Every finding on record at Courtland Terrace

Based on observations and staff interviews, the facility failed to ensure thawed, raw chicken available for use was labeled with a use by date in 1 of 4 walk-in refrigerators. This practice had the potential to affect food served to residents. Findings included:An observation of the walk-in refrigerator in the main kitchen was conducted on 2/10/26 at 10:18 AM with the Kitchen Operations Manager. At the front of the walk-in refrigerator on the bottom shelf was an opened 20-pound case with one package of raw chicken and one 20-pound case of raw chicken with a sticker that read use first. There was no use by date to specify when the chicken should not be used. The delivery dates on the cases was 2/3/26.During an interview on 2/10/26 at 10:18 AM, the Kitchen Operations Manager revealed when the raw chicken was delivered on 2/3/26 it was frozen and now it had thawed and was ready for use. He revealed the system in place was to rotate frozen raw chicken using a First In First Out policy and explained when raw chicken was delivered it was frozen and placed in the back of the walk-in refrigerator to thaw and rotated towards the front and a use first sticker was placed on the case to identify which one needed to be used. He did not state a use-by date was needed on thawed, raw chicken and confirmed it was not placed on chicken that was stored in the walk-in refrigerator. The Kitchen Operations Manager stated chicken stored in the walk-in refrigerator was typically used within seven days. During an interview on 02/13/26 at 12:06 PM, the Administrator revealed a use by date should be placed on thawed, raw chicken stored in the walk-in refrigerator and available for use.

Based on record reviews, Responsible Party (RP) interview, and staff interviews the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of Hospice Care for 1 of 7 residents reviewed for MDS accuracy (Resident #56). The findings included:Resident #56 was admitted to the facility on [DATE] with diagnoses which included chronic ischemic heart disease and chronic obstructive pulmonary disease (COPD). Review of Resident #56's electronic medical record (EMR) revealed a Hospice admission Agreement was signed by Resident #56's RP on 09/08/2025. Resident #56 transitioned to hospice services on 09/08/2025.Review of Resident #56's electronic medical record (EMR) revealed Resident #56's care plan was revised on 09/08/2025 and included the following area of focus, in part: Resident requires Hospice Care and will be kept comfortable through next review.Review of Resident #56's quarterly Minimum Data Set (MDS) assessment dated [DATE] did not indicate Resident #56 was receiving Hospice care.An interview with Resident #56's RP on 02/10/2026 at 11:32 AM revealed Resident #56 had been receiving Hospice care since last fall. The RP stated the Hospice nurse telephoned her weekly and provided her with updates on Resident #56's condition. An interview was conducted with the MDS Coordinator on 02/12/2026 at 2:32 PM. The MDS Coordinator reviewed Resident #56's quarterly MDS assessment dated [DATE] and verified that Hospice services had not been captured on the assessment. The MDS Coordinator stated the MDS was coded incorrectly and should have indicated Resident #56 had received Hospice services. An interview was conducted with the Administrator on 02/12/2026 at 2:40 PM. The Administrator stated that her expectation was for all MDS assessments to be completed accurately based on the resident's clinical condition.

Based on record review, and staff interviews, and psychiatrist interview the facility failed to refer one resident with a new mental health diagnosis for a Level II Preadmission Screening and Resident Review (PASRR) evaluation for 1 of 1 resident for PASRR (Resident #10).The findings included:Review of Resident #10's medical record revealed Resident #10 was admitted to the facility on [DATE]. A PASRR level I was completed prior to Resident #10's admission with a recommendation to resubmit paperwork for PASRR level II if a new mental health diagnosis was suspected or if there was a significant change in the resident's condition.Review of the electronic medical record (EMR) revealed Resident #10 was diagnosed with post-traumatic stress disorder (PTSD) on 09/30/2025. There was no evidence in the medical record that a request was submitted for a Level II PASRR evaluation.An interview with Resident #10's psychiatrist was conducted on 02/12/2016 at 2:00 PM. The psychiatrist stated when Resident #10 was admitted to the facility, she had no known history of PTSD. The psychiatrist explained Resident #10 started having panic attacks out of the blue and during a conversation with Resident #10's family member, the family member asked if Resident #10's past experience of sexual trauma could have anything to do with her panic attacks. The psychiatrist also stated that she added the PTSD diagnosis to Resident #10's EMR on 09/30/2025, removed all male caregivers from her assignment, and made some medication adjustments to Resident #10's medication profile. The psychiatrist further stated that Resident #10's panic attacks had markedly decreased in frequency and severity.An interview on 02/12/26 at 1:00 PM with the Social Worker revealed she was responsible for completing PASRR paperwork for residents. The SW revealed she was aware of Resident #10's diagnosis of PTSD but she failed to submit a request for an evaluation for a Level II PASRR. The SW further explained that she was not sure how she missed requesting the evaluation for a Level II PASRR. The SW also stated that she was aware PASRR level II requests should be completed for residents when they received a new mental health diagnosis including PTSD. The SW stated that based on Resident #10's new mental health diagnosis, a request for PASRR level II should have been completed. The SW stated that she received the information regarding Resident #10's PTSD diagnosis during the morning clinical meetings.During an interview on 02/12/26 at 1:11 PM with the Administrator, she communicated her understanding that PASRR level II should be completed in a timely manner upon the admission or readmission of a resident with a mental health diagnosis and anytime a resident has had a change of condition or received a new mental health diagnosis.

Based on record review, observations, and resident and staff interviews, the facility failed to secure medications left unattended in a resident's room for 1 of 1 resident reviewed medication storage (Resident #90). Findings included:Resident #90 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation and hypertension.Review of Resident #90's active physician orders included apixaban (anticoagulant) 5 milligrams (mg) twice a day started on 2/3/26, metoprolol (antihypertensive) extended release 25 mg with directions to hold for systolic blood pressure (SBP) less than 100 or diastolic blood pressure (DBP) less than 50 or a heart rate less than 50 started on 2/3/26, and diltiazem hydrochloride (antiarrhythmic) extended release 300 mg with directions to hold for SBP less than 120 or DBP less than 60 started on 2/3/26. There was no active physician's order for dextromethorphan/guaifenesin (analgesic/decongestant) 600 mg.During an observation on 2/11/26 at 8:29 AM, a clear resealable plastic storage bag was left unattended in Resident #90's room and contained 3 brown colored medication bottles and a single foil package of medication. The bag was left on the counter by the sink in clear view. The labels on the medication bottles indicated it contained apixaban 5 mg, metoprolol extended release 25 mg, and diltiazem hydrochloride extended release 300 mg. The single foil package contained dextromethorphan/guaifenesin (analgesic/decongestant) 600 mg.During an interview on 02/11/26 at 8:29 AM, Resident #90 stated a family member brought the medications in the bag to the facility. Resident #90 revealed the family member brought the medications to help the nurses identify what she had taken prior to being admitted . Resident #90 stated she took the medications the nurses gave her and she did not want to self-administer medications.On 02/11/26 at 8:38 AM, Nurse #1 was made aware that a resealable plastic storage bag containing medications was not securely stored in Resident #90's room.An interview was conducted on 02/11/26 at 9:12 AM with Nurse #1. Nurse #1 confirmed she was assigned to administer Resident #90's medications on 2/11/26 and had been in the room earlier but did not notice the resealable plastic storage bag of medications. Nurse #1 stated medications should be stored in the medication cart for safety. Nurse #1 confirmed she had removed the bag of medications from Resident #90's room after she was made aware by the surveyor.An interview was conducted on 02/11/26 at 8:38 AM with the Director of Nursing (DON). The DON revealed medications should not be left unattended in a resident's room and should be stored in the medication cart. The DON revealed she would review Resident #90's physician orders to ensure the medications in the resealable plastic storage bag had an order.During an interview on 02/13/26 at 11:56 AM, the Administrator stated medications should not be left in a resident's room and she expected unsecured medications were removed by staff when identified. The Administrator stated the medications were removed from Resident #90's room when the nurse was made aware. It was explained to the Administrator during the interview that the nurse was made aware of the medications left in Resident #90's room by the surveyor.

Based on observation, record review, Guardian, Podiatrist, and staff interviews, the facility failed to provide personal privacy for Resident #28 when the Podiatrist cut her toenails in the facility's day room visible to other residents. This deficient practice was for 1 of 1 resident reviewed for personal privacy (Resident #28). The findings included: Resident #28 was admitted to the facility on [DATE] with diagnoses that included dementia with mood disturbance and cognitive communication deficit. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #28 was severely cognitively impaired and exhibited no behaviors or rejections of care during the assessment period. An observation conducted in the facility's day room on 10/30/24 at 12:00 PM revealed there were 10 residents seated at tables around the room. Resident #28 sat in her wheelchair in the center of the room and the Podiatrist sat on the floor in front of her and cut her toenails. There was no privacy curtain or shield in place around Resident #28. Nurse Aide (NA) #1 knelt beside Resident #28 and held her hand. An interview was conducted with NA #1 on 10/30/24 at 2:10 PM. NA #1 indicated when she was assigned to make rounds with the Podiatrist, they went to the residents' rooms to provide foot care. NA #1 revealed on 10/30/24 Resident #28 was in the day room with other residents. She stated she went into the day room with the Podiatrist, and he cut Resident #28's toenails. NA #1 indicated the Podiatrist was not concerned that there were other residents in the room, so she did not think it was an issue. NA #1 revealed that she should have taken Resident #28 to her room or a private area to have her toenails cut. A phone interview was conducted with the Podiatrist on 10/30/24 at 3:30 PM. He indicated that he had been providing podiatry services to the facility for 2 years. He stated during his scheduled visits he made rounds with a staff member and provided foot care in the residents' rooms. The Podiatrist revealed on 10/30/24 NA #1 brought him to the day room where Resident #28 was sitting with other residents. He stated NA #1 did not offer to take Resident #28 to her room, so he tried to be discreet and cut Resident #28's toenails in the day room. The Podiatrist further stated he preferred residents to be in a private area that was not visible to others when he provided foot care. A telephone interview was conducted with Resident #28's Guardian on 10/31/24 at 9:23 AM. She revealed that Resident #28 had always taken pride in her appearance and was very put together when she went out in public. She stated that Resident #28 would not have wanted to receive foot care in an area that was visible to others. The Guardian further stated if Resident #28 was cognitively intact and able to communicate her needs she would have requested to go to her room or a private area to have her toenails cut. An interview was conducted with the Director of Nursing (DON) on 10/30/24 at 2:00 PM. The DON indicated that the facility contracted with an outside company to provide podiatry services. She revealed a staff member was assigned to make rounds with the Podiatrist on the day he was scheduled to visit, and he provided foot care in the residents' rooms. She stated NA #1 was assigned to make rounds with the Podiatrist on 10/30/24. The DON revealed that she was aware Resident #28 received foot care in the day room, visible to other residents. She stated the Podiatrist and NA #1 should have taken Resident #28 to her room to cut her toenails. The DON indicated resident foot care should be provided in a private area that was not visible to others. An interview was conducted with the Administrator on 10/31/24 at 1:07 PM. She stated the facility had a contract with an outside company that provided podiatry services to the residents. She revealed on the day the Podiatrist was scheduled to visit he made rounds with an assigned staff member and foot care was provided in the residents' rooms. The Administrator indicated she was aware that the Podiatrist cut Resident #28's toenails in the day room visible to other residents. She stated Resident #28 should have been taken to her room or a private area to have her toenails cut.

Based on observation, record review and staff interview the facility failed to maintain the kitchen equipment clean and in a sanitary condition to prevent cross contamination by failing to clean the undershelf of one of one steamtables. The findings included: Review of the Equipment Cleaning Log week of June 18th there was no mention of the steamtable under splash area to be cleaned. An observation of the steamtable undershelf on 6/27/23 at 10:04 AM revealed the steamtable to have splatters of dark black dried food particles covering the under-splash area of the top shelf directly above the food [NAME]. During the meal temperature observation on 6/28/23 at 8:28 AM revealed the 5 well steamtable was observed on and pans of food were in the steamtable ready to serve. The steamtable was observed to have splatters of dark black dried food particles covering the under-splash area of the top shelf directly above the steaming food [NAME]. In an interview on 6/28/23 at 8:39 AM the Operations Manager stated the steamtable should have been cleaned. In an interview on 6/28/23 at 8:45 AM the kitchen manager revealed staff should have cleaned the splash area and they would clean the area immediately.

Based on staff interviews, and record reviews, the facility failed to submit the 5-day investigation report to the state survey Agency for 1 of 3 sampled residents (Resident #119) reviewed for abuse. The Findings included: Review of the facility policy revised on 10/22 read as: B. Report must be made on all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property. C. Complete investigation in 5 working days. Fax 5-Day report from and result of investigation to NCDHHD. (North Carolina Department of Health and Human Division). Review of the Facility 24-Hour Initial Report dated 9/30/22 documented the facility reported to the State Agency that Resident #119 reported she had been abused. There was no documentation to indicate the facility reported the 5-day investigation report to the State Agency. An interview with the Administrator on 6/27/23 at 4:11 pm, revealed that he was not the Administrator at the time and was not aware Resident #119 had reported abuse. He indicated they had looked and could not find the 5-day investigative report. An interview with the Social Worker on 6/28/23 at 4:17 pm, she revealed she was not aware Resident #119, reported she had been abused. She revealed staff were trained to report any incident or resident concern related to abuse to the administrative staff. She indicated a 5-day investigation report should have been sent to the State agency.

Based on record review and staff interviews the facility failed to develop care plans in the areas of suprapubic catheter (Resident #45) and pressure ulcers (Residents #4, #9, and #5) for 4 of 4 residents reviewed for care planning. The findings included: 1. Resident #45 was admitted to the facility on [DATE] with diagnoses that included benign prostatic hyperplasia (BPH) obstructive uropathy. A physician note dated 11/3/22 indicated an indwelling urinary catheter had been placed this day. Review of the admission Minimum Data Set, dated dated dated [DATE] revealed Resident #45 had an indwelling urinary catheter. Review of the Resident #45's Comprehensive Care Plan dated 11/8/22 contained no information or interventions regarding suprapubic catheter care. An interview was conducted with the Minimum Data Nurse on 6/28/23 at 4:32 PM. She revealed Resident #45's catheter should have been care planned. An interview was conducted with the Director of Nursing (DON) 6/28/23 at 4:40 PM. The DON stated Resident #45's care plan chould have been updated to the indwelling urinary catheter. 41772 2a. Resident #4 was admitted to the facility on [DATE] with diagnoses that included Rheumatoid arthritis. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 was cognitively intact and had a Stage III pressure ulcer injury. Review of the Wound Evaluation and Management assessment dated [DATE] revealed Resident #4 had a Stage IV pressure ulcer to her coccyx that measured 3.0 centimeters (cm) X 2.7 cm X 1.0 cm. Review of the Dressing Treatment Plan dated 6/22/23 revealed an order to wash wound with Dakins Solution, Apply three times a week for sixteen days. Negative Pressure Wound Therapy apply three times per week for sixteen weeks 125mmHG; Continuous. Collagen sheets apply three times per week for thirty days. Skin prep-Apply three time per week for 16 days. Review of the care plan initiated 10/24/22 revealed a focus of resident was at risk for pressure ulcer related to immobility. There was no entry or reference to the presence of a wound to the coccyx or interventions. b. Resident #9 was admitted to the facility on [DATE]. Review of the 5 Day Minimum Data Set (MDS) Assessment revealed Resident #9 was cognitively intact and at risk for pressure ulcer injuries. There was no documentation of a pressure ulcer. Review of the Wound Evaluation and Management assessment dated [DATE] revealed Resident #9 had a Stage III pressure ulcer of the left posterior heel that measured 0.2 centimeters (cm) X 0.2 cm X 0.1 cm. Review of the Dressing Treatment Plan dated 6/22/23 revealed a dressing order for calcium alginate with silver apply once daily for nine days. Apply Sterile gauze sponge once daily for thirty days. Apply Foam without boarder to heel once weekly for thirty days. Apply Kerlix dressing once daily for thirty days. Review of the care plan dated 3/4/23 revealed a focus of resident was at risk for pressure ulcer related to immobility. There was no entry or reference to the presence of a wound to the left heel or interventions. 45044 c. Resident #5 was admitted to the facility on [DATE] with diagnoses that included peripheral vascular disease and osteomyelitis (infection of bone) of the lumbar (lower back) region. An admission assessment dated [DATE] revealed Resident #5 was admitted with a stage 3 pressure ulcer to the lumbar region. The 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was cognitively intact, required limited assistance from 1 staff member to complete activities of daily living, and was coded as having an unhealed stage 3 pressure ulcer. A review of the Care Area Assessments (CAA) for the 5-day MDS assessment indicated he had a pressure wound to his lumbar region. The CAA for pressure ulcer indicated he was at risk for developing further ulcers. The CAA worksheet for pressure ulcers contained a checkmark to indicate that pressure ulcers would be addressed in the Resident's care plan. The care plan for Resident #5 created on 5/1/23 noted the potential for skin breakdown but there was no entry or reference to the presence of a wound to the lumbar region or of any interventions in place. An interview was completed on 6/28/23 at 11:23am with the MDS Nurse. The Nurse indicated she was responsible for the creation of all care plans but the wound care plan. She stated the Wound Nurse was responsible for creating a resident's wound care plan. An interview was completed on 6/28/23 at 11:27am with the Director of Nursing (DON). She revealed there was confusion among management nursing staff who was responsible for creating a resident's wound care plan. The DON stated the MDS Nurse was responsible for creating the initial wound care plan and the Wound Nurse updated the care plan accordingly. An interview was completed on 6/28/23 at 11:32am with the Wound Nurse. The Nurse stated the MDS Nurse creates the intial wound care plan and she updates accordingly. An interview was completed on 6/28/23 at 6:40pm with the facility Administrator. He stated management staff were aware of incomplete comprehensive care plans and were attempting to update all resident's care plans to reflect their current medical diagnoses.

Based on observation and staff interview the facility failed to discard an expired medications for 1 of 1 medication room reviewed for medication storage. The findings included: 1.During an observation of the medication room for medication storage on 6/28/23 at 12:02 PM, 1 multidose vial of opened and accessed Tuberculin Purified Diluted (Aplisol) was in the medication refrigerator. The vial had an opened date of 4/15/23. A review of the manufacturer ' s instruction label on the box indicated the medication should be discarded 30 days from the date medication was opened. During an interview with the Director of Nursing on 6/28/23 at 12:10 PM, she stated it was the night shift nurses responsibility to check the refrigerators and medication carts for expired medication. The DON stated the expired medications should have been discarded or returned to the pharmacy. 2. An observation of the medication storage room conducted on 6/28/23 at 12:02 PM revealed 2 bags of Vancomycin 750 milligrams(mg)/ in 250 milliliters (ml) of normal saline with an expiration date of 6/12/23 was in the medication refrigerator. The instructions read Infuse intravenously (IV) over 90 minutes at 175ml/hour(hr) every 12 hours until 6/12/23. During an interview with the Director of Nursing on 6/28/23 at 12:10 PM, she stated it was the night shift nurses responsibility to check the refrigerators and medication carts for expired medication. The DON stated the expired medications should have been discarded or returned to the pharmacy. An interview was conducted with the Administrator on 6/28/23 at 8:44 AM. The Administrator indicated that he expected expired medications would be discarded per manufacturer ' s instruction.

Based on record reviews and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put in place following the recertification and complaint survey conducted on 7/9/21. This was for a recited deficiency on the current recertification and complaint survey in the area of development and implementation of comprehensive care plans. The continued failure during two surveys shows a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag is cross referenced to: F656: Based on record review and staff interviews the facility failed to develop care plans in the areas of suprapubic catheter (Resident #45) and pressure ulcers (Residents #4, #9, and #5) for 4 of 4 residents reviewed for care planning. During the recertification survey on 7/9/21 the facility was cited for failing to develop a comprehensive care plan in the areas of indwelling catheter usage and anticoagulant, diuretic, and opioid medication usage. An interview was complete on 6/28/23 at 6:23pm with the Administrator, Director of Nursing (DON), and Director of Patient Care. The Administrator indicated the QAA committee met monthly to discuss the facility's ongoing performance improvement plans. The DON indicated there were no current monitoring plans for the development and implementation of comprehensive care plans.

Based on record review and staff interview the facility failed to provide written notice of reason for discharge to hospital to the resident and/or resident representatives and to provide the Ombudsman with a copy of the written notice for 2 of 2 residents reviewed for hospitalization . (Resident #9, Resident #39) The findings included: 1. Resident #9 was readmitted to the facility on [DATE]. A review of the 5 Day Medicare Minimum Data Set (MDS) dated [DATE] revealed Resident #9 was cognitively intact. Review of a physician ' s order dated 4/1/23 revealed an order to send to hospital for follow up of abnormal critical lab and abnormal computed tomography (CT) imaging. The medical record included no evidence that Resident #9 or her resident representative were provided with written notice that included the reason for discharge to the hospital on 4/1/23. During an interview with Resident #9 on 6/26/23 at 9:18 AM. the resident indicated she had no recollection of receiving written notice that explained the reason for his discharge to the hospital that occurred on 4/1/23. A phone interview was attempted with the Ombudsman on 6/27/23 at 3:18 PM An interview was conducted with the Social Worker (SW) on 6/27/23 at 4:40 PM. The Social Worker stated she was not aware that she was supposed to send out a written notice of discharge to the resident or resident representative and the Ombudsman. The SW stated she had been documenting the follow up phone call in the electronic medical record. During an interview with the Administrator and Senior Director of Patient Care on 6/28/23 at 8:44 AM. The Administrator indicated the Social Worker was responsible for providing the written notice of transfer/discharge to the hospital and notifying the Ombudsman. He revealed that during this survey he realized the Social Worker had not been completing this responsibility and that written notice of discharge/transfer had not been provided to the resident, resident representative, or the Ombudsman for any transfer/discharge to the hospital. The Administrator was unsure of how long the facility had not been providing these notices. Immediate education was provided to the Social Worker on discharge notices. 20710 2. Resident #39 was readmitted to the facility on [DATE]. A review of the 5 Day Medicare Minimum Data Set (MDS) Assessment revealed the Resident #39 had severe cognitive impairment. Review of a physician ' s order dated 5/18/23 revealed an order to send to hospital for evaluation and treatment of lethargy and decreased blood pressure. The medical record included no evidence that Resident #39 ' s resident representative was provided with written notice that included the reason for discharge to the hospital on 5/18/23. A phone interview was attempted with the Ombudsman on 6/27/23 at 3:18 PM An interview was conducted with the Social Worker (SW) on 6/27/23 at 4:40 PM. The Social Worker stated she was not aware that she was supposed to send out a written notice of discharge to the resident or resident representative and the Ombudsman. The SW stated she had been documenting the follow up phone call in the electronic medical record. During an interview with the Administrator and Senior Director of Patient Care on 6/28/23 at 8:44 AM. The Administrator indicated the Social Worker was responsible for providing the written notice of transfer/discharge to the hospital and notifying the Ombudsman. He revealed that during this survey he realized the Social Worker had not been completing this responsibility and that written notice of discharge/transfer had not been provided to the resident, resident representative, or the Ombudsman for any transfer/discharge to the hospital. The Administrator was unsure of how long the facility had not been providing these notices. Immediate education was provided to the Social Worker on discharge notices.

Based on record review, family and staff interviews, the facility failed to complete baseline care plans in conjunction with the Interdisciplinary Team (IDT), resident and/or responsible party and failed to provide the resident or their responsible party with a written summary of the baseline care plan for 6 of 11 sampled residents reviewed (Resident #49, #3, #4, #226, #232, and #240). Findings included: 1. Resident #49 was admitted on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) dated [DATE] coded Resident #49 with severe cognitive impairment for daily decision making. The MDS noted he required extensive to total staff assistance with all activities of daily living and received oxygen therapy during the MDS assessment period. The computerized baseline care plan initiated on 06/01/21 noted Resident #49 was admitted for short-term rehab to improve function and contained preprinted sections with boxes to check that indicated the sections were reviewed and/or completed by members of the IDT. Further review revealed the following sections had no boxes checked or comments noted: discharge planning, social services, or signature of resident and/or Responsible Party (RP). Additionally, there was no documentation included on the form in the areas for staff in attendance to list their names, department, or their signature. The baseline care plan had no completion date or evidence a copy was provided to the resident and/or RP. During a telephone interview on 07/07/21 at 12:20 PM, Resident #49's RP stated she met with the IDT to discuss his plan of care and discharge goals but was not provided a written summary of the baseline care plan. During an interview on 07/09/21 at 4:08 PM, the Clinical Manager (CM) explained a Registered Nurse (RN) must initiate the baseline care plan but once initiated, any member of the IDT could fill in the information. The CM stated the information included in a baseline care plan was based on the admission assessment and level of care exhibited by the resident during the first 48 hours of their stay. She added it was her understanding that the information included in the baseline care plan provided a snapshot of the resident's care needs until they were thoroughly assessed and a comprehensive care plan developed. The CM was not sure when the initial care plan meeting was held with the resident and/or RP or when they were given a written summary of the care plan and stated she personally never provided the resident or their RP a copy of the baseline care plan. The CM stated there was no staff member assigned to ensure baseline care plans were completed within 48 hours of admission. During a joint interview, Social Worker (SW) #1 and SW #2 explained the IDT met with the resident and/or their RP within 7 to 10 after the resident's admission to review the plan of care at which time they also received a copy of the completed baseline care plan; however, they stated if the baseline care plan was not marked complete, then the resident and/or their RP were not provided a copy. During an interview on 07/09/21 at 5:38 PM, the Administrator stated she would expect for the baseline care plans to include input from IDT, be completed within 48 hours of the resident's admission and a written summary of the care plan provided to the resident and/or their responsible party. 2. Resident #232 was admitted to the facility 06/14/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5-day Minimum Data Set (MDS) dated [DATE] revealed Resident #232 was cognitively intact and required extensive assistance with bed mobility, transfers, dressing, and toilet use. Review of the computerized baseline care plan initiated 06/14/21 revealed the areas of occupational history, bed mobility, transfer, walking, toileting, high risk black box medication, locomotion, bathing, isolation precautions, eating, grooming/hygiene, equipment, relocation stress, treatments/therapies, and Preadmission Screening and Resident Review (PASRR) recommendation, signatures of the interdisciplinary team (IDT), and signature of the resident or responsible party were blank. An interview with Clinical Manager on 07/08/21 at 04:15 PM revealed a Registered Nurse (RN) must initiate the baseline care plan and complete the baseline care plan. She explained once the baseline care plan was initiated any member of the IDT could document on the baseline care plan. The Clinical Manager stated there was no staff member assigned to ensure completion of baseline care plans within 48 hours of admission. A joint interview with Social Worker (SW) #1 and SW#2 on 07/09/21 at 02:57 PM revealed an IDT meeting was conducted with the resident and/or responsible party usually 7 to 10 days after admission to review the plan of care. They explained a copy of the baseline care plan was provided to the resident or the responsible party during the care plan meeting if the baseline care plan was marked as complete. An interview with the Administrator on 07/09/21 at 05:42PM revealed she expected the baseline care plan to be completed within 48 hours of admission and the IDT should be documenting on the baseline care plan. The Administrator stated the process for completing the baseline care plan within 48 hours needed to be revamped. 3. Resident #240 was admitted to the facility 06/29/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS for Resident #240 was opened but had not been completed at the time of the survey. The baseline care plan for Resident #240 initiated 06/30/21 was completely blank. An interview with Clinical Manager on 07/08/21 at 04:15 PM revealed a Registered Nurse (RN) must initiate the baseline care plan and complete the baseline care plan. She explained once the baseline care plan was initiated any member of the IDT could document on the baseline care plan. The Clinical Manager stated there was no staff member assigned to ensure completion of baseline care plans within 48 hours of admission. A joint interview with Social Worker (SW) #1 and SW#2 on 07/09/21 at 02:57 PM revealed an IDT meeting was conducted with the resident and/or responsible party usually 7 to 10 days after admission to review the plan of care. They explained a copy of the baseline care plan was provided to the resident or the responsible party during the care plan meeting if the baseline care plan was marked as complete. An interview with the Administrator on 07/09/21 at 05:42PM revealed she expected the baseline care plan to be completed within 48 hours of admission and the IDT should be documenting on the baseline care plan. The Administrator stated the process for completing the baseline care plan within 48 hours needed to be revamped. 4. Resident #3 was admitted to the facility 06/30/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5-day MDS dated [DATE] for Resident #3 was opened but had not been completed at the time of the survey. Review of Resident #3's baseline care plan initiated 06/30/21 revealed occupational history, PASRR recommendation, signatures of IDT members, and signature of the resident or responsible party were blank. An interview with Clinical Manager on 07/08/21 at 04:15 PM revealed a Registered Nurse (RN) must initiate the baseline care plan and complete the baseline care plan. She explained once the baseline care plan was initiated any member of the IDT could document on the baseline care plan. The Clinical Manager stated there was no staff member assigned to ensure completion of baseline care plans within 48 hours of admission. A joint interview with Social Worker (SW) #1 and SW#2 on 07/09/21 at 02:57 PM revealed an IDT meeting was conducted with the resident and/or responsible party usually 7 to 10 days after admission to review the plan of care. They explained a copy of the baseline care plan was provided to the resident or the responsible party during the care plan meeting if the baseline care plan was marked as complete. An interview with the Administrator on 07/09/21 at 05:42PM revealed she expected the baseline care plan to be completed within 48 hours of admission and the IDT should be documenting on the baseline care plan. The Administrator stated the process for completing the baseline care plan within 48 hours needed to be revamped. 5. Resident #4 was admitted to the facility 06/30/21 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The admission MDS dated [DATE] for Resident #4 was opened but had not been completed at the time of the survey. Review of Resident #4's baseline care plan initiated 06/30/21 revealed occupational history, grooming/hygiene, social services, PASRR recommendation, signatures of IDT members, and signature of the resident or responsible party were blank. An interview with Clinical Manager on 07/08/21 at 04:15 PM revealed a Registered Nurse (RN) must initiate the baseline care plan and complete the baseline care plan. She explained once the baseline care plan was initiated any member of the IDT could document on the baseline care plan. The Clinical Manager stated there was no staff member assigned to ensure completion of baseline care plans within 48 hours of admission. A joint interview with Social Worker (SW) #1 and SW#2 on 07/09/21 at 02:57 PM revealed an IDT meeting was conducted with the resident and/or responsible party usually 7 to 10 days after admission to review the plan of care. They explained a copy of the baseline care plan was provided to the resident or the responsible party during the care plan meeting if the baseline care plan was marked as complete. An interview with the Administrator on 07/09/21 at 05:42PM revealed she expected the baseline care plan to be completed within 48 hours of admission and the IDT should be documenting on the baseline care plan. The Administrator stated the process for completing the baseline care plan within 48 hours needed to be revamped. 6. Resident #226 was admitted to the facility 06/25/21 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS dated [DATE] for Resident #226 was opened but not completed at the time of the survey. Review of Resident #226's baseline care plan initiated 06/26/21 revealed occupational history, anticoagulation therapy, high risk black box medications, treatments/therapies, discharge planning, social services, PASRR recommendation, signatures of IDT members, and signature of the resident or responsible party were blank. An interview with Clinical Manager on 07/08/21 at 04:15 PM revealed a Registered Nurse (RN) must initiate the baseline care plan and complete the baseline care plan. She explained once the baseline care plan was initiated any member of the IDT could document on the baseline care plan. The Clinical Manager stated there was no staff member assigned to ensure completion of baseline care plans within 48 hours of admission. A joint interview with Social Worker (SW) #1 and SW#2 on 07/09/21 at 02:57 PM revealed an IDT meeting was conducted with the resident and/or responsible party usually 7 to 10 days after admission to review the plan of care. They explained a copy of the baseline care plan was provided to the resident or the responsible party during the care plan meeting if the baseline care plan was marked as complete. An interview with the Administrator on 07/09/21 at 05:42PM revealed she expected the baseline care plan to be completed within 48 hours of admission and the IDT should be documenting on the baseline care plan. The Administrator stated the process for completing the baseline care plan within 48 hours needed to be revamped.

Based on record review, observations, and staff interviews the facility failed to code the Minimum Data Set (MDS) assessments accurately in the areas of restraints (Resident #6), pressure ulcers (Resident #33), falls (Resident #33, #175), and for the use of a non-invasive mechanical ventilator (Resident#49) for 4 of 20 residents reviewed for accuracy. The findings included: 1. Resident #6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE] for physical restraints used in bed revealed a restraint identified as other was used less than daily. Observations revealed on 7/8/21 at 10:31 AM revealed Resident #6 sitting upright in a wheelchair covered with a blanket. A second observation on 7/8/21 at 2:32 PM revealed Resident #6 resting in bed. There were no bed rails in place. The bed was low to the floor with 1 side against the wall. An interview conducted on 7/08/21 at 3:43 PM with the Physical Therapist (PT) revealed she worked at the facility for approximately 2 years and stated it was restraint free. The facility didn't use wrist or lap boards, quarter, or full-length bed rails, or bed and chair alarms. During an interview on 7/9/21 at 2:46 PM MDS Coordinator #1 explained it was an error to code Resident #6's quarterly MDS for the use of physical restraints. MDS Coordinator #1 explained the facility didn't use restraints. During an interview the on 7/9/21 at 6:10 PM the Administrator confirmed the facility didn't use restraints and the quarterly MDS dated [DATE] for Resident #6 was inaccurate. The Administrator indicated a modification would be done to reflect restraints weren't used for Resident #6. 2. a. Resident #33 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A wound evaluation and management summary dated 3/11/21 identified a stage 3 pressure wound of the right heel. Based on the evaluation the duration of the wound was greater than 19 days measuring 0.5 centimeters (cm) in length and 3 cm in width and 0.1 cm in depth and had improved. Review of the quarterly MDS dated [DATE] assessed Resident #33 as having no unhealed pressure ulcers. The skin and ulcer/injury treatments included a pressure reducing device for the bed and chair and applications of ointments and/or medications. During an interview on 7/9/21 at 2:44 PM MDS Coordinator #1 revealed the quarterly MDS dated [DATE] should've coded the presence of an unhealed pressure ulcer based on the wound evaluation dated 3/11/21. MDS Coordinator #1 revealed the quarterly MDS dated [DATE] was inaccurate for pressure ulcer and was a coding error. An interview was conducted on 7/9/21 at 5:42 PM with the Administrator. The Administrator confirmed the quarterly MDS dated [DATE] was coded inaccurately and explained during weekly meetings residents at risk were discussed for wound care and pressure ulcers. The MDS Coordinators currently didn't attend those meetings but it would be good for them to start to ensure they were aware of residents with wounds. 2. b. Resident #33 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the incident report dated 3/30/21 revealed Resident #33 had a witnessed fall when attempting to stand unassisted and step over the leg rest of the wheelchair. The incident report explained Resident #33 fell to the floor landing on her left side. The quarterly MDS dated [DATE] was coded as there had been no falls since the previous assessment. The previous MDS assessment was a quarterly dated 3/13/21. During an interview on 7/9/21 at 2:49 PM MDS Coordinator #1 explained not coding a fall occurred was an error; therefore, the MDS was inaccurate. During an interview on 7/9/21 at 5:47 PM the Administrator confirmed the MDS should reflect a fall occurred. The Administrator explained the MDS Coordinator was new to the position and more training would be done to help clarify how to document falls on the MDS. 3. Resident #175 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the incident report dated 6/26/21 revealed Resident #175 was observed on floor in her room. The admission MDS dated [DATE] was coded as there had been no falls since Resident #175's admission to the facility. During an interview on 7/9/21 at 2:49 PM MDS Coordinator #1 explained not coding a fall occurred was an error; therefore, the MDS was inaccurate. During an interview on 7/9/21 at 5:47 PM the Administrator confirmed the MDS should reflect a fall occurred. The Administrator explained the MDS Coordinator was new to the position and more training would be done to help clarify how to document falls on the MDS. 4. Resident #49 was admitted to the facility 06/01/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) dated [DATE] assessed Resident #49 with severe cognitive impairment. The MDS noted he used a [CONDITION(S)] (Bilateral Positive Airway Pressure)/[CONDITION(S)] (Continuous Positive Airway Pressure) (type of devices that help with breathing) while a resident. An observation conducted on 07/08/21 at 8:38 AM of Resident #49's room revealed no evidence of a [CONDITION(S)] or [CONDITION(S)] device. During an interview on 07/09/21 at 1:11 PM, MDS Coordinator #2 confirmed she coded Section O, Special Treatment on the admission MDS dated [DATE] for Resident #49. MDS Coordinator #2 explained she had coded use of [CONDITION(S)]/[CONDITION(S)] for Resident #49 based on the hospital discharge summary which noted he used it at bedtime. She verified Resident #49 did not have a [CONDITION(S)]/[CONDITION(S)] in his room and there was no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS Coordinator #2 stated Resident #49's use of a [CONDITION(S)]/[CONDITION(S)] while a resident was incorrectly coded on the MDS assessment dated [DATE] and a modification would be submitted. During an interview on 07/09/21 at 5:38 PM, the Administrator explained MDS Coordinator #2 was new to the position and just made an error coding Resident 49's admission MDS dated [DATE]. The Administrator stated a modification would be submitted to reflect Resident #49 did not use a non-invasive mechanical ventilator while a resident at the facility.

Based on record review and staff interviews, the facility failed to develop a comprehensive, individualized care plan that addressed the areas: indwelling catheter and anticoagulant, diuretic and opioid medication use for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #35). Findings included: Resident #35 admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) dated [DATE] coded Resident #35 with moderate impairment in cognition and the presence of an indwelling catheter. The MDS noted she received the following medications daily during the MDS assessment period: anticoagulant (blood thinner), diuretic (medication used to help the body get rid of extra fluid and salt), and opioid (pain medication). Review of Resident #35's Medication/Treatment Administration Records for the months of June 2021 and July 2021 revealed the following physician orders: · 04/13/21: [MEDICATION(S)] (pain medication) 50 milligrams (mg) every 6 hours as needed. Discontinued on 06/14/21. · 04/30/21: Change indwelling catheter monthly on the 29th. · 04/30/21: Perform catheter care every shift and as needed. · 05/07/21: [MEDICATION(S)] (pain medication) 100 mg twice a day. · 06/17/21: [MEDICATION(S)] (anticoagulant) 2.5 milligrams (mg) twice a day with instructions to stop [MEDICATION(S)] on 06/21/21 in anticipation of surgery. · 06/21/21: [MEDICATION(S)] 2.5 mg twice a day. · 06/27/21: [MEDICATION(S)]-acetaminophen (pain medication) 5-325 mg every 6 hours as needed. · 07/07/21: [MEDICATION(S)] (diuretic) 20 mg once a day. Review of Resident #35's active care plans, last reviewed/revised 05/26/21, revealed no care plans that addressed catheter care, anticoagulant, diuretic or pain medication use. During an interview on 07/09/21 at 1:11 PM, MDS Coordinator #2 explained she was new to the MDS position and was not trained to develop specific care plans, such as an indwelling catheter or anticoagulant medication use; however, the problem areas would be addressed under the category they triggered on the MDS assessment. MDS Coordinator #2 confirmed there were no care plans that addressed Resident 35's indwelling catheter or her use of anticoagulant, diuretic and pain medications and stated those areas should have been addressed. During a telephone interview on 07/09/21 at 2:37 PM, MDS Coordinator #1 explained both she and MDS Coordinator #2 were new to the MDS position and confirmed comprehensive care plans were developed based off the triggers from the Care Area Assessment (CAA) of the MDS. She added they still had a lot to learn and the only explanation she could provide was it was an error on their part that Resident #35's indwelling catheter and use of anticoagulant, diuretic and pain medications were not addressed in her comprehensive care plan. During an interview on 07/09/21 at 5:38 PM, the Administrator explained the MDS Coordinators were new to the positions and likely did not know that specific care plans could be developed when the problem area did not trigger on the MDS. She added more training would be provided to the MDS Coordinators related to developing comprehensive care plans.

Based on record review and staff interviews, the facility failed to revise and update a care plan related to an upgraded diet for 1 of 18 sampled residents (Resident #49). Findings included: Resident #49 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The baseline care plan initiated on 06/01/21 noted under the eating section that Resident #49 had a feeding tube (medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation) and under the diet section was noted NPO (no solids or fluids by mouth), feeding tube and at risk for weight loss. The admission Minimum Data Set (MDS) dated [DATE] coded Resident #49 with severe cognitive impairment. The MDS noted he required extensive staff assistance with eating and received 51 percent or more of total calories through a feeding tube. Review of Resident #49's active care plans, initiated on 06/10/21, revealed a nutrition care plan in place that read in part he was at risk for weight loss due to dysphagia and NPO status. The care plan noted his nutritional needs were provided through a feeding tube. Review of Resident #49's medical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 07/09/21 at 1:11 PM, MDS Coordinator #2 reviewed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS Coordinator #2 stated she thought it would be the responsibility of dietary to revise the care plan with changes in diet or inform her and MDS Coordinator #1 so they could update the care plan. During a telephone interview on 07/09/21 at 2:37 PM, MDS Coordinator #1 explained both she and MDS Coordinator #2 were new to the MDS position and was not sure who was ultimately responsible for revising/updating care plans. She added they still had a lot to learn and the only explanation she could provide was it was an error and part of the learning process. During an interview on 07/09/21 at 5:38 PM, the Administrator explained the MDS Coordinators currently did not attend the weekly meetings where residents at risk were discussed and felt it would be good to start including them in the meetings so they would be aware of changes and new orders for the resident care plans to be updated/revised accordingly.

Based on record review and staff interviews, the facility failed to develop a grievance policy that included: the residents' right to receive a written summary of the grievance resolution, the name and contact information of the designated grievance official and the contact information of independent entities with whom grievances may also be filed such as pertinent State agency, State Long Term Care Ombudsman or Quality Improvement Organization. Findings included: Review of the facility's grievance policy, with a revised date of 11/04/17 and provided by the Administrator, specified in part the facility would provide residents, resident's responsible party or representatives an opportunity for resolution of a concern, complaint, grievance, or ethical issue that may arise during a resident's stay without fear of reprisal in any form. Further review revealed the grievance policy did not include the name, business address or email of the Grievance Official or the contact information of independent entities with whom grievances may also be filed. In addition, the grievance policy specified a written response of the grievance resolution would be provided to the resident or responsible party upon request. During an interview on 07/08/21 at 5:25 PM, the Administrator explained residents, or their responsible party, did not receive a copy of the grievance resolution unless requested. She confirmed the grievance policy, with a revised date of 11/04/17 and review date of 05/2020, was the most current policy. The Administrator was not familiar with the federal regulation related to grievances and acknowledged the facility's current grievance policy did not contain all the required components as outlined in the regulation and would need to be updated.

Based on record review, observation, resident and staff interviews, the facility failed to transfer a resident using the total lift with two person assist for 1 of 1 resident observed during transfer (Resident #32). Findings included: 1. Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set ((MDS) dated [DATE] coded Resident #32 as cognitively intact and required two-person extensive assistance for transfers. A review of Resident #32's care guide, a guide that let's nursing staff know what type of care to provide for residents, dated 7/12/18 revealed he was a 2 person assist using a total lift for transfers. A review of Resident #32's care plan dated 3/22/19 revealed he was to be transferred using a total lift. An observation was made on 6/03/19 at 2:20 PM of Nurse Aide #1 transferring Resident #32 from the bed to the wheelchair with the total lift with no assistance. An interview conducted on 06/03/19 at 2:31 PM with NA #1 revealed Resident #32's care guide indicated he was a total lift that required a 2 person assist. She stated she felt it was ok to transfer him alone since the housekeeper was in the room to watch. She further stated she was aware facility policy was to have for a 2 person assist with all total lift transfers. An interview with Resident #32 on 6/05/19 at 4:15 PM revealed he was transferred with 1 staff member on 06/03/19. He further stated sometimes he was transferred with the total lift by only 1 staff member but it was usually 2 staff members. An interview on 6/03/19 at 2:37 PM with the Director of Nursing (DON) revealed NA #1 should have asked for lift assistance and should not have transferred Resident #32 without another NA or nurse and the housekeeper being in the room was not the same as having 2 staff transfer a resident. The DON stated that NA #1 performed an unsafe transfer when utilizing the total life without 2 staff members. She further stated Resident #32's care guide was marked for a 2 person transfer with the total lift. An interview on 6/03/19 at 3:10 PM with the Administrator revealed that Resident #32 should have had 2 NAs to safely transfer him and she didn't know what happened or why NA #1 did not ask for assistance.

Based on record review and staff interviews, the facility failed to complete a Significant Change MDS (Minimum Data Set) assessment and failed to transmit Admission, Annual and Quarterly MDS assessments within the required time frame for 6 of 6 residents (Resident #33, #1, #2, #3, #4, and #19) reviewed for Resident Assessments. Findings included: 1. Resident #33 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A review of Resident #33's most recent MDS had an Assessment Reference Date (ARD) of 04/03/18 and was coded as a significant change assessment. The MDS was noted to be in process. During an interview on 05/01/18 at 3:14 PM the MDS Nurse stated she was the one responsible for signing and transmitting completed MDS assessments. The MDS Nurse explained they were in the process of switching computer systems and each week she ran a submission report that indicated the MDS assessments ready to be signed and transmitted. She further explained when an MDS assessment was transmitted and approved by the Centers for Medicare & Medicaid Services (CMS) it would indicate production accepted. She confirmed the significant change MDS for Resident #33 was not done due to an oversight and would need to be completed and transmitted. During an interview on 05/02/18 at 12:51 PM the Director of Nursing (DON) stated it was her expectation for MDS assessments to be completed and transmitted within the required time frames. 2. Resident #1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A review of Resident #1's most recent MDS had an ARD of 03/19/18 and was coded as a quarterly assessment. The MDS was noted to be in process. During an interview on 05/01/18 at 3:14 PM the MDS Nurse stated she was the one responsible for signing and transmitting completed MDS assessments. The MDS Nurse explained they were in the process of switching computer systems and each week she ran a submission report that indicated the MDS assessments ready to be signed and transmitted. She further explained when an MDS assessment was transmitted and approved by CMS it would indicate production accepted. She was unable to explain why Resident #1's quarterly MDS assessment dated [DATE] was showing as in process and confirmed the MDS assessment was completed and should have been transmitted. During an interview on 05/02/18 at 12:51 PM the Director of Nursing (DON) stated it was her expectation for MDS assessments to be completed and transmitted within the required time frames. 3. Resident #2 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A review of Resident #2's most recent MDS had an ARD of 03/19/18 and was coded as a quarterly assessment. The MDS was noted to be finalized. During an interview on 05/01/18 at 3:14 PM the MDS Nurse stated she was the one responsible for signing and transmitting completed MDS assessments. The MDS Nurse explained they were in the process of switching computer systems and each week she ran a submission report that indicated the MDS assessments ready to be signed and transmitted. She further explained when an MDS assessment was transmitted and approved by CMS it would indicate production accepted. She confirmed Resident #2's quarterly MDS assessment dated [DATE] was completed and should have been transmitted. During an interview on 05/02/18 at 12:51 PM the Director of Nursing (DON) stated it was her expectation for MDS assessments to be completed and transmitted within the required time frames. 4. Resident #3 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A review of Resident #3's most recent MDS had an ARD of 03/20/18 and was coded as an annual assessment. The MDS was noted to be validated. During an interview on 05/01/18 at 3:14 PM the MDS Nurse stated she was the one responsible for signing and transmitting completed MDS assessments. The MDS Nurse explained they were in the process of switching computer systems and each week she ran a submission report that indicated the MDS assessments ready to be signed and transmitted. She further explained when an MDS assessment was transmitted and approved by CMS it would indicate production accepted. She confirmed Resident #3's annual MDS assessment dated [DATE] was completed and should have been signed and transmitted. During an interview on 05/02/18 at 12:51 PM the Director of Nursing (DON) stated it was her expectation for MDS assessments to be completed and transmitted within the required time frames. 5. Resident #4 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A review of Resident #4's most recent MDS had an ARD of 03/20/18 and was coded as a quarterly assessment. The MDS was noted to be finalized. During an interview on 05/01/18 at 3:14 PM the MDS Nurse stated she was the one responsible for signing and transmitting completed MDS assessments. The MDS Nurse explained they were in the process of switching computer systems and each week she ran a submission report that indicated the MDS assessments ready to be signed and transmitted. She further explained when an MDS assessment was transmitted and approved by CMS it would indicate production accepted. She confirmed Resident #4's quarterly MDS assessment dated [DATE] was completed and should have been transmitted. During an interview on 05/02/18 at 12:51 PM the Director of Nursing (DON) stated it was her expectation for MDS assessments to be completed and transmitted within the required time frames. 6. Resident #19 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A review of Resident #19's most recent MDS assessments revealed a 5-day Prospective Payment System (PPS) assessment with an ARD of 03/14/18 and an admission MDS with an ARD of 03/14/18. The admission MDS was noted to be in process. During an interview on 05/01/18 at 3:14 PM the MDS Nurse stated she was the one responsible for signing and transmitting completed MDS assessments. The MDS Nurse explained they were in the process of switching computer systems and each week she ran a submission report that indicated the MDS assessments ready to be signed and transmitted. She further explained when an MDS assessment was transmitted and approved by CMS it would indicate production accepted. She stated due to Resident #19's insurance policy the PPS and admission MDS assessments were completed and transmitted separately. She confirmed the admission MDS dated [DATE] for Resident #19 was completed and should have been transmitted. During an interview on 05/02/18 at 12:51 PM the Director of Nursing (DON) stated it was her expectation for MDS assessments to be completed and transmitted within the required time frames.

Based on observations, record review, resident, and staff interviews the facility failed to assess the need for side rails for 7 of 7 residents reviewed for side rails who were using ¼ side rails (Resident #232, #236, #39, #3, #17, #38, and #51). Findings Included: 1. Resident #232 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #232 was cognitively intact and required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Bed rails were not coded under Section P0100A. A review of the medical record revealed Resident #232 had no side rail assessment. The following observations were conducted of Resident #232: On 04/30/18 at 11:45 AM Resident #232 was lying in bed and ¼ side rails were up on both sides of the bed. On 05/01/18 at 04:28 PM Resident #232 was resting in bed with eyes closed and ¼ side rails were up on both sides of the bed. On 05/03/18 at 09:25 AM Resident #232 was sitting up in bed feeding herself breakfast and ¼ side rail were up on both sides of the bed. On 05/02/18 at 3:15 PM an interview was conducted with the Nursing Supervisor (NS) who stated the facility did not conduct side rail assessments on residents. She stated she would speak with the Director of Nursing (DON) because no side rail assessments were conducted. On 5/2/18 at 4:05 PM an interview was conducted with the Administrator and DON who stated they were unaware side rail assessment were required and confirmed no side rail assessments had been completed. On 05/03/18 at 9:26 AM an interview was conducted with Resident #232 who stated she liked to have side rails on the bed because she was able to position herself in the bed by using the side rails. On 05/03/18 at 10:30 AM an interview was conducted with the DON who stated there was no rhyme or reason as why the nurse or nurse aide used side rails for the resident. The DON stated there was no formal guideline, procedure, or assessment for side rail use in the facility. The DON stated some families were old school and wanted side rails used for the resident. The DON stated some residents came to facility from the hospital and wanted to continue the use of side rails. The DON stated some staff used side rails for resident safety and further stated the facility had no formalized assessment developed and implemented for side rail use. 2. Resident #236 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #236 was cognitively intact and required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Bed rails were not coded under Section P0100A. A review of the medical record revealed Resident #236 had no side rail assessment. An observation was conducted on 04/30/18 at 9:43 AM and revealed Resident #236 was observed lying in bed with the head of bed elevated and ¼ side rails were up on both sides of the bed. On 05/02/18 at 3:15 PM an interview was conducted with the Nursing Supervisor (NS) who stated the facility did not conduct side rail assessments on residents. She stated she would speak with the Director of Nursing (DON) because no side rail assessments were conducted. On 5/2/18 at 4:05 PM an interview was conducted with the Administrator and DON who stated they were unaware side rail assessment were required and confirmed no side rail assessments had been completed. On 05/03/18 at 10:04 AM an interview was conducted with Resident #236 who stated she like having side rails on her bed because they helped her with positioning in the bed. On 05/03/18 at 10:30 AM an interview was conducted with the DON who stated there was no rhyme or reason as why the nurse or nurse aide used side rails for the resident. The DON stated there was no formal guideline, procedure, or assessment for side rail use in the facility. The DON stated some families were old school and wanted side rails used for the resident. The DON stated some residents came to facility from the hospital and wanted to continue the use of side rails. The DON stated some staff used side rails for resident safety and stated the facility had no formalized assessment developed and implemented for side rail use. 3. Resident #39 was admitted to the facility 2/13/18 with [DIAGNOSES REDACTED]. A review of the Admission Minimum (MDS) data set [DATE] noted Resident #39 had severe cognitive impairment and required extensive assistance of staff for bed mobility and transfers. Bed rails were not coded under Section P0100a. A review of the medical record revealed Resident #39 had no side rail assessment. On 05/03/18 at 7:47 AM Resident #39 was observed, in his room, seated on the side of his bed. The bed was against the wall and a 1/4 side rail was observed in the upright position, towards the head of the bed. Resident #39 was observed holding onto the side rail for support while seated at the side of the bed. On 05/02/18 at 4:05 PM an interview was conducted with the Administrator and Director of Nursing and they both stated they were unaware side rail assessments were required and confirmed no side rail assessments had been completed. On 05/03/18 at 2:40 PM the nursing assistant care guide (used to know specific needs of individual residents) was reviewed and included an area under the category equipment to address the need for side rails. The care guide for Resident #39 was blank beside the area for side rails. On 05/03/18 at 2:42 PM Nursing Assistant #1 stated she routinely worked on the hall where Resident #39 resided and typically put 1/4 bed rails up on all of the residents to use when she assisted them with repositioning. Nursing Assistant #1 stated she was not aware of any systems in place to let staff know whether or not to use side rails for residents. 4. Resident #3 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A review of the annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 was severely impaired in cognition and required extensive to total staff assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Bed rails were not coded as being used under Section P0100A. A review of the medical record revealed Resident #3 had no side rail assessment. An observation on 04/30/18 at 2:50 PM revealed Resident #3 lying in bed with the bed pushed up against the wall and a ¼ side rail up on the opposite side of the bed. Observations of Resident #3's room on 05/01/18 at 3:15 PM and 05/02/18 at 8:45 AM revealed the bed against the wall with a ¼ side rail up on the opposite side of the bed. Resident #3 was unable to be interviewed due to cognition. An interview on 05/02/18 at 3:15 PM with the Nursing Supervisor (NS) revealed the facility did not conduct side rail assessments on residents. She stated she would speak with the Director of Nursing (DON) because no side rail assessments were conducted. An interview on 05/02/18 at 4:05 PM with the Administrator and DON revealed they were unaware side rail assessments were required and confirmed no side rail assessments had been completed. 5. Resident #17 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #17 was severely impaired in cognition and required total staff assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Bed rails were not coded as being used under Section P0100A. A review of the medical record revealed Resident #17 had no side rail assessment. An observation of Resident #17's room on 04/30/18 at 2:50 PM revealed the bed pushed up against the wall with a ¼ side rail up on the opposite side of the bed. Observations of Resident #17's room on 05/01/18 at 2:38 PM and 05/02/18 at 11:01 AM revealed the bed against the wall with a ¼ side rail up on the opposite side of the bed. Resident #17 was unable to be interviewed due to cognition. An interview on 05/02/18 at 3:15 PM with the Nursing Supervisor (NS) revealed the facility did not conduct side rail assessments on residents. She stated she would speak with the Director of Nursing (DON) because no side rail assessments were conducted. An interview on 05/02/18 at 4:05 PM with the Administrator and DON revealed they were unaware side rail assessments were required and confirmed no side rail assessments had been completed. 6. Resident #38 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #38 was severely impaired in cognition and required total staff assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Bed rails were not coded as being used under Section P0100A. A review of the medical record revealed Resident #38 had no side rail assessment. An observation of Resident #38's room on 05/01/18 at 12:07 PM revealed the bed pushed up against the wall with a ¼ side rail up on the opposite side of the bed. An observation of Resident #38's room on 05/02/18 at 12:10 PM revealed the bed against the wall with a ¼ side rail up on the opposite side of the bed. Resident #38 was unable to be interviewed due to cognition. An interview on 05/02/18 at 3:15 PM with the Nursing Supervisor (NS) revealed the facility did not conduct side rail assessments on residents. She stated she would speak with the Director of Nursing (DON) because no side rail assessments were conducted. An interview on 05/02/18 at 4:05 PM with the Administrator and DON revealed they were unaware side rail assessments were required and confirmed no side rail assessments had been completed. 7. Resident #51 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A review of the annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #51 was severely impaired in cognition and required extensive staff assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Bed rails were not coded as being used under Section P0100A. A review of the medical record revealed Resident #51 had no side rail assessment. An observation on 04/30/18 at 2:24 PM revealed Resident #51 lying in bed with the bed pushed up against the wall and a ¼ side rail up on the opposite side of the bed. Observations of Resident #51's room on 05/01/18 at 2:40 PM and 05/02/18 at 10:11 AM revealed the bed against the wall with a ¼ side rail up on the opposite side of the bed. Resident #51 was unable to be interviewed due to cognition. An interview on 05/02/18 at 3:15 PM with the Nursing Supervisor (NS) revealed the facility did not conduct side rail assessments on residents. She stated she would speak with the Director of Nursing (DON) because no side rail assessments were conducted. An interview on 05/02/18 at 4:05 PM with the Administrator and DON revealed they were unaware side rail assessments were required and confirmed no side rail assessments had been completed.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) to reflect the Level II Preadmission Screening and Resident Review (PASRR) determination for 1 of 1 resident (Resident #51) identified as PASRR Level II. Findings included: Resident #51 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of the Annual MDS dated [DATE] revealed Resident #51 was not considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability. The results of this screening and review are used for formulating a determination of need, determination of an appropriate care setting and formulating a set of recommendations for services to help develop an individual's plan of care. Review of the Skilled Nursing Facility (SNF) Level II authorization dated 03/27/17 for Resident #51 indicated she was approved for a level II PASRR number with no expiration date. During an interview on 05/03/18 at 3:30 PM the MDS Nurse stated she was under the assumption that last year Resident #51 had received a lifetime PASRR that was not considered a Level II. The MDS Nurse reviewed the SNF Level II authorization dated 03/27/17 for Resident #51 and confirmed the approval indicated a Level II PASRR. During an interview on 05/03/18 at 6:09 PM the Admissions Coordinator confirmed the SNF Level II authorization dated 03/27/17 for Resident #51 was the most recent PASRR approval received. During an interview on 05/03/18 at 7:20 PM the Administrator stated it was his expectation for MDS assessments to be accurately coded.

Based on observations, staff interviews and record review the facility failed to secure a resident's legs during a mechanical lift transfer resulting in a fall with arm fracture (Resident #3), and failed to use two staff for mechanical lift transfers (Resident # 2 and #3) for 2 of 3 sampled residents. The findings include: 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] specified the resident had short and long term memory impairment and moderately impaired cognitive skills for decision making. The MDS also specified the resident was totally dependant on staff for activities of daily living (ADL) and the resident was transferred with a mechanical lift. Review of Resident #3's medical record revealed a nurse's entry made by Nurse #1 dated 02/07/13 that specified the resident had pain and swelling in his left arm. A physician was in the facility to assess Resident #3 and ordered an X-ray of the left arm. The X-ray results dated 02/07/13 specified the resident's left humerus was fractured. Resident #3 was sent to the hospital for treatment of [REDACTED]. Resident #3's ADL/care plan guide revealed a document titled "Transfer Recommendation" dated 03/19/13 that specified Resident #3 required 2 person assistance with a mechanical total lift for transfers. Attached to the ADL/care plan guide was a document (not dated) that specified, "Resident #3 is to be transferred in the Hoyer lift (a type of mechanical lift) with 2 assist. Always use 2 persons for any transfer, turning and positioning." On 03/20/13 at 10:45 AM nurse aide (NA) #1 was interviewed and reported she was assigned to care for Resident #3. She stated she was aware the resident had fractured his arm. NA #1 explained that Resident #3 was totally dependant on staff for care and was to be transferred with the total lift (a lift that used a sling pad and lever arm to physically move the resident not requiring involvement of the resident). She stated she was assigned to give Resident #3 a shower on 02/04/13. She explained that she was not sure how to transfer the resident to shower him because the sling pad for the total lift was not to get wet. She added she asked NA #3 how to transfer the resident in the shower room and was told by NA #3 to use the sit to stand lift rather than the total lift. NA #1 explained she used the sit to stand lift to transfer Resident #3 out of his Broda chair into a large reclining shower chair. She added that NA #3 assisted her with the transfer. NA #1 reported that in the process of transferring the resident his foot (not specified right or left) slipped off the foot rest and the resident slumped down in the sling. She stated NA #3 called Nurse #1 for assistance and together they lowered the resident into a wheelchair. NA #1 reported that after the incident Resident #3 did not complain of pain and she did not recall him bumping or hitting his left arm. During the interview, NA #1 reported that she was trained to reference a resident's ADL/care plan guide to know how to safely transfer a resident. She stated that on 02/04/13 she did not refer to Resident #3's ADL/care plan guide prior to transferring him in the shower room. NA #1 reported she was trained on the use of mechanical lifts. She stated that she was trained that when using the "sit to stand" lift she had to ensure the resident's feet were squarely on the platform and secured with a safety belt that fastened around a resident's lower legs and that the resident had to hold onto the handles of the lift while the lift was in use. She stated that in the case of Resident #3 he was not able to hold on to both handles because of his paralysis on the left side. NA #1 was unable to recall if Resident #3's feet were secured with the safety belt. She offered no explanation how the resident's foot could have slipped off the foot rest if his feet were secured with the safety belt. On 03/20/13 at 11:00 AM Nurse #1 was interviewed and reported that on 02/04/13 she was called into the shower room because Resident #3 had slid down in the sit to stand lift while being transferred. She stated the resident did not fall but was lowered into a wheelchair. She stated she assessed the resident and he did not complain of pain. Nurse #1 was unable to recall if the resident's legs were secured with the safety belt on the sit to stand lift. Nurse #1 was unaware if Resident #3 was assessed for being safe to transfer with the sit to stand lift. She explained that the resident's left side was paralyzed and he was unable to support his left side. On 03/20/13 at 11:25 AM nurse aide (NA) #2 was interviewed and reported that she was trained on the use of the mechanical lifts and specified the "Hoyer" or total lift required 2 trained staff persons to transfer a resident. She added that she was able to use the total lift by herself and it was her usual practice to not use 2 persons when transferring a resident in the total lift. She stated she was assigned to care for Resident #3 and when she transferred him with the mechanical lift she did it by herself. She added that when she transferred the resident out of bed on 03/20/13 into his Broda chair (specialized wheelchair) she did it by herself. She stated she was trained to reference the "ADL/care plan guide" to know how to transfer residents. On 03/20/13 at 11:50 AM the Staff Development Coordinator (SDC) was interviewed and stated nurse aides were trained when using the total mechanical lift they were to have 2 persons. She stated this was for the safety of the residents. She added that the therapy department assessed residents to determine their transfer status and nurse aides were expected to transfer residents accordingly. On 03/20/13 at 12:30 PM the Administrator was interviewed and reported she and the Director of Nursing (DON) conducted an investigation for an injury of origin when Resident #3 was diagnosed with [REDACTED]. She added that Resident #3 was assessed on 04/07/11 to be safe to be transferred with the sit to stand lift. The Administrator was unaware if the resident's general condition had changed since 04/07/11 that would cause him to not be appropriate for the sit to stand lift. She added that since the incident the resident was reassessed and determined that he was only to be transferred with the total mechanical lift. On 03/20/13 at 1:55 PM the physician was interviewed and reported that on 02/07/13 he was asked to assess Resident #3 for pain and swelling in his left arm. The physician stated that Resident #3 had very brittle bones and stiffness on his left side with contractures. He reported that Resident #3 most likely sustained the fracture to his left arm during the event that occurred in the shower room on 02/04/13. On 03/20/13 at 2:05 PM NA #2 was observed transferring Resident #3 from his Broda chair to bed. She used a mechanical total lift by herself to lift the resident out of the chair and over onto the bed. On 03/20/13 at 2:10 PM the Director of Nursing (DON) was interviewed and stated the nurse aide was to have 2 people in the room to assist with the transfer and operation of the mechanical lift. On 03/20/13 at 2:15 PM the DON was interviewed. DON stated the safety belt should have been secured around the resident's lower legs and was unable to explain how the resident's foot slipped off the foot rest if the safety belt was secured around his legs. On 03/20/13 at 2:20 PM NA #3 was interviewed and stated that she had cared for Resident #3 many times and had always used the sit to stand lift to transfer the resident for a shower. She explained that all other times she used the total lift to transfer the resident. She added that she helped NA #1 transfer the resident on 02/04/13 using the sit to stand lift and the resident's foot slipped off the foot rest. NA #3 reported she thought the resident's legs were secured with the safety belt at the time of the incident. She offered no explanation how the resident's foot could have slipped off the foot rest if his feet were secured with the safety belt. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] specified the resident's cognition was not impaired and that she required extensive assistance with activities of daily living (ADL). The MDS also specified the resident had a fall while in the facility. Review of Resident #2's ADL/care plan guide revealed a document titled "Transfer Recommendation" dated 03/19/13 that specified the resident was dependent on 2 people to transfer her with the mechanical total lift. The document also specified the resident had a change in transfer status and to remind resident that a lift must be used for safety. On 03/20/13 at 10:45 AM nurse aide (NA) #1 was interviewed and reported that she was trained on the use of the mechanical lifts and specified the "Hoyer" or total lift required 2 trained staff persons to transfer a resident. She added that she was able to use the total lift by herself and it was her usual practice to not use 2 persons when transferring a resident in the total lift. She stated she was assigned to care for Resident #2 and when she transferred her with the mechanical lift she did it by herself. She stated she was trained to reference the "ADL/care plan guide" to know how to transfer residents. On 03/20/13 at 11:50 AM the Staff Development Coordinator (SDC) was interviewed and stated nurse aides were trained when using the total mechanical lift they were to have 2 persons. She stated this was for the safety of the residents. She added that the therapy department assessed residents to determine their transfer status and nurse aides were expected to transfer residents accordingly. On 03/20/13 at 2:12 PM NA #1 was observed transferring Resident #2 out of her wheelchair into bed. NA #1 used a mechanical total lift by herself to transfer the resident. On 03/20/13 at 2:15 PM the Director of Nursing (DON) was interviewed and stated the nurse aide was to have 2 people in the room to assist with the transfer and operation of the mechanical lift. On 03/20/13 at 3:20 PM the Rehabilitation Manager was interviewed and stated she developed a new form titled "Transfer Recommendation" for nurse aides to utilize to know a resident's transfer status. She reported that she had assessed residents to determine the safest transfer method. She also reported that changes had been made to some of the residents transfer status. She reported the changes were filed in the ADL/care plan guide book for nurse aides to review. She confirmed she had not notified nurse aides or educated them on the use of the new document but stated nurse aides were aware they should reference the book at the beginning of each shift to see if changes had been made.

Based on observations, record review and staff interviews, the facility failed to a) clean or disinfect one (1) blood glucose meter (used to check blood sugar) before and/or after each use on two sampled residents (Residents #16 and #17) who shared the same blood glucose meter and b) clean one (1) blood glucose meter in a manner to adequately disinfect it before/or after performing blood glucose testing of two sampled residents (Residents #12 and #18) from a total sample of nine (9) residents Immediate Jeopardy began on 5/31/11 when Licensed Nurse (LN) #1 failed to clean and disinfect the blood glucose meter (glucometer) before use when she obtained fresh blood samples to monitor the blood sugar levels of Resident #17. Immediate Jeopardy was removed on 6/7/11 when the facility provided and implemented a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity level of D (an isolated deficiency, no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems which were put into place and the completion of employee training. The findings are: Review of the facility policy titled "Disinfecting Blood Glucose Meters" dated 11/2/2010 revealed the following: "Blood glucose meters will be cleaned after each use and/or between resident uses when used for more than one resident. Each device is to be thoroughly wiped with a Sani Cloth HB (or comparable product) after each use on a resident. Discard wipe into trash." 1. Medical record review revealed Resident #16 was admitted with [DIAGNOSES REDACTED]. On 5/31/2011 at 4:45 p.m. Licensed Nurse (LN) #1 was observed performing a fingerstick blood sugar test on Resident #16. LN #1 entered the resident's room with the blood glucose meter she had removed from the medication cart. She did not clean or disinfect the blood glucose meter prior to donning gloves and inserting the glucose strip into the machine. The resident's finger was pricked using a new lancet and a drop of blood was collected on the test strip. After the test was completed LN #1 returned the machine to the top drawer of the medication cart without cleaning or disinfecting it. Review of the May 2011 Medication Administration Record (MAR) for Resident #16 revealed a pharmacy notation that instructed staff to clean the blood glucose meter with Saniwipe with HB before and after each use. Medical record review revealed Resident #17 was admitted with [DIAGNOSES REDACTED]. On 5/31/11 at 5:30 p.m. Licensed Nurse (LN) #1 obtained the same blood glucose meter used on Resident #16 from the medication cart and entered Resident #17's room to perform a fingerstick blood sugar test. LN #1 did not clean or disinfect the blood glucose meter before she donned gloves and inserted the glucose strip into the machine. The resident's finger was pricked using a new lancet and a drop of blood was collected on the test strip. After the test was completed LN #1 returned the blood glucose meter to the top drawer of the medication cart without cleaning or disinfecting it. Review of the May 2011 Medication Administration Record (MAR) for Resident #17 revealed a pharmacy notation that instructed staff to clean the blood glucose meter with Saniwipe with HB before and after each use. In an interview with LN #1 on 05/31/2011 at 6:05 p.m. she stated the blood glucose meter shared by residents on the hall should be disinfected using a bleach wipe between each resident use. She stated she did not clean the blood glucose meter after checking either Resident #16's or Resident #17's blood sugar. An interview with the Director of Nursing on 06/02/2011 at 11:30 a.m. revealed she expected that the blood glucose meters be disinfected after each use. On 6/7/11 at 5:15 p.m. the Staff Development Coordinator (SDC) and DON were interviewed together. The SDC reported she helped develop the new policy for cleaning and disinfecting blood glucose meters last year when the facility was made aware of the concern for the potential spread of blood borne pathogens with the use of the meters. She stated the blood glucose meters should be cleaned before and after each use with the Saniwipes. She confirmed she contacted outside resources for additional help and attempted to develop a simple policy that all licensed nurses would understand. She specified that all licensed nurses were in-serviced on the proper technique for cleaning and disinfecting the blood glucose meters with the approved Sani Cloth HB wipes. The SDC stated that in-serving on this topic had remained on going. The SDC confirmed that licensed nurses were given verbal instructions for disinfecting the blood glucose meters and reported that return demonstrations were not part of the in-service. She added that licensed nurses who performed finger sticks were observed several months previous by the facility's pharmacy consultant. The SDC and DON both confirmed that the licensed nurses observed cleaned and sanitized the blood glucose meters correctly as reported to them by the consultant Pharmacist. The DON reported that there was no ongoing monitoring of cleaning the blood glucose meters because no concerns had been identified. The Administrator was notified of the Immediate Jeopardy on 6/7/11 at 10:40 a.m. The facility provided a credible allegation of compliance on 6/7/11 at 6:00 p.m. The following interventions were put into place by the facility to remove the Immediate Jeopardy: Licensed Nurse (LN) #1 observed on 5/31/11 not cleaning the glucose monitoring device before and after use for Resident #16 and #17 was immediately in-serviced related to the Policy and Procedure for Disinfecting Blood Glucose Meters on 5/31/11 by the Director of Nursing. One on one in-service was provided related to the importance of disinfecting blood glucose meters and the use of Sani Cloth HB (approved disinfectant wipes) to prevent the spread of infection. Residents #16 and #17 showed no signs/symptoms of any blood borne pathogen as evidenced by medical record review and Residents #16 and #17. Resident medical records and infection reports dated 5/1/11 to 5/31/11 were reviewed. The Infection Control nurse reviewed and analyzed infection control reports and determined no residents who resided in the facility on 5/31/11 were identified as having blood borne pathogens. In-service education was completed for all staff responsible for obtaining blood sugars with blood glucose meters on 6/1/11. The in-services were conducted by the Director of Nursing and the Infection Control nurse. The in-services for all licensed staff included the proper procedure for obtaining specimen, the importance of disinfecting blood glucose meters between residents and the importance of using a Sani Cloth HB. On 6/1/11 the facility identified one (1) licensed nurse to be on vacation. This licensed nurse will be in-serviced prior to accepting assignment by the Infection Control nurse. The identified licensed nurse will not be scheduled for duty until documented evidence that she has completed the in-service related to disinfecting blood glucose meters. The Policy and Procedure for disinfecting blood glucose meters is included in the orientation required for new licensed staff and reviewed during in-services by the Staff Development Coordinator. An audit was completed on 6/7/11 to identify all residents requiring blood glucose monitoring by reviewing pharmacy records. This review was conducted by the Director of Nursing and identified a total of twenty-one (21) residents who required blood glucose monitoring. The purpose of this review was to identify all residents who require finger sticks to complete medical record review for each resident to ascertain no residents had acquired blood borne pathogens. Medical record review for each resident was conducted by the Infection Control nurse revealed none of the twenty-one (21) identified residents exhibited signs/symptoms of blood borne pathogens. A Quality Assurance Monitoring tool was developed to ensure staff members are using a Sani Cloth HB to disinfect the blood glucose meters to ensure compliance, according to facility policy. This Quality Assurance tool was developed and implemented on 6/7/11 by the Administrator. The Quality Assurance Monitoring tool will be completed by the Charge Nurse on each shift (3). The Quality Assurance Monitoring tool will be completed daily for two (2) weeks; then three (3) times a week for two (2) weeks; then once weekly for two (2); then once monthly for two (2) months. The Quality Assurance Monitoring tool will be incorporated into the monthly facility Quality Assurance program to evaluate compliance and effectiveness. Immediate Jeopardy was removed on 6/7/11 at 6:15 p.m. A review of the facility's in-service attendance records verified licensed nurses were trained on the proper technique for cleaning and disinfecting glucometers. Interviews with licensed nursing staff who worked on the day and evening shifts confirmed that they had received recent training on how to correctly clean and disinfect blood glucose meters to prevent the spread of infections and correctly explained how to disinfect glucometers by using a sani cloth HB. Observations of licensed nurses on the day and evening shifts using a blood glucose meter to monitor blood glucose levels revealed that the meter was correctly cleaned and disinfected with a sani cloth to prevent the spread of infections. 2. A continuous observation was made on 5/31/11 at 5:17 p.m. of Licensed Nurse (LN) #3 providing a finger stick blood sugar (FSBS) check on Resident #18. Prior to using the blood glucose meter on Resident #18, LN #3 cleaned the blood glucose meter with an alcohol wipe. She then proceeded to check Resident #18's FSBS. After using the blood glucose meter on Resident #18, LN #3 cleaned the blood glucose meter with an alcohol wipe. LN #3 then used the same blood glucose meter to check Resident #12's FSBS. After using the blood glucose meter she cleaned it with an alcohol wipe. An interview was conducted on 05/31/11 at 6:20 p.m. with LN #3. LN #3 reported that she was supposed to clean the blood glucose meter with a Sani Cloth. She stated there were no Sani Cloths in her medication cart. An interview conducted on 05/31/11 at 6:40 p.m. with the Director of Nursing revealed that it is her expectation that the blood glucose meters are cleaned after each use with Sani Cloth HP.

Based on observation, record review, and staff interview the facility staff failed to remove soiled gloves and wash hands after the completion of incontinence care in one (1) of two (2) residents observed. (Resident #4) The findings are: A review of a facility policy dated 03/06/07 titled "Handwashing" stated in part gloves should be used for hand-contaminating activities. Gloves should be removed and hands washed when such activity is completed. A review of a facility document with a revised date of 06/27/11 titled "Guidelines for Perineal Care" stated to remove gloves and place in appropriate receptacle. Wash hands before leaving room. On 07/20/11 at 9:42 a.m. Resident #4 was observed as he was transported into his room in a wheelchair by NA #1. NA #1 put on gloves, transferred Resident #4 from the wheelchair to his bed using a lift, undressed the resident and removed the resident's brief that was soiled with urine and stool. She filled a wash basin with water, placed washcloths in the water, picked up a bottle of liquid soap and cleaned the resident. She placed her soiled linens into a plastic bag, put a clean brief on the resident and re-dressed him. NA #1 attached the lift pad to the lift with her soiled gloves on and transferred the resident back to his wheelchair. She emptied the wash basin, opened a cabinet and put the basin inside with her soiled gloves still on. NA #1 removed her gloves, opened the door to the resident's room and took the soiled linen out of the resident's room down the hallway to a soiled linen room. On 07/20/11 at 9:50 a.m. during an interview NA #1 stated she should have taken her gloves off and washed her hands after she finished the incontinence care and before transferring the resident with the lift. On 07/20/11 at 2:58 p.m. during an interview with the Staff Development Coordinator (SDC) she stated in-services were done recently regarding incontinence care. She further explained after the in-service was completed staff was observed doing incontinence care and their initials were written on an observation monitoring form. She stated if a staff member's initials were not on the form, they were not observed. She verified NA #1's initials were not on the observation monitoring form and explained the observations of staff were done at random. She further stated it was her expectation that staff should remove soiled gloves and wash their hands after incontinence care and before touching any items in the resident's room. On 07/20/11 at 3:50 p.m. during an interview with LN #1 she stated she was one of the nurses who observed staff when they provided incontinence care after the inservice's were completed. She stated she observed various staff members doing incontinence care but explained the observations of staff were done at random. She stated Nursing Assistants were told to let a nurse know if they were going to do incontinence care and a nurse would go and observe them. She verified they had not observed all staff and confirmed NA #1's initials were not on the observation monitoring form. LN #1 stated since NA #1's initials were not on the observation form she had not been observed. She explained during the observation they looked at hand washing, putting on gloves and changing gloves during care. On 07/20/11 at 4:22 p.m. during an interview with the Director of Nursing (DON) she stated it was her expectation for staff to remove soiled gloves and wash their hands after incontinence care and before they touched any other items in the resident's room.