Every finding on record at Crestwood Center

Based on interview and record review, it was determined that the facility failed to develop and implement a comprehensive care plan for 1 of 1 residents reviewed for mood and behavior in a final sample of 17 residents (Resident identifier is #6). Findings include: Review on 12/18/25 of Resident #6's medical record revealed a progress note, dated 10/5/2025, indicating that Resident #6 was asking another resident to Get over here and give me a kiss. Further review of Resident #6's medical record revealed another progress note, dated 12/17/25 that indicated sexual behaviors noted this shift. Review on 12/18/25 of Resident #6's medical record revealed a provider note, dated 12/12/2025, that indicated Patient has recent increase in citalopram (antidepressant medication) for disinhibition with increased sexual comments . Non-Pharmacological Recommendations: monitor for improvement in inappropriate behaviors . continue with redirecting patient, use distraction, changing subject to decrease inappropriate comments. Review on 12/18/25 of Resident #6's care plan revealed no non-pharmacological interventions as stated above. Interview on 12/18/25 with Staff C (Director of Nursing) at approximately 10:30 a.m. confirmed the above findings.

Based on observation, interview, and record review, it was determined that the facility failed to implement the facilities infection control policies for TBP (Transmission Based Precautions) for 2 of 2 dining observation. (Resident Identifier is #50.)Findings include:Resident #50 Observation on 12/16/25 at approximately 12:00 p.m. revealed a Contact Precaution sign posted outside Resident #50's room that read: .Clean hands before entering the room and before leaving the room. Staff: Wear .Gown and gloves . Further observation revealed Staff H (Business Manager) entered the room carrying a lunch tray. Staff H did not don a gown and gloves. Interview on 12/16/25 at approximately 12:10 p.m. with Staff H confirmed the above observation. Staff H stated that he/she delivered the lunch tray to Resident #50. Review on 12/17/25 of Resident #50's medical record revealed a physician order for contact precaution with an order date of 12/16/25. Review on 12/17/25 of the facility policy titled, IC306 Transmission Based Precautions, Revision Date 5/1/25, revealed . 8.3 An order for Transmission Based Precautions will be obtained for patients who are known or suspected to be infected or colonized with infectious agents that require additional controls to prevent transmission effectively. 9.3 Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. 9.4 Donning PPE (Personal Protective Equipment) upon room entry. Review on 12/18/25 of the Centers for Disease Control and Prevention (CDC) Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Setting (2007), revision date 9/19/2024, revealed .Standard Precaution .IV.A Hand Hygiene .If hands are not visibly soiled, or after removing visible material with nonantimicrobial soap and water, decontaminate hands in the clinical situations described in IV.A.3.a-f. The preferred method of hand decontamination is with an alcohol-based hand rub. Alternatively, hands may be washed with an antimicrobial soap and water .Perform hand hygiene in the following clinical situations: IV.A.3.a. Before having direct contact with patients .Category IB IV.A.3.d. If hands will be moving from a contaminated-body site to a clean-body site during patient care. Category II IV.A.3.e. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient .

Based on interview and record review, it was determined that the facility failed to ensure that the facility assessment included specific staffing needs for each resident unit in the facility and specific staffing needs for each shift such as day, evening, night for a census of 65 residents. Findings include: Review on 12/17/25 of the Facility Assessment revealed that the assessment did not include specific staffing needs for each resident unit in the facility and/or identify specific staffing needs by shift. Review on 12/17/25 of facility Daily Nursing Schedule, dated 12/17/25 , revealed the facility has Unit 1, Unit 2, and Unit 3.Interview on 12/17/25 with Staff G (Administrator) confirmed the above findings.

Based on interview and record review, it was determined that the facility failed to ensure that 2 of 4 residents reviewed for insulin were free from potential exposure to bloodborne pathogen transmission when staff administered insulin to two residents using the same insulin pen (Resident Identifiers are #1 and #2). Findings include: Interview on 6/26/24 at 10:45 a.m. with Staff B (Licensed Practical Nurse) revealed that on 6/13/24 at around 9:00 a.m. he/she administered Resident #2's used Aspart insulin pen to Resident #1 by mistake. Resident #2's insulin pen was labeled for Resident #2. Staff B stated that he/she did not discard the insulin pen and used it shortly after on Resident #2 and then placed it back in the medication cart for continued use. Staff B stated that they thought that since the needle had been changed, there was no infection control concerns. Interview on 6/26/24 at approximately 9:15 a.m. with Staff A (Unit Manager) confirmed that Resident #1 had received Resident #2's Aspart insulin in error on 6/13/24 and that the insulin pen was returned to the medication cart for use for Resident #2 after it was used on Resident #1. Review on 6/26/24 of Resident #2's June Medication Administration Record (MAR) revealed the following orders for Aspart insulin: Aspart insulin 12 units two times a day, with a start date of 6/11/12 and an end date of 6/12/24; Aspart Insulin 12 units with meals, with a start date of 6/12/24 and an end date of 6/19/24. Further review of the June MAR revealed that Resident #2 received the following administrations of Aspart insulin from 6/13/24 through 6/17/24: 6/13/24- 3 doses administered; 6/14/24- 3 doses administered; 6/15/24- 3 doses administered; 6/16/24- 3 doses administered; and 6/17/24- 1 dose administered. Interview on 6/26/24 at approximately 1:00 p.m. with Staff C (Previous Director of Nursing) confirmed that Resident #2 had continued to receive Aspart insulin with the same insulin pen that was used on Resident #1 from 6/13/24 until 6/17/24. Staff C notified Public Health because the pen had been used on two different residents potentially exposing both residents to blood borne pathogens. Interview on 6/26/24 at 10:05 a.m. with Staff C revealed that he/she did not realize that there was an infection control concern with the above medication error until Monday 6/17/24. Staff C stated that he/she discarded Resident #2 Aspart insulin pen on 6/17/24 that had been in use. Interview on 6/26/24 at 11:40 a.m. with Staff D (Administrator) confirmed that he/she had been made aware of the medication error on 6/14/24; however, was not made aware of the infection control issue until 6/17/24 when the insulin pen was removed from the medication cart by Staff C. 43408 Interview on 6/26/24 at 1:15 p.m. with Staff D revealed that education regarding insulin pens was started for all staff on duty who administer insulin on 6/17/24 and all other staff received education prior to working their next shift. Review on 6/26/24 of the manufacturers' instructions for Insulin Aspart, provided by the facility, revealed: .Do Not share your Insulin Apart FlexPen or needles with anyone else. You may give an infection to them or get an infection from them . Review on 6/26/24 of the facility policy titled Insulin Pens revised on 2/28/21, revealed: .Insulin pens containing multiple doses of insulin are meant for single patient use only and must never be used for more than one person, even when the needle is changed . Review on 6/26/24 of the Centers for Disease Control and Prevention (CDC) handout, retrieved 6/4/24, from https://www.cdc.gov/injection-safety/media/pdfs/Insulin-Pen-Safety-Handout-P.pdf revealed: .Injection equipment (e.g., insulin pens, needles and syringes) should never be used for more than one person . It is critical to remember that insulin pens are meant for only one person .Although invisible to the eye, back flow of blood into the insulin pen can happen during an injection. This creates a risk of bloodborne and bacterial pathogen transmission to patients if the pen is used for more than one person, even when the needle is changed . Review on 6/26/24 of the facility's documentation of education for medication administration and insulin pen safety to staff who administer medications was initiated on 6/17/24. This included the risk of bloodborne pathogens. Review on 6/26/24 of the facility's Quality Assurance and Performance Improvement (QAPI) meeting held on 6/18/24 revealed the facility reviewed the above incident which included a root cause analysis and plan for auditing. Review on 6/26/24 of the facility competencies revealed that they were started on 6/20/24 for staff insulin medication competencies.

Based on interview, the facility failed to employ a full-time qualified dietician or other clinically qualified nutrition professional to carry out the functions of the food and nutrition services. Findings include: Interview on 1/28/24 at 9:33 a.m. with Staff G (Food Services Director) revealed that Staff G became the director a month ago. Staff G started as a dietary aide and part-time chef 7 years ago at the facility. Interview further revealed that Staff G was not certified as a dietary or food service manager, did not have a degree in food service management or in hospitality, and had not had two or more years of experience as director of food services. Interview on 1/28/24 at 2:00 p.m. with Staff C (Administrator) revealed that the facility does not employ a full-time qualified dietician.

Based on interview and record review, it was determined that the facility failed to provide sufficient staff to meet residents' needs in September 2023 and October 2023. Findings include: Review on 1/30/24 of the Facility Assessment revealed that Consider the overall needs of your resident population based on your Facility Assessment, MDS [Minimum Data Set], Resident Population Profile and any additional source when indicating the number, average, range or ratio needed. Further review of the Facility Assessment revealed the following staffing levels for direct care staff: first and second shifts - Licensed Nurses (Registered Nurse (RN), Licensed Practical Nurse (LPN)) - Unit 1 was 1:10, Unit 2 was1:27, and Unit 3 was1:32; and Nurse aides (Certified Nursing Assistant (CNA), Licensed Nursing Assistant (LNA)) - Unit 1 was1:10, Unit 2 was1:14, and Unit 3 was 1:13. Review on 1/30/24 of the Daily Staffing Sheets from September 2023 to October 2023 revealed the following: 9/18/23 - Monday - Day shift - Unit 3 - 2 LPN, 1 CNA - Unit census 32 9/20/23 - Wednesday - Day shift - Unit 2 - 1 LPN, 7 a.m.-1 p.m. 1 CNA - Unit census 27 9/21/23 - Thursday - Evening shift - Unit 3 - 1 RN/ LPN, 1 CNA from 3-3:30 p.m. and 2 CNAs from 3:30 p.m.-5 p.m. - Unit census 31 9/22/23 - Friday - Day shift - Unit 3 - 1 RN/LPN, 1 CNA from 7:30 a.m.-9:30 a.m. - Unit census 31 9/22/23 - Friday - Eve shift - Unit 3 - 1 RN, 2 CNAs from 4:30 p.m.-7:00 p.m. - Unit census 31 9/25/23 - Monday - Day shift - Unit 3 - 0 RN/LPN, 1 CNA from 7:00 a.m.-1:00 p.m. and 2 CNAs from 1:00 p.m.-3:00 p.m. - Unit census 31 9/26/23 - Tuesday - Day shift - Unit 3 - 2 RN/LPN, 1 CNA from 7 a.m.-9:00 a.m. and 2:00 p.m.-3:00 p.m. - Unit census 31 9/27/23 - Wednesday - Day shift - Unit 2 - 1 RN, 1 CNA from 12:00 p.m.-3:00 p.m. - facility - Unit census 27 9/28/23 - Thursday - Day shift - Unit 3 - 1 LPN, 1 CNA- Unit census 31 9/29/23 - Friday - Day shift - Unit 2 - 1 RN, 1 CNA from 7:00 a.m.-12:30 p.m. - Unit census 26 9/29/23 - Friday - Day shift - Unit 3 - 1 LPN, 1 CNA from 7:00 a.m.-9:00 a.m. - Unit census 30 9/29/23 - Friday - Eve shift - Unit 3 - 1 RN, 1 CNA from 3:00 p.m.-4:30 p.m. - Unit census 30 9/30/23 - Saturday - Day shift - Unit 3 - 2 RN/LPN, 1 CNA from 7:00 a.m.-11:00 a.m. - Unit census 30 9/30/23 - Saturday - Eve shift - Unit 3 - 0 RN/LPN, 1 CNA from 3:00 p.m.-7:00 p.m. - Unit census 30 10/1/23 - Sunday - Eve shift - Unit 3 - 1 RN, 1 CNA - Unit census 30 10/15/23 - Sunday - Day shift - Unit 1 - 1 RN, 0 CNA - Unit Census 9 10/15/23 - Sunday - Eve shift - Unit 1 - 1 RN, 0 CNA - Unit Census 9 10/16/23 - Monday - Day shift - Unit 3 - 1 LPN, 1 CNA - Unit Census 32 10/17/23 - Tuesday - Day shift - Unit 1 - 1 LPN, 0 CNA - Unit Census 9 10/17/23 - Tuesday - Day shift - Unit 2 - 1 RN, 1 CNA - Unit Census 27 10/17/23 - Tuesday - Day shift - Unit 3 - 1 LPN, 1 CNA - Unit Census 32 10/18/23 - Wednesday - Day shift - Unit 1 - 1 LPN, 0 CNA - Unit Census 8 10/18/23 - Wednesday - Day shift - Unit 2 - 1RN, 1 CNA - Unit Census 27 10/18/23 - Wednesday - Day shift - Unit 3 - 0 RN/LPN, 2 CNA - Unit Census 31 10/20/23 - Friday - Day shift - Unit 1 - 1 LPN, 0 CNA - Unit Census 10 10/20/23 - Friday - Day shift - Unit 2 - 1 RN, 1 CNA - Unit Census 27 10/21/23 - Saturday - Day shift - Unit 1 - 1 RN, 0 CNA - Unit Census 10 10/21/23 - Saturday - Day shift - Unit 3 - 1 LPN, 1 CNAs - Unit Census 30 10/21/23 - Sunday - Day shift - Unit 1 - 1 RN, 0 CNA - Unit Census 10 10/25/23 - Wednesday - Day shift - Unit 3 - 0 RN/LPN, 3 CNA - Unit Census 31 Interview on 1/30/24 at 12:40 p.m. with Staff C (Administrator) confirmed the above findings. Interview on 1/29/24 with Staff N (Regional Nurse) revealed that a staffing action plan resulted from a November meeting with staff where staffing concerns were voiced. Staff revealed that staffing was monitored by weekly calls to address staff call outs and schedule patterns. Review on 1/30/24 of meeting announcement for staff input on 11/20/23 revealed staff voiced staffing concerns to management.

Based on interview and record review, it was determined that the facility failed to ensure that residents' formulated advance directives would be followed for 1 out of 17 residents in a final sample (Resident Identifier is #16). Review on 1/29/24 of Resident #16's care plan, with a revision date of 9/19/22, revealed Resident #16's code status to be Full Code. Review on 1/29/24 of Resident #16's current Electronic Medication Administration Record (eMAR) revealed code status of Do Not Resuscitate (DNR). Review on 1/29/24 of Resident #16's current paper chart revealed Resident #16's pink portable DNR form signed by the provider on 7/20/23. Interview on 1/29/24 at 2:06 p.m. with Staff H (Unit Manager) revealed resident #16's code status is DNR and Staff H confirmed the above findings. Review on 1/30/24 of facility policy OPS416 Person-Centered Care Plans, revised 10/24/22, revealed .review and revise the care plan after each assessment . assessment means after each . Minimum Data Set (MDS).

Based on interview and record review, it was determined that the facility failed to ensure that all allegations of abuse were reported to the administrator for 3 of 8 residents reviewed for abuse in a final sample of 17 residents (Resident Identifiers are #2, #4, and #36.) Findings include: Resident #2 Review on 1/28/24 of the facility investigation into an allegation of abuse by Staff A (Medication Nursing Assistant (MNA)) with Resident #2 revealed that on 1/10/24 an interview was conducted with Staff B (Licensed Nursing Assistant (LNA)) regarding another concern. During this interview, Staff B revealed that on 1/9/24 there was an incident that occurred with Staff A and Resident #2. Staff B stated that he/she left Staff A in Resident #2's room to go and get linen and upon returning to the room, Staff A was next to Resident #2 and in an elevated voice stating, Don't tell me to shut up, I'll just leave you here. Resident #4 Review on 1/29/24 of the facility investigation into an allegation of abuse by Staff A revealed that the facility compliance line received the following anonymous complaint from an LNA on 1/10/24 of an abuse allegation with Resident #4, While preparing food for resident, [LNA name omitted] entered the room and yelled at the other LNA stating, Get out of here, [pronoun omitted] is not a feed, you have no business being in here. [LNA name omitted] then clapped [pronoun omitted] hands in the resident's face and said, Get up and eat your food. It's no one's job to feed you, you need to do it yourself. The incident happened on 1/9/24. Resident #36 Review on 1/30/24 of the facility investigation revealed that during an interview with Staff E (LNA), he/she witnessed Staff A yell at Resident #36 because Resident #36 wanted his/her medication. Staff E stated that Staff A told Resident #36 that if he/she did not stop bothering Staff A they would not get their medications at all. Staff E also observed Staff A raising his/her voice and slamming the drawers of the medication cart. Interviews on 1/29/24 and 1/30/24 with Staff C (Administrator) confirmed that he/she was not notified of the above allegation of abuse with Resident #2 until 24 hours later, the allegation of abuse with Resident #4 until 24 hours later, and the allegation of abuse with Resident #36 until over 48 hours later. Staff C revealed that a facility-wide education on abuse and timely reporting of allegations to the administator had been done on 1/10/24 (prior to the 1/16/24 incident). Review on 1/30/24 of the facility policy titled, OPS300 Abuse Prohibition, revision date 10/24/22 revealed: Process .6.1. Anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately, regardless of shift worked .

Based on observation and interview, it was determined that the facility failed to ensure that the residents' environment remained as free of accident hazards as was possible regarding one resident room heater on 1 of 3 units observed (Unit 3). Findings include: Observation on 1/28/24 at 10:49 a.m. of resident room [ROOM NUMBER] revealed a heater along the base of the window wall missing a heater cover, exposing sharp metal heater fins extending approximately 4 feet in length along the bottom of the wall. Interview on 1/29/24 at 1:15 p.m. with Resident #30 revealed the heater cover had been missing approximately 2 months, and they had caught their socks on the exposed metal fins, while in their wheelchair in resident room [ROOM NUMBER]. Interview on 1/29/24 at approximately 1:30 p.m. with Staff J (Facilities Director) revealed a work order had not been submitted for the missing heater cover through the facility's work order system. Review on 1/31/24 of the facility's policy titled SH100 Safety Management Program, revised 4/15/23, revealed: Purpose - To provide a safe environment of care to our patients/residents and a safe work environment for our employees.

Based on interview and record review, it was determined that the facility failed to honor residents' choice for showers for 1 out of 3 residents reviewed for Activities of Daily Living (ADL) in a final sample of 17 residents (Resident Identifier is #60). Findings include: Interview on 1/28/24 at 10:45 a.m. with Resident #60 revealed that he/she had not had a shower in 2 weeks and that he/she had requested one be given today and was told they would check and let him/her know. Resident #60 revealed that he/she wants to shower at least once a week. Review on 1/29/24 of Resident #60's admission Minimum Data Set (MDS) with an assessment reference date of 11/6/23 revealed that Resident #60 had a Brief Interview of Mental Status (BIMS) score of 14, indicating cognitively intact. Interview on 1/29/24 at 9:10 a.m. with Resident #60 revealed that he/she had not received a shower when requested on 1/28/24. Review on 1/30/24 of Resident #60's tub/shower schedule under tasks in the electronic medical record for bathing revealed the following: In November 2023 he/she received 3 of 5 scheduled showers (11/14/23, 11/22/23, and 11/30/23); In December 2023 he/she received 2 of 4 scheduled showers (12/19/23 and 12/27/23); and as of January 28, 2024, he/she had received 2 of 4 scheduled showers (1/2/24 and 1/9/24). Further review revealed no documentation that Resident #60 refused showers. Review on 1/30/24 of the 200-floor shower schedule revealed that Resident #60 was scheduled for Wednesdays on the 7-3 shift. Interview on 1/30/24 at 11:54 a.m. with Staff H (Unit Manager) confirmed the above findings. Interview on 1/30/24 at 12:12 p.m. with Staff H revealed that on Wednesday, 1/24/24, Resident #60's scheduled day for a shower, Resident #60 was out of the facility at a doctor's appointment. Interview further revealed that Resident #60 was not rescheduled for a shower that week and that the facility would not offer the resident a shower outside of their scheduled time unless the resident asked. Review on 1/30/24 of the facility's policy titled Activities of Daily Living (ADLs), revised on 5/1/23, revealed, .Based on the comprehensive assessment of a patient and consistent with the patient's needs and choices, the Center must provide the necessary care and services to ensure that a patient's activities of daily living (ADL) abilities are maintained or improved . Activities of daily living (ADLs) include . bathing . ADL assistance that is not documented within 24 hours of occurring is considered late documentation . To ensure ADLs are provided in accordance with accepted standards of practice, the care plan, and the patie7nt's [sic] choice and preferences . 5. ADL care is documented every shift by the nursing assistant .

Based on interview and record review, it was determined that the facility failed to provide timely notifications of the Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) and Notice of Medicare Non-Coverage (NOMNC) for 3 out of 3 residents reviewed for Beneficiary Notices (Resident Identifiers are #50, #18, and #270). Findings include: Resident #50 Review on 1/29/24 of Resident #50's SNF Beneficiary Notification Review for Residents who Received Medicare Part A Services (FORM CMS-20052) revealed that the facility/provider initiated discharge from Medicare Part A Services when benefit days were not exhausted (he/she stayed at the facility) and that his/her last covered skilled day was 1/5/24, the ABN and the NOMNC provided by facility revealed .services end date 1/5/24 . notification to Resident/Resident's representative was given on 1/4/24. Resident #18 Review on 1/29/24 of Resident #18's SNF Beneficiary Notification Review for Residents who Received Medicare Part A Services revealed that the facility/provider initiated discharge from Medicare Part A Services when benefit days were not exhausted (he/she stayed at the facility) and that his/her last covered skilled day was 12/18/23, the ABN and the NOMNC provided by the facility revealed .services end date 12/18/23 . notification to Resident/Resident's representative was given on 12/18/23. Resident #270 Review on 1/29/24 of Resident #270's SNF Beneficiary Notification Review for Residents who Received Medicare Part A Services revealed that the facility/provider initiated discharge from Medicare Part A Services when benefit days were not exhausted (he/she was discharged home from the facility) and that his/her last covered skilled day was 12/18/23. The NOMNC provided by facility revealed that .services end date 12/18/23 . notification to Resident/Resident's representative was given on 12/18/23. Interview on 1/29/24 at 1:19 p.m. with Staff D (Business Office Manager) confirmed the above findings. Review on 1/29/24 of the facility policy 50.8 - Effective ABN Delivery revealed ABN delivery is considered to be effective when the ABN is: .4. Provided far enough in advance of delivering potentially non-covered items or services to allow sufficient time for the beneficiary to consider all available options .

Based on interview and record review, it was determined that the facility failed to provide residents with activities designed to meet their preferences, interests, and needs in the evenings since November 2023. Findings include: Interview on 1/28/24 at approximately 2:00 p.m. with members of the Resident Council revealed that activities were not offered in the evening and that residents have asked for Movie Nights to be offered in the evenings during the week and on weekends. Review on 1/28/24 of the Activities Calendars for December 2023 and January 2024 revealed the facility did not provide activities in the evenings after 3 p.m. Interview on 1/29/24 at approximately 12:30 a.m. with Staff C (Administrator) confirmed the above findings. Review on 1/31/24 of the facility's policy titled REC200 Resident's/Patient's Choice, revised 4/7/18, revealed: Residents/Patients have the right to participate or not participate in leisure and recreation of their choosing.

Based on interview and record review, it was determined that the facility failed to ensure that the required committee members attended meetings at least quarterly for 3 of the 4 quarterly meetings reviewed in 2023. Findings include: Review on 1/26/24 of the Quality Assurance Performance Improvement (QAPI) meeting attendance sheets from 2023 revealed the following required members were not in attendance: Quarter 1 - Administrator and Infection Preventionist; Quarter 2 - Administrator and Infection Preventionist; and Quarter 4 - Administrator and 2 other members of the facility's staff. Interview on 1/28/24 at approximately 2:35 p.m. with Staff C (Administrator) confirmed the above findings. Review on 1/28/24 of the facility's policy titled Center Quality Assurance Performance Improvement Process, revised 10/24/22, revealed: . 2. The QAA Committee: . 2.1.1 Administrator, 2.1.2 Director of Nursing, 2.1.3 Medical Director, 2.1.4 Infection Preventionist, or designee .

Based on observation, interview and record review, it was determined that the facility failed to follow physician's orders and standards of practice when checking a blood glucose level and administering insulin to a resident in a timely manner for 1 of 4 residents observed for medication pass in a standard survey sample of 19 residents (Resident identifier is #45). Findings include: Professional reference: Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders .The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Page 706-709-Standards .The prescriber often gives specific instructions about when to administer a medication Page 707 .To prevent medication errors, follow the six rights of medication administration consistently every time you administer medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication 2. The right dose 3. The right client 4. The right route 5. The right time 6. The right documentation . Observation on 12/15/22 at 8:25 a.m. of Staff B (Registered Nurse) administering medications to Resident #45, revealed that Resident #45's finished breakfast tray was on the over bed tray table. Staff B checked Resident #45's blood glucose level and got a reading of 355 mg/dL (milligrams per deciliter). Staff B then administered Resident #45's scheduled 10 units of Humalog insulin. Interview on 12/15/22 at 8:25 a.m. with Resident #45 revealed that he/she had consumed his/her breakfast and had eaten several cookies after breakfast. Review on 12/15/22 of Resident #45's December 2022 Medication Administration Record revealed a physician's order (with a start date of 12/13/22) for a blood sugar check and insulin administration at 7:30 a.m. Further review revealed the order was to administer 10 units of scheduled Humalog insulin approximately 10 minutes prior to meal [breakfast]. Staff B documented Resident #45's blood glucose level of 355 mg/dL and checked that the Humalog insulin had been administered (corresponding with the above observation). Review on 12/15/22 of Resident #45's care plan revealed, . Focus . the resident has a diagnosis of diabetes: insulin dependent . Interventions . Access and record blood glucose levels as ordered . Administer hypoglycemic medications as ordered . Interview on 12/14/22 at 1:24 p.m. with Staff B confirmed that Resident #45's blood sugar check and insulin were ordered by the physician for 7:30 a.m. and that the insulin was ordered to be administered 10 minutes before breakfast. Staff B confirmed that this was not done. Review on 12/16/22 of the facility's policy titled .General Dose Preparation and Medication Administration revised 1/1/22, revealed, .4.1 Facility staff should . Verify each time a medication is administered that is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time . 5. During medication administration, Facility staff should take all measures required by Facility policy and Applicable Law, including, but not limited to the following . 5.4 Administer medications within timeframes specified by Facility policy or manufacturer's information .

Based on interview and record review, it was determined that the facility failed to inform residents, their representatives, and families of those residing in the facilities, by 5:00 p.m. the next calendar day, following the occurrence of a single confirmed infection of COVID-19 for 2 out of 4 days of positive test results. Findings include: Review on 12/15/22 of the facility's COVID Line Listing revealed two residents were tested in the facility for COVID-19 on 12/8/22 and tested positive. Interview on 12/16/22 at 10:10 a.m. with Staff A (Administrator) revealed that the facility did not inform residents, their representatives or families of the positive COVID-19 cases confirmed on 12/8/22 by 5:00 p.m. the next calender day.

Based on observation, interview and policy review, the facility failed to adhere to infection control practices regarding wearing eye protection per the Centers for Disease Control and Prevention (CDC) guidelines during the COVID-19 pandemic in a community with substantial spread on 2 of 3 units observed. Finding include: Interview on 9/21/21 at approximately 8:50 a.m. with Staff A (Administrator) revealed that the facility was not currently wearing eye protection within the facility by staff. Observation on 9/21/21 at approximately 9:00 a.m. on 2 of 3 nursing units revealed nursing and housekeeping staff not wearing eye protection while on the resident units. Observations included: medication administration, assisting residents with ambulation, pushing wheelchairs and walking in and out of resident rooms. Interview on 9/21/21 at approximately 9:15 a.m. with Staff B (Infection Preventionist) revealed that the county was in substantial spread of COVID-19. Staff B was unaware that eye protection was needed to be worn by healthcare personnel within resident areas during periods of substantial community spread. Observation on 9/22/21 at 8:50 a.m. revealed Staff E (housekeeping) standing in the hallway by resident rooms at the end of 300 hall (near rooms 312/314). Staff E was not wearing eye protection. There were staff and residents in the hallway. Interview on 9/22/21 at 8:50 a.m. with Staff E confirmed that he/she did not have on eye protection. Staff E stated he/she had just entered the building to be COVID-19 tested and did not know eye protection was needed. Interview at 9/22/21 at 8:51 a.m. with Staff A confirmed that Staff E should be wearing eye protection. Observation on 9/22/21 at 1:50 p.m. revealed Staff F (Speech Therapist) at the end of 300 hall outside of resident room [ROOM NUMBER]. Staff F was not wearing eye protection and was holding a face shield in his/her hand. There were staff and residents in the hallway. Interview on 9/22/21 at 1:50 p.m. with Staff F confirmed that eye protection was not being worn. Staff F stated he/she was taking a break from wearing the eye protection. Staff F confirmed that he/she had been trained to wear eye protection when inside the facility. Review on 9/23/21 of facility policy titled Use of Goggles, Face Shields and N95 Respirators On and Off Units, effective date of 5/25/21 revealed, .To remain in alignment with CDC [Centers for Disease Control and Prevention] guidance, face shields or goggles are still required under certain conditions .3. Units without outbreaks: b. Vaccinated staff do not need to wear routine eye protection except for compliance with Standard Precautions or Transmission-Based Precautions .4b. Eye protection is required for unvaccinated staff in all areas in the building where staff might encounter a patient, except under the Genesis guidance for lower community risk conditions . Review on 9/23/21 of CDC website titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 9/10/21, found at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html revealed, .1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic .Implement Universal Use of Personal Protective Equipment for HCP [Healthcare Personnel]. If [CONDITION(S)]-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP working in facilities located in counties with substantial or high transmission should also use PPE [personal protective equipment] as described below: .Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters .

Based on interview and record review, it was determined that the facility failed to support resident choice to leave the facility by implementing unncessarilty restrictive quarentive policies for 1 of 5 residents reviewed for choices in a final sample of 23 residents. (Resident identifier is #23.) Findings include: Resident #23 Interview on 9/22/21 at approximately 9:54 a.m. with Resident #23 revealed that Resident #23 arranged to go to their home on 9/19/21 and return the same day. Resident #23 was fully vaccinated for COVID-19. Resident #23 arranged for their daughter to transport Resident #23 to the home. Resident #23 stated that their daughter was also fully vaccinated. Resident #23 stated that they were informed by facility that if they left the facility they would have to quarantine in a room that was not theirs for 10 days. Interview on 9/23/21 at approximately 11:15 a.m. with Staff G (Center Nurse Executive) who revealed that they were aware that Resident #23 was going home and returning to the facility the same day. Interview on 9/23/21 at approximately 11:34 a.m. with Staff B (Infection Preventionist) confirmed that on 9/19/21 Staff B received a phone call from Staff H (Licensed Practical Nurse) asking if it was okay for Resident #23 to go home. Staff B informed Staff H that per facility policy Resident #23 would need to admit to the quarentine unit for 10 days. Staff B confirmed that Resident #23 did not leave the facility because of this restriction. Review on 9/23/21 of Centers for Disease Control and Prevention guidance titled Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated September 10, 2021,retrieved from: www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html revealed the following: .Create a Plan for Residents who leave the Facility. Residents who leave the facility should be reminded to follow recommended IPC practices (e.g., source control, physical distancing, and hand hygiene) and to encourage those around them to do the same. -Individuals accompanying residents (e.g., transport personnel, family members) should also be educated about these IPC practices and should assist the resident with adherence. In most circumstances, quarantine is not recommended for unvaccinated residents who leave the facility for less than 24 hours (e.g., for medical appointments, community outings with family or friends) and do not have close contact with someone with [CONDITION(S)]-CoV-2 infection. -Quarantining residents who regularly leave the facility for medical appointments (e.g., [CONDITION(S)], [CONDITION(S)]) would result in indefinite isolation of the resident that likely outweighs any potential benefits of quarantine.

Based on observation, interview and policy review, it was determined that the facility failed to remove expired food items from use in accordance with professional standards of food service safety in the kitchen refrigerator and 1 of 2 unit refrigerators. Findings include: Observation on [DATE] at approximately 10:30 a.m. of the Unit ,d+[DATE] nourishment refrigerator, revealed a container of yogurt with a manufacturer's use by date of [DATE]. Further observation revealed a box of 8 Gogurts with a manufacturer's use by date of [DATE] and handwritten on the box was a residents name and a date of [DATE]. Interview on [DATE] at approximately 10:30 a.m. with Staff C (unit manager) confirmed the above findings. Staff C revealed that the Gogurts were brought in by the resident's family on [DATE]. Review on [DATE] of facility policy titled Food: Safe Handling for Foods from Visitors revised ,d+[DATE] revealed, .5. Refrigerator/freezer for storage of foods brought in by visitors will be properly maintained .Daily monitoring for refrigerated storage duration and discard of any food items that have been stored for over 7 days . Observation on [DATE] at approximately 10:45 a.m. of the kitchen walk in refrigerator revealed a box of 20 yogurts with a manufacturer's use by date of [DATE]. Interview on [DATE] at approximately 10:45 a.m. with Staff D (dietary aide) confirmed the above findings.

Based on record review, interview, and policy review, it was determined that the facility failed ensure that pharmacy irregularities were reviewed by the attending physician for 1 resident out of 8 residents reviewed for unnecessary medications in a final sample of 23 residents. (Resident identifier is #42). Findings: Review on 9/23/21 at approximately 9:10 a.m. of Resident #42's progress notes dated 2/12/21, 4/6/21, and 6/16/21 revealed A medication regimen review was performed-see report for comments/recommendation(s) noted. Review on 9/23/21 at approximately 9:10 a.m of Resident #42 medical record revealed there was no documentation of the pharmacy recommendations dated 2/12/21, 4/6/21, and 6/16/21. Interview on 9/23/21 at approximately 1:50 p.m. with Staff G (Director of Nursing) confirmed the above findings.

Based on interview and record review, the facility failed to ensure that services provided met professional standards for following physcianc orders for 2 residents in a final sample of 23 resdients. (Resident identifier are #1 and #48.) Findings include: Professional reference: Potter, Patricia A., and Anne Griffin Perry. Fundamentals of Nursing. 7th Edition, St. Louis, Missouri: Mosby Elsvier, 2009 Chapter 23 Legal Implications Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' order unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Resident #1 Review on 9/21/21 at 1:54 p.m. of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The start date of this order was 9/10/21. Review on 9/21/21 at 1:54 p.m. of Resident #1's September Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Review on 9/23/21 of Resident #1's medical record including the physician and nursing progress notes revealed no documentation that Resident #1' physician was notified of the above blood sugars. Interview on 9/23/21 at 12:07 a.m. with Staff J (Licensed Practical Nurse) confirmed that Resident #1's physician was not notified of the above mentioned blood sugars and should have been notified based on the order. Staff J stated that the notification would be documented in the Resident's progress notes. Interview on 9/23/21 at 1:13 p.m. with Staff G (Center Nurse Executive) confirmed the above. Resident #48 Review on 9/22/21 at approximately 10:48 a.m. of Resident # 48's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 9/22/21 of Resident #48's medical record revealed that there was no documentation or results that the stool sample was collected. Review on 9/22/21 of Resident #48's LNA (Licensed Nursing Assistant) documentation revealed that Resident #48's last documented bowl movement was documented as being on 9/17/21 at 6:34 p.m. There was no documentation that Resident #48 had a bowel movement from 9/18/21 to 9/22/21 (5 days). Interview on 9/22/21 at approximately 11:30 a.m. with Staff G CNE (Center Nurse Executive) revealed that the facility policy for bowel management was titled Standing Orders Template Constipation with the following orders: -If no bowel movement in three days, give Milk of Magnesia 30 ml (milliliters) PO (by mouth) one dose at bedtime. -If no bowel movement within next shift, give [MEDICATION(S)] suppository PR (Per Rectum) one time. -If no bowel movement within two hours, give Fleet enema. -If no results from Fleet enema, call physician/advanced practice provider for further orders. Review on 9/22/21 at approximately 11:00 a.m. of Resident #48s September EMAR revealed that Resident #48 had the above physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed that none of the above bowel management interventions had been administered between 9/20/21 and 9/22/21. Interview on 9/23/21 at approximately 10:28 a.m. with Staff C (Unit Manager) confirmed the above findings that the stool sample for Resident #48 had not been collected and the bowel management procotol had not be impletmented.