. to locate administration of the sliding scale insulin on 12/13/12 at 3:55 p.m. The nurse manager registered nurse #1 reviewed the eMAR and nurse's notes and found no evidence that the regular sliding scale insulin was administered. "The nurse probably held it based on the resident's statement to the therapist. The resident probably refused the sliding scale based on how she felt. If the nurse didn't give it, she should have at least notified the physician and documented what had been done." During the interview with the nurse manager registered nurse #1, she was asked if insulin was considered a significant medication. She replied, "Yes it is." The surveyor informed the nurse manager registered nurse #1 and the chief nursing officer of the above finding on 1/8/13 at 12:45 p.m. prior to the exit conference. No further information was provided prior to the exit conference on 1/8/13.

Based on observation and staff interview, the facility staff failed to ensure that the dumpster area was maintained in a clean and sanitary manner. The findings included: On January 7, 2013 at 1:15 p.m., the surveyor and the chief nursing officer observed the dumpster area. The following items were observed on the ground around the two dumpsters and the loading docks that lead to the two dumpsters: purple disposable glove, multiple discarded paper products, a laboratory test tube, ink pens, and egg shells. All along the base of one of the two dumpsters was a collection of leaves. The area was " wet " looking in appearance. The surveyor interviewed the chief nursing officer if the dumpster area was clean and sanitary and he stated "It looks like it needs to be cleaned." The chief nursing officer stated he thought a better job could be done maintaining the dumpster area. The surveyor interviewed the dietary supervisor other #1 on 1/8/13 at 11:30 a.m. During the interview, she was asked if she was responsible for maintaining the dumpster area. She stated "No. That's not my department." The surveyor informed the nurse manager registered nurse #1 and the chief nursing officer of the above finding on 1/8/13 at 12:45 p.m. The surveyor interviewed the "Plant Operations" staff member other #2 on 1/8/13 at 1:00 p.m. about the dumpster area. The plant operations staff member other #2 stated staff in the environmental department are responsible for cleaning and maintaining that area. No further information was provided prior to the exit conference on 1/8/13.