Every finding on record at Delta Blues Health & Rehabilitation

Based on Centers for Disease Control and Prevention (CDC) guidelines, (Named Glucometer-a device/meter used to check blood sugar levels with the use of a blood sample) User Instruction Manual review, facility policy and protocol review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when multi-use glucometers were not cleaned and disinfected with an Environmental Protection Agency (EPA) approved disinfecting wipe to prevent the cross-contamination of bloodborne pathogens, failed to ensure staff allowed the proper drying time for multi-use blood glucose meters (glucometers), failed to perform hand hygiene after glove removal during medication administration, and failed to clean reusable equipment for 8 of 14 (Resident #7, #10, #11, #75, #94, #131, #142, and #146) sampled residents reviewed for medication administration. On 9/30/2025, Registered Nurse (RN) A and RN B failed to clean and disinfect the multi-use blood glucose meter before and after use on each resident in accordance with current infection control recommendations, User's Guide recommendations and the facility policy for Resident #10, #94, and #131. Licensed Practical Nurse (LPN) F and LPN G failed to properly clean and disinfect a multi-use glucometer and allow proper drying time for Residents #7, #11, #75, and #142. The facility census included 4 of 158 (Resident #2, #73, #100, and #174) residents with a diagnosis of Diabetes and Hepatitis C (a transmittable viral infection that causes inflammation to the liver). LPN F failed to perform hand hygiene after the removal of gloves for Resident #75 and LPN E failed to clean reusable equipment for Resident #146 during medication administration. The facility's failure to ensure staff properly disinfected the glucometer that was used for multiple residents resulted in Immediate Jeopardy for Resident #10, #94, and #131. Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to appropriately clean and disinfect a multi-use glucometer during medication administration for Residents #10, #94 and #131. The Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on 9/30/2025 at 6:13 PM, in the Conference room. The facility was cited Immediate Jeopardy at F-880 at a scope and severity of J. An extended survey was conducted and completed on 10/2/2025. An acceptable removal plan, which removed the immediacy of the Jeopardy, was received 10/1/2025 and validated on 10/2/2025 through policy review, review of staff in-services, audits, and staff interviews. The Immediate Jeopardy for F-880 began on 9/30/2025 and continued through 10/1/2025. The Immediate jeopardy was removed on 10/2/2025. The facility's non-compliance at F-880 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the CDC recommendation titled, Considerations for Blood Glucose Monitoring and Insulin Administration, dated 8/7/2024, revealed .Clean and disinfect blood glucose meters after every use, per the manufacturer's instructions .These recommendations apply in .Long-term care settings .Blood glucose meters can easily become contaminated during use. When used in healthcare or other group settings, germs and infections can spread if preventive measures are not in place .If healthcare providers use blood glucose testing or insulin administration devices on more than one patient, equipment and supplies may become contaminated. Unsafe practices during assisted monitoring of blood glucose and insulin administration contribute to the spread of hepatitis B virus [HBV-a serious liver infection most commonly spread by exposure to infected body fluids], hepatitis C virus [HCV-an infection caused by a virus that attacks the liver and is spread by contact with contaminated blood], HIV [Human Immunodeficiency Virus-an immune system disease that interferes with the body's ability to fight infection and disease], and other infections. Unsafe practices include .Using a blood glucose meter for more than one person without cleaning and disinfecting it in between uses .Failing to change gloves and perform hand hygiene between fingerstick procedures . 2. Review of the [Named Glucometer] User Instruction Manual, revised 6/2022, revealed .Cleaning and Disinfecting Guidelines.Healthcare professionals should wear gloves when cleaning the [named] meter. Wash hands after taking off gloves.We suggest cleaning and disinfecting the meter between patient use.Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicide wipe.With all recommended meter cleaning and disinfecting methods, it is critical that the meter be completely dry before testing.Please follow the disinfectant product label instructions to ensure proper drying time. 3. Review of the facility policy titled, Glucose Monitoring via [by way of] Glucometer, dated 8/2014, revealed .Residents with signs and symptoms of hypo/hyperglycemia will be monitored.Clean the blood glucose monitor per manufactures guidelines. Review of the facility protocol titled, How to Clean and Disinfect Your Blood Glucose Meter, dated 8/2025, revealed Cleaning and disinfecting materials.Step 1.Perform hand hygiene, donn [don-put on] gloves, use 1 disinfectant wipe (purple top) to clean the device.Step 2.Use a clean disinfectant wipe (purple top) to disinfect device, wipe the entire surface of the meter horizontally and vertically, wipe around the port.Treated surface must remain wet for recommended contact time (2 minutes with purple top wipes).(Wipe continuously for 2 min [minutes].After disinfecting place on a barrier (Do not place on cart without barrier). Remove gloves and sanitize hands. Review of the facility policy titled, Standard Precautions, dated 9/2019, revealed .Standard Precautions will be utilized to provide a primary strategy for the prevention of healthcare-associated infectious agents among patients and healthcare personnel.During delivery of care, avoid unnecessary touching of surfaces in close proximity to the patient to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surface. Wash hands.immediately after the removal of gloves and between patient contacts.Handle soiled patient care equipment in a manner that prevents transfer of microorganisms to others and to the environment if visibly contaminated; perform hand hygiene.follow procedures for routine care, cleaning and disinfection of environmental surfaces. 4. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE], with diagnoses including Diabetes, Hypertension, and Kidney Disease. Review of the Physician's Order dated 8/4/2022, and recertified by the Physician on 7/11/2025, revealed a blood glucose check every morning and notify provider of blood glucose greater than 300. Review of the Physician's Order dated 3/10/2025, and recertified by the Physician on 7/112025, revealed Insulin Glargine Solution (medication used to treat diabetes) 100 Unit/milliliter (ML) Inject 20 units subcutaneously (under the skin) at bedtime. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #10 was cognitively intact. Resident #10 had an active diagnosis of Diabetes. Observation on the 300 Front East Hall on 9/30/2025 at 4:17 PM, revealed RN B removed a multi-use glucometer from the medication cart, gathered blood glucose monitoring supplies, donned gloves, cleaned the glucometer with an alcohol prep pad, placed the glucometer on top of a plastic cup, and entered Resident #10's room. RN B placed the glucometer on the over bed table, cleaned Resident #10's right hand thumb with an alcohol prep pad, obtained a blood specimen using the blood glucose meter, removed gloves, and exited the room. RN B placed the glucometer on top of the medication cart, cleaned the glucometer with an alcohol prep pad. 5. Review of the medical record revealed Resident #94 was admitted to the facility on [DATE], with diagnoses including Diabetes, Hypertension, and Schizophrenia. Review of the Physician's Order dated 11/21/2024, revealed .Aspart Insulin [medication used to treat Diabetes] .per sliding scale subcutaneously before and after meals and at bedtime . Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 13, which indicated Resident #94 was cognitively intact with a diagnosis of Diabetes. Observation on the 300 Front East Hall on 9/30/2025 at 4:25 PM, revealed RN B gathered the blood glucose monitoring supplies, picked up the glucometer that was previously cleaned with an alcohol prep pad, entered Resident #94's room, obtained a pair of gloves, and placed the supplies on the over bed table. The Surveyor asked RN B to step outside and to bring the blood glucose supplies. RN B was asked what the facility policy is for cleaning the glucometer. RN B stated, I am not sure, I have always cleaned it with an alcohol wipe since I've been here in July [2025]. 6. Review of the medical record revealed Resident #131 was admitted to the facility on [DATE], with diagnoses including Diabetes, Alzheimer's Disease, Pulmonary Embolism, and Heart Failure. Review of the Physician's Order dated 11/20/2024, and recertified by the Physician on 8/19/2025, revealed BLOOD GLUCOSE CHECK BEFORE MEALS AND AT BEDTIME . Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 6, which indicated Resident #131 was severely cognitively impaired. During an observation and interview on the 100 Back [NAME] Hall on 9/30/2025 at 11:17 AM, revealed RN A obtained glucometer supplies from the 100 Back [NAME] Medication Cart and entered Resident #131's room, cleaned the glucometer with an alcohol prep pad and performed Resident #131's blood glucose check. RN A exited the Resident's room and returned to the 100 Back [NAME] Medication Cart. RN A cleaned the glucometer with an alcohol prep pad and placed the glucometer on top of the 100 Back [NAME] Medication Cart. RN A was asked if she had completed all tasks related to the blood glucose check. RN A stated, Yes. RN A placed the glucometer in the top drawer of the medication cart. 7. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE], with diagnoses including Diabetes, Anxiety, and Congestive Heart Failure. Review of the Physician's Order dated 6/22/2025, revealed Insulin Aspart .Inject as per sliding scale .subcutaneously before meals related to .DIABETES . Review of the significant change MDS assessment dated [DATE], revealed a BIMS score of 14, which indicated Resident #7 was cognitively intact. Observation on the 300 Back East Hall on 9/30/2025 at 4:15 PM, revealed LPN G gathered the glucometer and placed it on top of the medication cart without cleaning the cart. LPN G placed a blood glucose test strip into the glucometer and entered Resident #7's room. LPN G placed the glucometer on the over the bed table without cleaning the table and without a barrier. LPN G performed the blood glucose test. LPN G removed her gloves and went out to the medication cart. LPN G retrieved a purple top germicidal wipe and swiped the glucometer once and placed the glucometer on the top of the medication Cart. LPN G failed to wipe the entire surface of the glucometer horizontally and vertically. and failed or let air dry for 2 minutes according to the facility's policy for cleaning and disinfecting the glucometer and failed to perform hand hygiene during the blood glucose testing for Resident #7. 8. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE], with diagnoses including Diabetes, Schizophrenia, and Dissociative Identity Disorder (characteristic of two or more distinct personalities, formerly known as multiple personality disorder). Review of the Physician's Order dated 9/3/2024, and recertified by the Physician on 9/14/2025, revealed an order to check the blood glucose two times a day before breakfast and supper. Sliding scale insulin was not ordered and the staff were instructed to notify the Nurse Practitioner if the blood glucose was less than 60 or greater than 200. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 14, which indicated Resident #11 was cognitively intact. Observation on the 300 Back East Hall on 9/30/2025 at 4:06 PM, revealed LPN G gathered the supplies and placed the items on top of the medication cart without cleaning the cart. LPN G donned gloves, retrieved a purple top germicidal wipe, and cleaned down the front of the glucometer with one swipe. LPN G immediately placed the strip into the glucometer and entered Resident #11's room to perform the blood glucose check without allowing dry time. After the blood glucose check, LPN G removed gloves and went to the medication cart, then placed the glucometer on top of the medication cart without a barrier. LPN G, with one swipe, wiped the glucometer with a purple top germicidal wipe and placed the glucometer on the narcotic book. LPN G failed to wipe the entire surface of the glucometer horizontally and vertically and failed to wait for 2 minutes dry time according to the facility's policy for cleaning and disinfecting the glucometer. 9. Review of the medical record revealed Resident #75 was admitted to the facility on [DATE], with diagnoses including Diabetes, Prostate Cancer, and Osteomyelitis. Review of the significant change MDS assessment dated [DATE], revealed a BIMS score of 12, which indicated Resident #75 was moderately cognitively impaired. Resident #75 had a diagnosis of Diabetes and received insulin. Review of the Physician's Order dated 8/13/2025, revealed Lispro insulin injections per sliding scale before meals. Observation on the 300 Back East Hall on 9/30/2025 at 11:31 AM, revealed LPN F gathered blood glucose monitoring supplies, removed gloves without performing hand hygiene, entered Resident #75's room, donned gloves, obtained a blood specimen from the right finger, removed gloves, and exited room. LPN F failed to perform hand hygiene before she donned and after she removed her gloves. During an interview on 9/30/2025 at 11:46 AM, LPN F was asked if she should perform hand hygiene before she donned and after the she removed her gloves. LPN F stated, Yes, I should have. Observation on the 300 Back East Hall on 9/30/2025 at 4:27 PM, revealed LPN G gathered the glucometer and supplies from the top of the medication cart and entered Resident #75's room. LPN G placed the glucometer on Resident #75's chest, replaced the Resident's binasal cannula oxygen tubing into the Resident's nasal passage, and performed the blood glucose check. LPN G exited Resident #75's room and placed the glucometer on the top of the medication cart. LPN G cleaned the glucometer with a purple top germicidal wipe with one swipe and placed the glucometer back on top of the medication cart. LPN G removed her gloves and placed the glucometer back into the drawer of the medication cart. LPN G failed to perform hand hygiene and failed to wipe the entire surface of the glucometer horizontally and vertically with the disinfectant wipe or wait for 2 minutes dry time according to the facility's policy for cleaning and disinfecting the glucometer during medication administration for Resident #75. 8. Review of the medical record revealed Resident #142 was admitted to the facility on [DATE], with diagnoses including Diabetes, Sepsis, Metabolic Encephalopathy, and Insomnia. Review of the Physician's Order dated 6/17/2025, revealed an order to monitor the blood glucose one time a day and call the physician if the blood glucose was less than 60 or greater than 400. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #142 was cognitively intact. Observation on the 300 Back East Hall on 9/30/2025 at 4:20 PM, revealed LPN G gathered the glucometer and 3 lancets, and laid them on top of the medication cart without cleaning the medication cart. LPN G donned gloves, retrieved a purple top germicidal wipe and cleaned the glucometer with one swipe. LPN G placed the glucometer back on top of the medication cart. LPN G failed to perform hand hygiene, failed to failed to wipe the entire surface of the glucometer horizontally and vertically, with the disinfectant wipe during the blood glucose test for Resident #142. 11. Review of the facility's Diagnosis Report dated 1/1/2025 through 9/30/2025, revealed Resident #2, #73, #100, and #174 were diagnosed with Hepatitis C and Diabetes. 12. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses including Diabetes, Viral Hepatitis C, and Insulin Use. Review of the Physician's Order dated 7/30/2025, revealed Blood Glucose Monitoring one time a day. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 12, which indicated Resident #2 was moderately cognitively impaired. Resident #2 had a diagnosis of Diabetes. 13. Review of the medical record revealed Resident #73 was admitted to the facility on [DATE], with diagnoses including Viral Hepatitis C, Dementia, and Diabetes. Review of the annual MDS assessment dated [DATE], revealed a BIMS score of 11, which indicated Resident #73 was moderately cognitively impaired. Resident #73 had a diagnosis of Viral Hepatitis C. 14. Review of the medical record revealed Resident #100 was admitted to the facility on [DATE], with diagnoses including Hepatitis C, Diabetes, and Encephalopathy. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 11, which indicated Resident #100 was moderately cognitively impaired. Resident #100 had a diagnosis of Diabetes and Hepatitis C. Review of the Physician's Order dated 8/19/2025, revealed Monitor blood glucose levels daily . 15. Review of the medical record revealed Resident #174 was admitted to the facility on [DATE], with diagnoses including Diabetes, Hepatitis C, and Sepsis. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 12, which indicated Resident #174 was moderately cognitively impaired. Resident #174 had a diagnosis of Diabetes. Review of the Physician's Order dated 9/19/2025, revealed Hyperglycemia protocol [elevated blood glucose parameters to notify provider] .Notify NP [Nurse Practitioner] if BS [Blood Sugar] Greater than 300. 16. Review of the medical record revealed Resident #146 was admitted to the facility on [DATE], with diagnoses including Hypertension, Depression, and Epilepsy (a seizure disorder). Review of the Physician's Order dated 3/24/2024, revealed an order to check the blood pressure twice daily. Observation on the 200 Back Central Hall on 10/1/2025 at 7:59 AM, revealed LPN E entered Resident #146's room and checked the Resident blood pressure check with a wrist cuff. LPN E exited the resident's room and placed the wrist cuff on top of the medication cart. LPN E was asked if she had completed all tasks. LPN E stated, Yes. LPN E was asked if the wrist cuff should be cleaned after use. LPN E stated, Yes. LPN cleaned the wrist cuff with a germicidal wipe and placed the cuff on top of the medication cart without a barrier. 17. During an interview on 10/2/2025 at 1:43 PM, the DON was asked if reusable equipment including glucometers should be cleaned and disinfected after resident use. The DON stated, Yes, the equipment should be cleaned with a sani wipe after use. The DON was asked if staff should perform hand hygiene before donning and after removal of gloves. The DON stated, Yes, they should. The DON was asked if staff should use a barrier during medication administration to prevent cross contamination. The DON stated, Yes. The DON was asked how long should staff allow for drying times. The DON stated, Kill time [a period of time allowed to effectively kill germs] should be allowed to dry for 2 minutes. An acceptable removal plan, which removed the immediacy of the Jeopardy, was received 10/1/2023 and validated on 10/2/2025, through policy review, review of staff in-services, audits, and staff interviews. IJ Removal Plan F880 #2 Action Plan: 1. All multi-use blood glucose meters were immediately removed from use and properly disinfection by RN MDS Nurse as defined in Attachment #1 (how to clean and disinfect your glucose meter). This was completed by 9pm on 9/30/25. 2. All residents with recent accuchecks were assessed for signs/symptoms of infection, to include no abnormal vital signs and no nausea/vomiting. No adverse outcomes identified. Completed by DNS, ADNS and Unit Managers on 9/30/25 8pm. 3. The two staff members observed (RN A, RN B) were immediately removed from medication pass duties pending retraining. Retraining and return demonstration completed on 9/30/25 at 8:30pm. 4. An emergency in-service was conducted with all licensed nursing staff on CDC/CMS guidelines for glucometer disinfection, specifically requiring use of EPA-approved disinfectants effective against HIV, Hepatitis B, Hepatitis C and other pathogens. Started on 9/30/25 at 7:30pm. All licensed nursed will not be allowed to return to work until they have completed this in-service. 5. The Infection Preventionist, Director of Nursing, Assistant Director of Nursing and Unit Managers, initiated 100% monitoring of all blood glucose testing to verify compliance with cleaning protocol. All licensed nurses will complete glucose cleaning competency prior to being allowed to work Facility policy on Cleaning & Disinfection of Blood Glucose Meters was reviewed and updated to specify approved disinfectant products, required contact times, and competency validation. 6. All glucometers were labeled and logged to ensure tracking of disinfection between uses. 7. Staff competencies for glucose meter disinfection are being re-validated by the DON/Infection Preventionist by 10/01/2025. All newly hired licensed staff will have competency of glucose monitor cleaning and disinfecting completed upon on hire or rehire during the orientation process starting 10/1/2025. 8. Central supply ordered adequate quantities of EPA-approved disinfectant wipes to ensure ongoing compliance. All 6 medication carts have (1) container of the approved disinfectant wipes on each cart. Facility currently has 61 containers of the disinfectant wipes available in stock. 9. Infection Preventionist or designee will conduct random observations of 10 blood glucose checks daily for 2 weeks, then weekly for 3 months. 10. AD HOC QAPI conducted with all members held on 9/30/2025, to discuss IJ template and removal plan to ensure compliance with proper cleaning and disinfecting of the glucose monitors. Results will be reported to the DON and QAPI Committee. QAPI Committee reviewed for staff competencies for need of further re-training. Noncompliance will result in immediate removal from resident care until retraining is completed. Immediate jeopardy was removed on 9/30/2025 at 9:00 PM with immediate removal of glucometers from use and properly disinfection by RN MDS Nurse. All systemic corrective actions will be completed by 10/01/2025. [Named], Executive Director.

Based on policy review, observation, and interview, 6 of 15 staff members (Certified Nursing Assistants (CNA) #2, #6, #10, #13, #14, and #15) failed to serve food under sanitary conditions for 19 of 155 residents (Resident #29, #30, #36, #55, #45, #78, #84, #98, #102, #108, #116, #123, #124, #125, #132, #135, #148, #164, and #165) observed during dining. The findings include: Review of the facility's policy titled, The Dining Experience: Objectives, dated 2016, revealed .Resident meals will be served in a sanitary environment with proper food handling procedures . Dining observations during the breakfast meal service on 1/10/2022 beginning at 8:48 AM, revealed the following: a. CNA #2 served a tray to Resident #102. CNA #2 touched the overbed table, set up the tray, and touched the biscuit with her bare hand. b. CNA #2 served a tray to Resident #123. CNA #2 touched the overbed table, set up the tray, and touched the biscuit with her bare hand. c. CNA #13 served a meal tray to Resident #165, took the tray back out of the room and placed it on the top of the tray cart, did not perform hand hygiene, and took a tray into Resident #98's room. CNA #13 touched the blanket, touched the bedrail and bed control, and touched the table. CNA #13 did not perform hand hygiene, and began to set up the tray for Resident #98 and touched all the items on the tray. CNA #13 performed hand hygiene at the sink, turned off the water with a paper towel, then used that same paper towel to dry her hands. d. CNA #13 placed a meal tray on the overbed table in Resident #148's room. CNA #13 touched the table, touched the blanket, touched the bed rail and bed control, and touched the privacy curtain. CNA #13 did not perform hand hygiene and donned clean gloves. She handed a cup to Resident #148 and the resident spit in the cup. CNA #13 picked up the trash can, and Resident #148 placed the cup in the trash can. CNA #13 used a napkin to wipe Resident #148's face, and, wearing the same gloves, began to set up the meal tray, touching all the items on the tray. e. CNA #14 placed a meal tray on the overbed table in Resident #30's room. CNA #14 did not perform hand hygiene and donned gloves. CNA #14 touched the overbed table and began to set up the meal tray, touching all the items on the tray. CNA #14 picked up the biscuit and put jelly on it, wearing the same gloves. f. After serving a tray to Resident #124, CNA #14 performed hand hygiene at the sink, turned off the water with a paper towel, and used the same paper towel to continue drying her hands. g. CNA #14 placed a meal tray on the overbed table in Resident #84's room. CNA #14 touched the resident's blanket and gown and pulled Resident #14 up in the bed. CNA #14 touched the bed control and the overbed table. CNA #14 did not perform hand hygiene and began to set up the meal tray, touching all the items on the tray. CNA #14 picked up the biscuit with her bare hand and put jelly on it. CNA #14 performed hand hygiene at the sink, turned off the water with a paper towel, then rolled the paper towel up with both hands and placed it in the trash can. Dining observations during the breakfast meal service on 1/10/2022 at 9:57 AM, revealed CNA #6 served a tray to Resident #108. CNA #6 placed the plate cover on the bed and set up the tray. CNA #6 picked up the plate cover, took it to the meal cart and placed it in the cart with other clean breakfast trays that were waiting to be served to other residents. Dining observations during the lunch meal service on 1/12/2022 beginning at 12:16 PM, revealed the following: a. CNA #15 placed a meal tray on the overbed table in Resident #148's room. CNA #15 touched the bed control and then began to set up the meal tray, touching all the items on the tray. b. CNA #15 placed a meal tray on the overbed table in Resident #45's room. CNA #15 touched the overbed table and the bed control and then began to set up the meal tray, touching all the items on the tray. c. CNA #15 placed a meal tray on the overbed table in Resident #78's room. CNA #15 touched the overbed table and then donned gloves, without performing hand hygiene. CNA #15 touched the blanket, touched Resident #78 to pull the resident up in bed, and then touched the overbed table. CNA #15 then began to set up the meal tray, touching all items on the tray. d. CNA #15 placed a tray on Resident #125's overbed table and touched the table. CNA #15 did not perform hand hygiene and obtained a tray from the meal cart and placed it on the overbed table in Resident #30's room. CNA #15 did not perform hand hygiene and obtained a meal tray for Resident #84. CNA #15 set up the meal tray for Resident #84, touching all the items on the tray. Dining observations during the lunch meal service on 1/12/2022 at 12:56 PM, revealed CNA #10 served a meal tray to Resident #164, touched the overbed table, and went back into the hall and pushed the meal cart in the hallway. CNA #10 did not perform hand hygiene and served a meal tray to Resident #132. CNA #10 set up the meal tray for Resident #132, opened the straw and touched the drinking tip of the straw. CNA #10 did not perform hand hygiene and served a meal tray to Resident #36. CNA #10 set up Resident #36's meal tray, touching all the items on the tray. CNA #10 did not perform hand hygiene, went out into the hallway, and continued to push the meal cart down the hall. CNA #10 did not perform hand hygiene and served a meal tray to Resident #55. CNA #10 touched the overbed table, touched the bed control, dropped the bed remote on the floor and picked it up, and touched Resident #55 to place a napkin over the resident's chest. CNA #10 did not perform hand hygiene, went back into the hallway, and continued to push the meal cart down the hall. CNA #10 served a meal tray to Resident #29 and touched the overbed table. CNA #10 did not perform hand hygiene and served a meal tray to Resident #135. CNA #10 touched the privacy curtain. CNA #10 did not perform hand hygiene. CNA #10 served a meal tray to Resident #116, set up the meal tray, and touched all the items on the tray. During an interview on 1/13/2022 at 5:35 PM, the Assistant Director of Nursing Services confirmed staff should perform hand hygiene between residents during the meal service, after touching objects in the room and before setting up meal trays, and should not touch a resident's food with their bare hands.

Based on policy review, observation, and interview, the facility failed to ensure medications were stored properly and securely in 4 of 8 medication storage areas (100 Back Hall Medication Cart, East Hall Medication Room, West Front Hall Medication Cart, and West Back Hall Medication Cart) and 2 of 96 resident rooms (room [ROOM NUMBER] and #335) observed. The findings include: Review of the facility's policy titled, Medication Storage, dated 4/2014, revealed .Medication supply must be accessible only to licensed nursing personnel, or staff members lawfully authorized to administer medications. All drugs, treatments, and biologicals must be stored securely and following the manufacturer's labeled recommendations, or per facility policy .Oral medications are physically separated from external items .Other treatments such as for eyes, ears, and nose are separated from each other, as well as away from other external medications .Medications will be stored on the medication cart, or in other designated area .Among Medications, Internal and External must be separated. Among External Medications, Eye, Ear, Nasal and Other External must be separated. Separate medications by route of administration . Observation in room [ROOM NUMBER] on 1/10/2022 at 6:35 AM, revealed 1 box of [MEDICATION(S)] (a bronchodilator medication used to treat wheezing and shortness of breath) nebulizer treatments and 1 box of a Wixela inhalation treatment lying on the overbed table next to Resident #139's bed. Observation in the 100 Hall on 1/10/2022 at 9:22 AM, revealed the 100 Back Hall Medication Cart sitting outside of room [ROOM NUMBER] with a bottle of Iron tablets sitting on top of the cart unattended. Observation in room [ROOM NUMBER] on 1/12/2022 at 1:08 PM and 6:16 PM, and on 1/13/2022 at 8:13 AM, revealed a plastic cup, containing [MEDICATION(S)] Ophthalmic Eye and Lantanopros eye drops, sitting on the bedside next to Resident #93's bed. Observation of the East Hall Medication Room on 1/13/2022 at 2:10 PM, revealed 5 easy pump (a pump that releases the medication via gravity) Intravenous (IV) medication balls containing [MEDICATION(S)] (an antibiotic) in Normal Saline (NS) with a use by date of 1/6/2022, and 3 easy pump IV medication balls containing [MEDICATION(S)] in NS with a use by date of 1/12/2022, stored in the medication refrigerator. Observation in the West Front Hall Medication Cart on 1/13/2022 at 2:32 PM, revealed 1 bottle of [MEDICATION(S)] eye drops, 1 bottle of [MEDICATION(S)] eye drops, and 1 bottle [MEDICATION(S)] eye drops stored in the top drawer in a compartment with insulin, two vials of injectable [MEDICATION(S)] (an antiemetic medication) stored in a plastic container with oral medications in the second drawer, and a Catapress (an antiadrenergic medication used to lower blood pressure) topical patch in a plastic container with oral medications, and a Catapress patch in a plastic container with oral medications in the third drawer. Observation in the West Back Hall Medication Cart on 1/13/2022 at 2:37 PM, revealed 1 bottle of Thera Tabs Multivitamin tablets with a best by date of 11/2021 stored in the top drawer of the medication cart. During an interview on 1/12/2022 at 3:50 PM, the Pharmacy Consultant confirmed that medications should be stored in the medication cart, not in a resident's room, and should not be left on top of a medication cart, unattended. During an interview on 1/13/2022 at 11:45 AM, Licensed Practical Nurse #1 confirmed eye drops should not be stored in a plastic cup at a resident's bedside table. During an interview on 1/13/2022 at 5:40 PM, the Assistant Director of Nursing Services confirmed that expired medications should be disposed of, on the day they expire; she confirmed medications such as eye drops, topical medications, injectables and oral medications should be stored separately in a medication dispenser in the medication room, and that medications should not be left unattended.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure Activities of Daily Living (ADL) assistance was provided related to shaving, nail care, and grooming for 5 of 5 sampled residents (Resident #64, #76, #143, #160, and #166) reviewed for ADLs. The findings included: Review of the facility's policy titled, .A.M. [morning] CARE dated 10/2009, revealed .A.M. Care will be given to residents daily .RESPONSIBILITY .All Nursing Assistants .Provide nail care as needed .Provide .assist with shaving . Review of the medical record, revealed Resident #64 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #64 had severe cognitive impairment and required extensive assistance for personal hygiene. Review of the Care Plan dated 11/30/2021, revealed nails were to be kept clean and trimmed. Observation in the resident's room on 1/10/2022 at 6:25 AM and 4:38 PM, and on 1/11/2022 at 9:47 AM and 2:12 PM, revealed Resident #64 had whiskers growing out on both sides of his face and neck, and had dirty, jagged fingernails on both hands. During an interview on 1/12/2022 at 8:47 AM, Certified Nursing Assistant (CNA) #16 confirmed Resident #64 was one of her regular residents and it appeared he had not been shaved since she last cared for him. She confirmed he should be shaved daily. Review of the medical record, revealed Resident #76 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan dated 11/24/2021, revealed Resident #76 had a self-care deficit related to [CONDITION(S)] with interventions that included keeping his nails clean and trimmed. Observation in the resident's room on 10/10/2022 at 6:42 AM and 4:35 PM, 1/11/2022 at 9:45 AM and 2:12 PM, 1/12/2022 at 12:07 PM, and on 1/13/2022 at 8:38 AM, revealed Resident #76's nails were dirty and jagged. Review of the medical record, revealed Resident #143 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS dated [DATE], revealed Resident #143 had intact cognition and required extensive assistance from staff for personal hygiene. Review of the Care Plan dated 12/30/2021, revealed Resident #143 had a self-care deficit due to his inability to independently perform his activities of daily living and included interventions to keep his nails clean and trimmed. Observation in the resident's room on 1/10/2022 at 6:52 AM and 4:42 PM, on 1/11/2022 at 10:50 AM and 1:57 PM, and on 1/13/2022 at 8:45 AM, revealed Resident #143's nails were dirty and jagged. Review of the medical record, revealed Resident #160 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan revised 10/12/2021, revealed Resident #160 had a self-care deficit related to right sided [CONDITION(S)] with interventions that included grooming, hair care, and keeping his nails clean and trimmed. Review of the quarterly MDS dated [DATE], revealed Resident #160 had severe cognitive impairment, did not exhibit rejection of care, and did not receive personal hygiene in the seven day look back period. Observation in the resident's room on 1/11/2022 at 9:42 AM, 1/12/2022 at 12:40 AM, and on 1/13/2022 at 8:35 AM, revealed Resident #160 was in bed wearing a hospital gown, and had unshaved whiskers and long, uncombed hair. Review of the medical record, revealed Resident #166 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan dated revised 10/21/2021, revealed Resident #166 had a self-care deficit related to right sided [CONDITION(S)] and had interventions which included assisting with personal hygiene. Review of the quarterly MDS dated [DATE], revealed Resident #166 had moderately impaired cognition and required extensive assistance for personal hygiene. Observation in the resident's room on 1/10/2022 at 6:15 AM and 4:20 PM, and on 1/11/2022 at 9:20 AM, revealed Resident #166 had long facial hair. Observation on 1/11/2022 at 11:35 AM, revealed Resident #166 was in the hall with Physical Therapy, and he had long facial hair. During an interview on 1/11/2022 at 9:42 AM, the Assistant Director of Nursing Services confirmed male residents should be shaved daily and nails should be clean, trimmed and filed. She confirmed staff should follow the Care Plan for resident grooming and personal hygiene.

Based on policy review, observation, and interview, the facility failed to promote care that maintained residents' dignity, respect, and quality of care when staff failed to provide privacy for 2 of 5 sampled residents (Resident #64 and #69) reviewed for urinary catheters, 3 of 15 staff members (Certified Nursing Assistant (CNA) #2, #11 and #12) did not knock on resident doors prior to entering the room, called residents feeders, and addressed them with pet names for 4 of 155 residents (Resident #2, #37, #88, 108 and #154) observed during dining. The findings include: Review of the facility's undated policy titled, Courtesy Titles Policy, revealed .All residents will be addressed by using the appropriate courtesy title . Review of the facility's policy titled, RESIDENT BILL OF RIGHTS, revised on 11/2017, revealed .Each resident has a right to a dignified existence .communication .in a manner and in an environment that promotes maintenance or enhancement of (his or her) quality of life . Observation in Resident #64's room on 1/10/2022 at 6:25 AM, 3:10 PM, and 4:38 PM, and on 1/11/2022 at 9:47 AM, 11:22 AM, and 2:12 PM, revealed the urinary catheter bag was not covered and the urinary catheter bag with urine was visible from the hallway. Observation in Resident #69's room on 1/11/2022 at 10:30 AM and 1:55 PM, revealed the urinary catheter bag was not covered and the urinary catheter bag with urine was visible from the hallway. During an interview on 1/13/2022 at 3:09 PM, the Assistant Director of Nursing Services(ADNS) confirmed urinary catheter bags should be stored in a dignity bag and urine should not be visible. Dining observation in the 200 Hall at the meal cart on 1/10/2022 at 9:00 AM, revealed CNA #2 referred to a resident as a feeder within hearing distance of staff and other residents. Dining observation in the resident's room on 1/10/2022 at 9:04 AM, revealed CNA #2 entered Resident #88's room without knocking or requesting permission to enter the resident's room. Dining observation in the resident's room on 1/10/2022 at 9:06 AM, revealed CNA #2 entered Resident #37's room without knocking or requesting permission to enter the resident's room. Dining observation in the 100 Hall on 1/10/2022 at 10:10 AM, revealed CNA #11 referred to Resident #2 as a feeder within hearing distance of staff and other residents. Dining observation in the resident's room on 1/12/2022 at 12:15 PM, revealed CNA #12 spoke to Resident #108 and said, .O.K. Baby .O.K. Honey . while serving the meal tray. Dining observation in the resident's room on 1/12/2022 at 12:20 PM, revealed CNA #12 spoke to Resident #154 and said, .Baby, I can find out what your food is . During an interview on 1/13/2022 at 5:35 PM, the ADNS confirmed that all staff should knock on doors prior to entering a resident's room or request permission to enter a resident's room, and staff should not refer to residents as feeders or with pet names.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure Residents were accurately assessed for falls, pressure ulcers, Hospice, [CONDITION(S)], and the use of alarms for 4 of 34 sampled residents (Resident #11, #24, #119, and #165) reviewed. The findings include: Review of the facility's policy titled, MDS [Minimun Data Set] Assessment, dated 11/2017, revealed, .The facility shall conduct interdisciplinary assessments using the MDS item sets as defined by Federal/State regulations. These assessments provide information on the resident's condition to facilitate development of an individualized pan [plan] of care . Review of the medical record, revealed Resident #11 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the IDT (Interdisciplinary Team) QA&A (Quality Assessment and Assurance) Fall Review Worksheet, dated 9/12/2021, revealed Resident #11 had a fall. Review of the quarterly MDS dated [DATE], revealed Resident #11 did not have a fall since the prior MDS assessment on 7/22/2021. During an interview on 1/13/2021 at 3:42 PM, Assistant MDS Coordinator #1 confirmed the MDS should have been coded for a fall. Review of the medical record, revealed Resident #24 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Initial Weekly Wound assessment dated [DATE], revealed .Wound Type: Pressure Ulcer .Present on Admission: False . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the significant change MDS dated [DATE], revealed Resident #24 had a pressure ulcer on admission or reentry. Review of the quarterly MDS dated [DATE], revealed Resident #24 had a pressure ulcer on admission or reentry, and was not coded for receiving Hospice services. During an interview on 1/12/2022 at 1:35 PM, Treatment Nurse #1 confirmed Resident #24 did not have pressure ulcers when she was readmitted on [DATE]. During an interview on 1/13/2021 at 3:44 PM, Assistant MDS Coordinator #1 confirmed the MDS dated [DATE] and 10/20/2021 should have been coded as not having pressure ulcers on admission, and the MDS dated [DATE] should have been coded for Hospice Services. Review of the medical record, revealed Resident #119 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #119's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #119 did not receive [CONDITION(S)]. During an interview on 1/13/2022 at 3:52 PM, Assistant MDS Coordinator #1 confirmed the MDS dated [DATE] should have been coded for [CONDITION(S)]. Review of the medical record, revealed Resident #165 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of quarterly MDS dated [DATE], revealed Resident #165 did not use alarms. Observation in the resident's room on 1/12/2022 at 6:21 PM, revealed an alarm to Resident #165's bed. During an interview on 1/13/2022 at 9:38 AM, Assistant MDS Coordinator #2 confirmed the MDS dated [DATE] should have been coded for a bed alarm.

Based on policy review, medical record review, observation, and interview, the facility failed to follow the Care Plan for 1 of 34 (Resident #165) sampled residents reviewed. The findings include: Review of the facility's policy titled, .COMPREHENSIVE PERSON CENTERED CARE PLANS, with a revision date of 3/2018, revealed .Each resident will have a person centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care .Assigned disciplines will be identified to carry out the intervention . Review of the medical record, revealed Resident #165 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan dated 10/29/2020, revealed .landing mats to both sides of bed . Review of the facility's IDT (Interdisciplinary Team) QA&A (Quality Assessment and Assurance) Fall Review Worksheet, dated 10/29/2021, revealed Resident #165 had a current Care Plan for falls which included an intervention for landing mats at the bedside. Observation in Resident #165's room on 1/10/2022 at 10:09 AM and 3:31 PM, 1/11/2022 at 11:33 AM and 6:44 PM, and on 1/12/2022 at 12:04 PM and 4:03 PM, revealed one landing mat to the right side of bed. During an interview on 1/12/2022 at 4:03 PM, Licensed Practical Nurse (LPN) #2 confirmed Resident #165 should have fall mats to both sides of the bed. During an interview on 1/13/2022 at 3:47 PM, the Assistant Director of Nursing Services confirmed staff should follow the Care Plan and confirmed that if the resident is care planned for bilateral fall mats, they should have one on each side of the bed.

Based on policy review, observation, and interview, the facility failed to ensure practices were followed to prevent the potential spread of infection and cross contamination when nebulizer tubing and a nebulizer mask were stored improperly during random observations for 2 of 2 sampled residents (Resident #76 and Resident #139), 1 of 11 staff members (Certified Nursing Assistant (CNA) #3) failed to properly clean reusable Personal Protective Equipment (PPE) after use, 1 of 1 laundry staff (Laundry Staff #1) failed to don (to put on) proper PPE when entering a contact isolation room and failed to properly dispose of PPE after use, and 1 of 1 environmental service staff (Environmental Service Staff #1) failed to don appropriate PPE when entering contact isolation rooms. The findings include: Review of the facility's policy titled, Contact Precautions, revised 9/2019, revealed .Contact Precautions are a transmission based precaution that will be utilized to reduce the risk of transmission of epidemiologically important micro-organisms by direct or indirect contact .remove gloves before leaving resident's room and wash hands .Remove the gown before leaving the room, place in plastic bag . Review of the facility's signage, DROPLET PRECAUTIONS .YOU MUST WEAR THE FOLLOWING PPE TO ENTER THIS ROOM .N95 MASK, GOWN, GLOVES, FACE SHIELD / GOGGLES . Review of the Centers for Disease Control and Prevention undated guidelines titled, HOW TO SAFELY REMOVE PERSONAL PROTECTIVE EQUIPMENT (PPE) EXAMPLE 1, revealed .Remove all PPE before exiting the patient room . Observation in Resident #139's room on 1/10/2022 at 6:37 AM, revealed a nebulizer mask and nebulizer tubing lying on top of a nebulizer machine. The nebulizer mask and nebulizer tubing were not stored in a bag. Observation in Resident #76's room on 1/10/2022 at 6:42 AM and 2:12 PM, and on 1/12/2022 at 12:07 PM, revealed a nebulizer mouthpiece and nebulizer tubing lying on top of a nebulizer machine on the bedside table. The nebulizer mouthpiece and the nebulizer tubing were not stored in a bag. Observation in Resident #76's room on 1/13/2022 at 8:38 AM, revealed a nebulizer mouthpiece and nebulizer tubing lying on top of the bedside table. The nebulizer mouthpiece and nebulizer tubing were not stored in a bag. During an interview on 1/13/2022 at 9:05 PM, the Assistant Director of Nursing Services (ADNS) confirmed that nebulizer masks, mouthpieces, and tubing should be stored in a labeled and dated plastic bag. Observation during the 200 Hall meal delivery on 1/10/2022 at 10:32 AM, revealed a sign outside of Resident #97's room stating, .DROPLET PRECAUTIONS, YOU MUST WEAR THE FOLLOWING PPE [PERSONAL PROTECTIVE EQUIPMENT] TO ENTER THIS ROOM, N95 MASK, GOWN, GLOVES, FACE SHIELD/GOGGLES . CNA #3 donned a mask, gown, gloves and a face shield, removed a meal tray from the dining cart, knocked and entered Resident #97's room and placed the meal tray on the overbed table. After delivering the meal tray and before exiting the room CNA #3 removed her gown and gloves and placed them in the biohazard trash, sanitized her hands and exited the room and returned to the dining cart. CNA #3 removed a meal tray from the dining cart, knocked and entered Resident #44's room, served the meal tray and exited the room. CNA #3 failed to remove or sanitize her face shield when going from a droplet precaution isolation room to a non-isolation room. Observation on the 200 Hall on 1/10/2022 at 11:00 AM, revealed a sign outside of Resident #20 and Resident #121's room stating, .DROPLET PRECAUTIONS, YOU MUST WEAR THE FOLLOWING PPE [PERSONAL PROTECTIVE EQUIPMENT] TO ENTER THIS ROOM, N95 MASK, GOWN, GLOVES, FACE SHIELD/GOGGLES . Further observations revealed Laundry Staff Member #1 donned a gown, mask, and gloves, removed clean clothes from a laundry cart, knocked and entered Resident #20 and Resident #121's room and placed the clean clothes in the closet. The Laundry Staff Member #1 exited the room and returned to the clean laundry cart, removed her gown and gloves, and folded it into a ball, walked down the hall past the nurses' station to the soiled utility room and disposed of the gown and gloves in the trash can, sanitized her hands and returned to the clean laundry cart. The Laundry Staff Member #1 failed to don a face mask or goggles before entering the contact isolation room and failed to remove and dispose of gown and gloves properly prior to exiting the contact isolation room. Observation on the 200 Hall on 1/10/2022 at 11:09 AM, revealed Environmental Services Staff #1, donned a gown, mask, and gloves and entered Resident #12 and Resident #14's room, removed soiled biohazard boxes and replaced them with clean biohazard boxes, exited the room and returned to the hallway. Environmental Services Staff #1 walked down the hall and entered Resident #97's room and removed the soiled biohazard boxes and replaced with clean biohazard boxes. The Environmental Services Staff #1 failed to don a face shield or goggles when entering the contact isolation rooms. During an interview on 1/13/2022 at 5:35 PM, the ADNS confirmed that staff should put on a gown, gloves, surgical mask and a face shield or goggles prior to entering a contact isolation room and when exiting the room staff should remove all PPE, dispose of the items in the biohazard containers in the resident's room, and wash their hands before leaving the room. The ADNS confirmed staff should clean the face shield or goggles with a bleach wipe in between uses or replace with a new face shield or goggles. The ADNS confirmed that staff should clean the face shield and goggles with a bleach wipe when leaving a contact isolation room and before entering a non isolation room or replace with a new face shield or goggles.

Based on policy review, observation and interview, the facility failed to ensure medications were stored properly and safely in 3 of 13 (East Back Medication Cart, Central Back Medication Cart and B Treatment Cart) medication storage areas. The findings include: 1. Review of the facility's undated MEDICATION STORAGE policy documented, .Among Medications, Internal and External must be separated .Among External Medications, Eye, Ear, Nasal, and Other External must be separated . Observations in the East Back Medication Cart 1/28/19 at 2:45 PM, revealed the following items in the same drawer with no separation: a. 1 Incruse Ellipta inhaler open with no open date b. 1 bottle of anti dandruff shampoo c. 1 container of Germicidal wipes d. 1 tube of [MEDICATION NAME] ointment e. 1 tube of skin protectant f. 1 tube of Calazinc body shield g. 4 tubes of [MEDICATION NAME] sodium topical gel h. 1 tube of [MEDICATION NAME] i. 1 bottle of Fleet enema j. 1 tube of [MEDICATION NAME] k. 1 bottle of [MEDICATION NAME] shampoo l. 1 bottle [MEDICATION NAME] m. 1 jar of Vaseline n. 1 box of skin prep pads 0. 1 tube of stoma adhesive Observations in the Back Central Medication Cart on 1/28/19 at 3:12 PM, revealed the following items in the same drawer with no separation: a. 1 container of Sani wipes b. 1 bottle of Sevelamer [MEDICATION NAME] tablets c. 1 can of Two Cal (a nutritional supplement) e. 6 boxes of [MEDICATION NAME] inhaler solution f. 6 boxes of Ipra-[MEDICATION NAME] (an inhalation solution) g. 1 bottle of [MEDICATION NAME] topical suspension h. 1 [MEDICATION NAME] inhaler i. 1 [MEDICATION NAME] inhaler j. 1 box of [MEDICATION NAME] hand inhaler tablets k. 1 bottle of Sterile water Observations in the B Treatment Cart on 1/28/19 at 4:40 PM, revealed the following items in the same drawer with no separation: a. 1 container of Sani cloths b. 2 bottles of Saline Wound wash Interview with the Director of Nursing (DON) on 1/30/19 at 8:23 AM, in the Conference Room, the DON was asked if it was acceptable to have chemicals in the same drawer as medications with no separation. The DON stated, No, it should be separated by a divider. The DON was asked if it was acceptable to have medication on the medication cart open and undated. The DON stated, No ma'am. The DON confirmed internal and external medications should be stored separately.

Based on observation and interview the facility failed to promote and maintain dignity for residents with an indwelling foley catheter when there was not a dignity bag or the dignity bag did not completely cover the drainage bag for 2 of 8 (Resident #15 and 41) sampled residents. The findings included: 1. Medical record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Observations in Resident #15's room on 3/12/18 at 10:50 AM, 12:12 PM, and 3:34 PM, 03/13/18 at 8:30 AM and 03/14/18 at 9:39 AM, revealed an indwelling catheter drainage bag that was not covered by a dignity bag. 2. Medical record review revealed Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set ((MDS) dated [DATE] revealed Resident #41 had an indwelling catheter. Observations in Resident #41's room on 3/12/18 at 10:42 AM and 2:45 PM, and 3/13/18 at 2:10 PM and 5:26 PM, revealed an indwelling catheter drainage bag that was not completely covered by a dignity bag. Observations in Resident #41's room on 3/13/18 at 8:02 AM, revealed an indwelling catheter not in a dignity bag. Interview with the Director of Nursing (DON) on 3/14/18 at 9:50 AM, at the East nurses' station, the DON was asked if a catheter should be in a dignity bag. The DON stated, Yes. The DON was asked if the catheter bag should be completely covered by the dignity bag. The DON stated, Yes, we want to cover that bag for privacy and dignity.

Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were followed for the care of indwelling urinary catheters for 2 of 8 (Resident #65 and 167) sampled residents reviewed with indwelling urinary catheters. The findings included: 1. The facility's CATHETERIZATION-FOLEY CATHETER INSERTION policy documented, .keep drainage system off the floor . 2. Medical record review revealed Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The (MONTH) (YEAR) physician's orders [REDACTED].DX (Diagnosis): SACRAL WOUND . Observations in Resident #65's room on 3/12/18 at 3:36 PM and 3/14/18 at 9:48 AM, revealed an indwelling catheter tubing lying on the floor. 3. Medical record review revealed Resident #167 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The (MONTH) (YEAR) physician's orders [REDACTED].FOLEY CATHETER CARE EVERY SHIFT . Observations in Resident #167's room on 3/12/18 at 12:17 PM, 12:30 PM, and 3:03 PM, revealed Resident #167 was seated in a gerichair, the indwelling urinary catheter tubing was touching the floor. Interview with the Director of Nursing (DON) on 3/14/18 at 9:49 AM, in Resident #65's room, the DON was asked if the catheter tubing should be lying on the floor. The DON stated, No ma'am .

Based on the manufacturer's recommendation, facility policy review, grievance log review, medical record review, observation and interview, the facility failed to store house supplement shakes according to manufacturers guidelines for 1 of 1 ( kitchen cooler) coolers in the kitchen. The facility had a census of 151 with 19 of those residents receiving supplemental house shakes. The findings included: 1. Review of the (Named Company) manufacturer's guidelines for the (Named Company) Imperial Frozen Shakes documented, .a one year shelf life from date of manufacture when kept frozen. Once thawed, product should be refrigerated and used within 14 days. 2. Review of the facility House Shakes Procedure revealed, .When house shakes are delivered .place in freezer .once refrigerated (thawed), house shakes need to be used in 14 days .Staff is to DISCARD any remaining shakes once the 14 days have passed . 3. Medical record review for Resident #9 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A dietary noted dated [DATE] revealed the resident received a pureed diet with house supplement milk shakes due to inadequate intake and pressure ulcers. The grievance log revealed a grievance dated [DATE] that Resident #9 had received an expired milk product dated ,[DATE] on [DATE]. A Departmental Communication form revealed written notification of the expired product to the Dietary Manager on [DATE]. There was no documentation in the medical record or the grievance report of any follow up provided by Dietary concerning the expired product. 4. Observations in the kitchen on [DATE] at 10:30 AM revealed a total of 26 cases of thawed (Named Company) Imperial Frozen Shakes in the cooler with manufacturer dates of [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. There were no other labels or dates recorded on the cases. There were no cases of frozen shakes observed in the freezer. Thirteen of the 26 cases of thawed shakes observed in the cooler were found to be outdated (cases dated [DATE]-[DATE]). Interview with the Head Cook on [DATE] at 10:30 AM in the kitchen, the Head Cook was asked the storage process of the house supplemental shakes. The Head Cook stated, When the box of cartons are opened we put a label for 14 days out it can not be served. The Head Cook was asked if the supplemental shakes were stored frozen and she stated, No, we do not freeze them. Interview with the Register Dietician (RD) on [DATE] at 9:55 AM in the Conference Room, the RD was asked the storage process of the house supplemental shakes. The RD stated, Keep it frozen, and thawed in the refrigerator for 14 days, when they take them out of the freezer they are suppose to put a use by sticker on them. The facility failed to ensure supplements were stored according to manufacturer recommendations.

Based on policy review, medical record review, and interview, the facility failed to follow facility policy and physician's orders for medication administration for 5 of 45 (Resident #13, 123, 141, 188 and 219) sampled residents included in the annual survey and complaint review. The findings included: 1. Review of facility's MEDICATION ADMINISTRATION-GENERAL GUIDELINES policy documented, Medications are administered as prescribed .1. medications are prepared, administered, and recorded only by licensed nursing .2. Medications are administered in accordance with written orders .3. Residents are allowed to self-administer medications when specifically authorized .in accordance with procedures for self-administration of medications .9. Only licensed or legally authorized personnel who prepare a medication may administer it .10. Medications are administered within the identified block of time .One hour before and one hour after scheduled time .11. The resident's MAR/TAR (Medication Administration Record/Treatment Administration Record) is initialed by the person administering a medication .14. If a dose of regularly scheduled medication is withheld, refused or given at other than the scheduled time .An explanatory note is entered .if several doses .withheld or refused, the physician and responsible party are notified and documentation of this notification is made in the nursing notes. For the eMAR (electronic Medication Administration Record), the dose is electronically marked as not administered with a reason as to why it was not given .18 .If the medication is discontinued, outdated, or unusable, remove the medication for proper disposal. Review of facility's PRINTED PHYSICIAN ORDERS policy documented, Physician orders, MAR's, TAR's for upcoming month will be accurately reconciled against the previous month's records .1. New Physician's Orders, MARs and TAR's will be printed, checked and corrections made necessary by licensed nurses prior to the implementation each month .The orders will reconcile thru the month end feature in software .2 .The reconciled orders MARs and TAR's will be signed by the nurse and dated when placed in the chart/books .eMAR, these records will be maintained electronically . Review of facility's ORDERING AND RECEIVING MEDICATIONS FROM PHARMACY . policy documented, .Medications are ordered and received from the pharmacy in a timely manner. The facility maintains accurate records of medications ordered and their receipt Receiving Medications . 2. A licensed nurse receives medications delivered to the facility and documents delivery on the shipping manifest. Check off each medication .sign at the bottom of the page . Review of facility's MEDICATION DESTRUCTION . policy documented, .When medications are discontinued by physician order .the medications are destroyed . 1. If a physician discontinues or changes a medication, the order is entered into the medical record . 2 .'Discontinued Medication' stickers is used or indicate 'D/C' beside the medication . 2. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's order dated 10/25/16 documented, .REPEAT UA (Urinalysis) WITH C&S (Culture and Sensitivity) FOR P/U (pick up) IN THE AM . Review of a urine culture collected 10/27/16 and reported on 10/29/16 revealed, .> (greater than) 100,000 CFU (colony forming units) / ML (milliliter} ESBL (Extended Spectrum Beta-Lactamase) Producing [DIAGNOSES REDACTED] pneumoniae . The physician's order dated 10/31/16 documented, .IMIPENEM 500 MG (milligrams) EVERY 8 HOURS TIMES 10 DAYS IV (Intravenously) .11/1/2106 2:09:00 AM . Review of the Medication Administration Record (MAR) for the month of November 2016 revealed, Resident #13 did not receive the Imipenem 500 mg until 11/3/16 at 10:00 PM. Interview with the Director of Nursing (DON) on 1/18/16 at 10:30 AM, in the admissions office, the DON was asked what date the Imipenem IV should have been administered. The DON stated, According to this order should have started on antibiotics on November 1st. Telephone interview with Pharmacist #3 on 1/18/16 at 12:50 PM, in the conference room, Pharmacist #3 was asked what the time the order for Imipenem 500 mg IV was received. Pharmacist #3 stated, We did not receive the order until 11/2/16 at 17:50. It was delivered on 11/2/16 at 11:31 PM, and was signed by (Named Nurse #7). 3. Medical record review revealed Resident #123 was admitted to facility 10/2/13 with [DIAGNOSES REDACTED]. Review of Physician's Telephone Orders for Resident #123 dated 9/29/16 documented .discontinue [MEDICATION NAME] 250 mg, start Methazoleamide 25 mg PO (by mouth) tid (three times a day) . Review of the Medication Administration Record (MAR) for Resident #123 for 9/30/16 through 10/26/16 revealed Methazoleamide 25 mg PO tid was entered on the handwritten MAR and signed as given. Review of the MARs dated 10/27/16 through 1/29/17 documented [MEDICATION NAME] 250 mg at bedtime as given when the resident didn't refuse the medication. Review of the physician orders for October 2016 through January 2017 revealed there were no physician orders to restart the [MEDICATION NAME] 250 mg. Review of the pharmacy CONSOLIDATED DELIVERY SHEETS on 1/31/17 on west hall for January 2017 confirmed neither medication had been delivered to the facility through 1/30/17. Interview with LPN #7 on 1/31/17 at 4:15 PM, on the west hall, LPN #7 was asked to review Resident #123's MAR with the surveyor. LPN #7 was asked if she had been giving Resident #123 the [MEDICATION NAME] 250 mg at bedtime as documented on the MAR. LPN #7 stated, Yes. LPN #7 reviewed the order to discontinue [MEDICATION NAME] 250 mg on 9/29/16 and was asked if the medication was discontinued, how she gave it. LPN #7 stated, To be honest, I documented giving it when I saw him taking it himself or his family member gave it to him. LPN #7 was asked how she knew the family member was giving the correct medication and dosage. LPN #7 stated, I didn't. LPN #7 was provided the order to discontinue the [MEDICATION NAME] 250 mg and start Methazoleamide 25 mg tid. LPN #7 was asked if she was aware of the physician order. LPN #7 stated, No, it wasn't on the MAR. LPN #7 was asked if a resident should take his own medication if he had not been evaluated for self-administration. LPN #7 stated, No. LPN #7 documented she administered [MEDICATION NAME] 250 mg 10 times from November 2016 through January 30, 2017 on the following dates: 11/10/16, 12/6/16, 12/15/16, 12/20/16, 12/24/16, 12/26/16, 1/10/17, 1/11/17, 1/24/17, and 1/27/17. Telephone interview with LPN #14 on 2/1/17 at 9:48 AM, LPN #14 was asked about Resident #123's medications. LPN #14 was asked how [MEDICATION NAME] 250 mg was given by LPN #14 on 1/4/17 if it was discontinued on 9/29/16 and no other doses was sent from pharmacy since 9/24/16. LPN #14 stated, It had to be an error. Telephone interview with LPN #10 on 2/1/17 at 12:49 PM, LPN #10 was asked about Resident #123's medications. LPN #10 was asked how [MEDICATION NAME] 250 mg was given by LPN #10 on 1/5/17 if it was discontinued on 9/29/16 and no other doses was sent from pharmacy since 9/24/16. LPN #10 verified it was an error that she had signed out the administration of the [MEDICATION NAME]. Telephone interview with LPN #11 on 2/1/17 at 12:49 PM, LPN #11 was asked about Resident #123's medications. LPN #11 was asked how [MEDICATION NAME] 250 mg was given by LPN #11 on 11/2/16 and 12/3/16 if it was discontinued on 9/29/16 and no other doses was sent from pharmacy since 9/24/16. LPN #11 stated, it had to be an error, I couldn't have given it. The [MEDICATION NAME] 250 mg was documented as given 23 times from 10/27/16 through 1/30/17. The [MEDICATION NAME] 250 mg was documented as not given 53 times from 10/27/16 through 1/30/17. Interview with the DON on 1/31/17 at 4:59 PM, in the DON's office, the DON was asked if she was aware that Resident #123 was receiving a medication that was discontinued and not receiving a medication that was ordered on [DATE]. The DON stated, Not until I received the email from pharmacy this morning. The DON was asked if the staff followed physician orders if they failed to give an ordered medication, the DON stated, No. The facility failed to follow facility policy and physician's orders for medication administration. 4. Medical record review revealed Resident #141 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The physician's order dated 6/29/16 documented, .[MEDICATION NAME] 1 gram IVPB (intravenous piggyback) Q (every) 8 hrs Gangrene feet wounds Stop 8/4/16 . The MAR for the month of July 2016 documented, .[MEDICATION NAME]-0.9 % (percent) NACL (Sodium Chloride) 1G (gram)/250 vial IVPB q (every) 12 hrs stop date 8/4/16 Dx (diagnosis) .Gangrene feet wound . was not documented as given on the [DATE]/1/16 at 9 PM. The physician's telephone order dated 7/13/16 documented, .Continue [MEDICATION NAME] 1gm IV (intravenously) Q 12 hours at 6am and 6pm stop date 8/4/16 . The physician's telephone order dated 7/26/16 documented, .Hold vanc ([MEDICATION NAME]) for 2 dose . The physician's telephone order dated 7/27/16 documented .Hold Vanc until trough 20 or less . The physician's telephone order dated 7/27/16 documented, .Restart [MEDICATION NAME] IV at 6pm . Review of the July 2016 MARs revealed no documentation of [MEDICATION NAME] 1gm IV Q 12 hours on the MAR. The [MEDICATION NAME] was not documented as administered from 7/13/16 to 7/31/16. Interview with the DON on 1/18/16 at 1:40 PM, in the conference room, the DON was asked if a medication was administered would you expect it to be signed out on the MAR. The DON stated, Yes. The physician's telephone orders dated 8/2/16 documented, .Do not give Vanc until trough is back and less than 20 . The physician's telephone orders dated 8/3/16 documented, .Stat Vanc Trough .8/3/2016 at 0400 . Review of the August 2016 MARS revealed .[MEDICATION NAME] 0.9% NACL @(at) 12pm . was documented as given on 8/2/16 at 11 PM, even though there was a physician's order to hold the [MEDICATION NAME]. Interview with the DON on 1/18/16 at 1:57 PM, in the conference room, the DON was asked if the [MEDICATION NAME] was on hold should the medication be documented as given. The DON stated, No, if it has a hold order. A physician's order dated 9/2/16 revealed .Mid line for IV (Intravenous) ABT (Antibiotic) TX (Treatment) . Wound infection of feet . Review of the Peripherally Inserted Central Catheter (PICC) Procedure Notes dated 9/6/16 revealed .Date/Time: 9-6-16 1750 . Review of a physician's order dated 9/6/16 revealed .[MEDICATION NAME] 1GM (gram) IV O (every) day .STAT (Immediately) . Interview with the DON on 1/18/16 at 1:40 PM, in the conference room, the DON was asked about the order for the mid line cath (catheter) ordered on [DATE], but not inserted until 9/6/16. The DON stated, Should be placed on the day of the order (9/2/16). 5. Medical record review revealed Resident #188 was admitted to the facility on [DATE] with admitting [DIAGNOSES REDACTED]. The Departmental Notes dated 10/11/6 at 11:08 PM documented, .RESIDENT NOTED WITH 3 EPISODES OF VOMITTING, DARK BROWN EMESIS, IN PAST 30 MINUTES .FNP (Family Nurse Practitioner) CALLED . The physician's Telephone Order dated 10/11/16 documented, .[MEDICATION NAME] 25MG (milligrams) IM (intramuscularly) NOW X (times) 1 .NAUSEA . Review of the MAR revealed [MEDICATION NAME] 25 mg was not documented as given as ordered. Interview with the DON on 1/18/16 at 1:40 PM, in the conference room, the DON was asked if a medication was administered would you expect it to be signed out on the MAR. The DON stated, Yes. 6. Medical record review revealed Resident #219 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. The physician's Telephone Order dated 7/7/16 documented, .KAYEXELATE NOW .INDICATION .K LEVEL . Review of the MAR for the month of July 2016 revealed no documentation that Kayexelate had been administered. Interview with the DON on 1/17/16 at 11:05 AM, in the administrative hallway, the DON was asked if she had found the information requested regarding the administration of the [MEDICATION NAME]. The DON stated, No, not on there. She shook her head No.

Based on medical record review and interview the facility failed to provide timely care and services for 1 of 1 (Resident #13) sampled residents reviewed for Urinary Tract Infection [MEDICAL CONDITION]. The findings included: Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Repeat UA (urinalysis) with C & S (culture and sensitivity) . The lab report of the C&S collected on 10/23/16 and reported on 10/25/16 documented, .THE FOLLOWING TEST (S) WERE REQUESTED AND NOT PERFORMED DUE TO THE REASON LISTED BELOW .UA C& .S SPECIMEN WAS RECEIVED WITHOUT A 2ND PATIENT IDENTIFIE (identifier) . A physician's orders [REDACTED].REPEAT UA WITH C&S FOR P/U (pick up) IN THE AM . The C&S lab results collected on 10/27/16 at 7:37 and reported 10/29/16 at 1:42 documented, > (greater than) 100,000 CFU (colony forming units)/ ML (milliliter) ESBL ( Extended Spectrum Beta-Lactamase) Producing [DIAGNOSES REDACTED] pneumoniae . Telephone interview with the (Named Laboratory Company) Customer Service Representative (CSR) #1 on 1/18/16 at 10:00 AM, CSR #1 was asked about the C & S lab results dated 10/25/16. CSR #1 stated, .The specimen has to have .2 patient identifiers, the name and either the date of birth or social . CSR #1 was asked if the specimen had 2 patient identifiers. CSR #1 stated, It did not have it on the specimen, had to send .notification so they can recollect and call for pick up Interview with the Director of Nursing (DON) on 1/18/16 at 10:30 PM, in the Admissions office, the DON reviewed the lab specimen dated 10/25/16. The DON was asked if the urine for the C & S should be labeled with 2 patient identifiers. The DON stated, Yes .

Based on policy review, observation and interview, the facility failed to ensure staff maintained resident privacy when providing Activity of Daily Living (ADL) care for 1 of 3 (Resident #76) residents observed receiving ADL care. The findings included: 1. The facility's INCONTINENT CARE policy documented .provide privacy .Avoid unnecessary exposure of the resident . 2. Medical record review revealed Resident #76 was admitted to the facility 7/15/16 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the Brief Interview of Mental Status (BIMS) score was left blank, indicating severe cognitive impairment. Admission Minimum Data Set (MDS) assessment dated [DATE] documented the BIMS was left blank, indicating severe cognitive impairment. Resident #76 was severely cognitively impaired and was totally dependent for Activity of Daily Living (ADL) care. Observations in Resident #76's room on 1/11/17 at 9:00 AM, revealed Certified Nursing Assistant (CNA)s #4 & #8 entered Resident #76's room after donning gloves and applying mask and gown. The CNAs did not close the door or pull the privacy curtain but proceeded to pull the covers back from Resident #76 and remove her brief. The surveyor asked the CNAs was there anything else they should have done before exposing the resident and CNA #4 stated, We should have pulled the curtain. CNA #4 pulled the curtain at that time but the resident was already exposed. Interview with the Director of Nursing (DON) on 1/18/17 at 2:19 PM, in the conference room, the DON was asked what is the expectation of staff when providing incontinence or peri care for a resident on contact isolation. The DON stated. Staff should follow the isolation protocol, wash their hands, put on gloves, gown and mask as indicated. The DON was asked if it was acceptable for staff to provide peri care with the door open and the privacy curtain not pulled. The DON stated, No, it is not acceptable.

Based on policy review, medical record review, observation, and interview, the facility failed to provide the resident a choice in the number of showers he received weekly for 1 of 3 (Resident # 114) residents reviewed for choices in the stage 2 review. The findings included: 1. The facility's BATH/SHOWER-DEPENDENT policy documented, .A bath (shower/tub) for cleanliness and comfort is scheduled at least weekly for each resident. 2. Medical record review reveals Resident #114 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Bathing Report for January and February documented showers were not given on the following dates: 1/1/17, 1/2/17, 1/3/17, 1/4/17, 1/5/17, 1/6/17, 1/7/17, 1/8/17, 1/9/17, 1/11/17, 1/12/17, 1/13/17, 1/14/17, 1/15/17, 1/16/17, 1/18/17, 1/20/17, 1/21/17, 1/22/17, 1/23/17, 1/24/17, 1/25/17, 1/26/17, 1/27/17, 1/28/17, 1/29/17, 1/30/17, 1/31/17, 2/1/17, 2/2/17, 2/3/17, 2/4/17, 2/5/17, 2/6/17, 2/7/17, 2/8/17, 2/10/17, 2/11/17, 2/12/17, 2/13/17, 2/14/17, 2/15/17, 2/16/17, 2/17/17, 2/18/17, 2/19/17, 2/20/17, 2/21/17, 2/22/17, 2/23/17, 2/25/17 and 2/26/17. The facility did not provide any documentation that the resident refused any showers. Observation in the central hallway on 2/28/17 at 2:15 PM, Resident #114 was down the hall and yelled out to the surveyor, I'm getting a shower as soon as you said something . Interview with the Administrator (ADM) on 3/1/17 at 1:47 PM, outside of the ADM's office, the ADM was asked how often residents should receive showers. The ADM stated, They can get one twice a week. They get a bath or shower twice a week. The ADM was asked if the resident wants a shower twice a week should he be getting getting it twice a week. The ADM stated, Right. Interview with the ADM on 3/1/17 at 2:08 PM, at the 200 hall nurses desk, the ADM stated, We have no documentation that he has refused (showers). The ADM was asked if there was no documentation of resident refusing showers as he stated he preferred. The ADM stated, Right.

Based on medical record review and interview, the facility failed to accurately code the Minimum Data Set (MDS) for unnecessary medications and [DIAGNOSES REDACTED].#9,140 and 219) sampled residents of the 45 residents included in the stage 2 review. 1. Medical record review revealed Resident #9 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of History of Urinary Tract Infections, Dementia without Behavioral Disturbance, [MEDICAL CONDITION] Disorder, [MEDICAL CONDITIONS] Fibrillation, Pain in Right and Left Knee, [MEDICAL CONDITION], Anxiety Disorder, Pain in Right Hip, Gastro-[MEDICAL CONDITION] Reflux Disease, Idiopathic Chronic Gout, Vitamin D Deficiency, Chest Pain, [MEDICAL CONDITIONS], Obesity, [MEDICAL CONDITION] Disorder, and Chronic Peripheral [MEDICAL CONDITION]. a. The December 2016 MAR indicated [REDACTED] .[MEDICATION NAME] 20 MG TABLET .ONE TAB BY MOUTH TWICE DAILY . was administered on 12/17/16 to 12/22/16. .[MEDICATION NAME] ER (extended release) 450 MG .ONE BY MOUTH TWICE DAILY . was administered on 12/17/16 to 12/22/16. .XARELTO 10 MG TABLET .ONE TABLET BY MOUTH DAILY . was administered on 12/17/16 to 12/22/16. .[MEDICATION NAME] 1 MG TABLET ONE .BY MOUTH DAILY . was administered on 12/17/16 to 12/22/16. .[MEDICATION NAME] 20 MG TABLET .ONE BY MOUTH EVERY DAY . was administered 12/17/16 to 12/22/16. .[MEDICATION NAME] 1 GM (Gram) VIAL GIVE ONE IM (INTRAMUSCULAR) EVERYDAY TIMES 14 DAYS . was administered 12/17/16 to 12/22/16. .[MEDICATION NAME] .100 MG .GIVE ONE CAPSULE BY MOUTH EVERY NIGHT . was administered 12/17/16 to 12/22/16. Review of the quarterly MDS dated [DATE] revealed antipsychotic, antianxiety, anticoagulant, antibiotic, and diuretic medications were coded as being administered for 7 days. [MEDICATION NAME] ER, Xarelto, [MEDICATION NAME], and [MEDICATION NAME] were administered for a total of 6 days during the 7 day look back period. Interview with MDS Nurse #1 on 1/18/17 beginning at 3:20 PM, in the MDS office, MDS Nurse #1 was asked how the medications should be coded on the MDS. MDS Nurse #1 confirmed the medications should be coded for 6 days. b. Review of the medical record revealed an admitting [DIAGNOSES REDACTED].#9 was receiving [MEDICATION NAME] 1 mg daily. Review of the quarterly MDS dated [DATE] revealed no [DIAGNOSES REDACTED]. Interview with MDS Nurse #1 on 1/18/17 beginning at 3:20 PM, in the MDS office, MDS Nurse #1 was asked if the MDS should be coded for anxiety. MDS Nurse #1 stated, Yes. c. The Medication Administration Record [REDACTED].XARELTO 10 MG (milligrams) TABLET .1 tablet by mouth daily . was administered on 3/11/16 to 3/15/16. Xarelto was administered for a total of 6 days during the 7 day look back period. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed anticoagulants were coded as being administered for 7 days. Interview with MDS Nurse #1 on 1/18/17 at 3:20 PM, in the MDS office, MDS Nurse #1 reviewed the MARs and was asked how Xarelto should be coded on the MDS. MDS Nurse #1 stated, 6. MDS Nurse #1 was asked if the MDS was coded correctly. The MDS Nurse #1 stated, Uh-uh (No). 2. Medical record review revealed Resident #140 was admitted to the facility on [DATE] with diagnoses of Diabetes Mellitus, Convulsions, Gastro-[MEDICAL CONDITION] Reflux Disease, [MEDICAL CONDITION], Hypertension, Dementia with Behavioral Disturbances, [MEDICAL CONDITIONS] Disease, and [MEDICAL CONDITION] Disorder. The Physician order [REDACTED].[MEDICATION NAME] 25 mg tablet give one tablet daily by mouth daily . The quarterly MDS dated [DATE] did not document Resident #140 received diuretics. Interview with MDS Coordinator on 3/1/17 at 11:47 AM, in the conference room, the MDS Coordinator was asked if the MDS was accurate for the diuretic. The MDS Coordinator stated, .the diuretic should be coded for the diuretic .it is inaccurate . 3. Medical record review revealed Resident #219 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of Pneumonitis due to Inhalation of Food and Vomit, Encounter for Attention to Gastrostomy, Adult Failure to Thrive, Non Pressure Chronic Ulcer of Left Heel and Mid Foot, Hypertension, [MEDICAL CONDITIONS] Stage 3, Immune [MEDICAL CONDITION] Purpura, Enlarged Prostate, [MEDICAL CONDITION], Hearing Loss, Dysphagia, Dementia without Behavioral Disturbance, and Other Mental Disorders Due to Known Physiological Conditions. Review of the Kidney Care Center . form dated 4/18/16 documented, CKD ([MEDICAL CONDITION]) Stage 3 Stable . Review of the quarterly MDS dated [DATE] did not reflect the [DIAGNOSES REDACTED]. Interview with MDS Nurse #1 on 1/12/17 at 10:20 AM, in the MDS office, MDS Nurse #1 was shown the MDS and was asked if the MDS should be coded for the [DIAGNOSES REDACTED].#1 stated, It is not there. MDS Nurse #1 was asked if you would expect it to be on the MDS. MDS Nurse #1 stated, You would.

Based on medical record review and interview the facility failed to revise the comprehensive care plan to reflect the current status for Activities, Activities of Daily Living (ADL's) and [DIAGNOSES REDACTED].#3 and 219) sampled residents reviewed of the 45 residents included in the stage 2 review. The findings included: 1. Medical record review revealed Resident #3 was admitted to the facility on ,[DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 9/21/15 and updated 9/27/16 documented, .Need assistance to perform activity tasks does have left sided weakness and impaired vision in left eye Affect is flat .Potential for social isolation prefer setting within room watching tv. Invite and escort to activity interests . Interview with the Minimum Data Set (MDS) Nurse #2 on 3/1/17 at 4:05 PM, in the MDS office, MDS Nurse #2 was asked how often care plans should be updated. MDS Nurse #2 stated, Quarterly MDS Nurse #2 was asked if the care plan for activities had been revised. MDS Nurse #2 stated, The Activities Director (AD) does that. Interview with the AD on 3/1/17 at 4:10 PM, in the MDS office, the AD was asked if the care plan had been reviewed last quarter. The AD stated, No. The AD was asked if the care plan for activities that was last revised on 9/27/16 was current. The AD stated, No, it is not current. The Care plan dated 9/18/15 and updated 9/27/16 documented, .Self Care Deficit related to inability to independently perform ADLs secondary to cognitive and physical deficit. Hx (History) of Dementia, Late [MEDICAL CONDITION] . Interview with MDS Nurse #2 and the MDS Coordinator on 3/1/17 at 5:35 PM, in the MDS office, MDS Nurse #2 was asked if the care plan had been revised. MDS Nurse #2 stated, No. The MDS Coordinator was asked when should the care plan be revised. The MDS Coordinator stated, In December. 2. Medical record review revealed Resident #219 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of the Kidney Care Center . form dated 4/18/16 documented, CKD ([MEDICAL CONDITION]) Stage 3 Stable . The care plan revised on 6/22/16 did not reflect the [DIAGNOSES REDACTED]. Interview with the MDS Coordinator on 1/12/17 at 10:15 AM, in the MDS office, the MDS Coordinator was asked if the [DIAGNOSES REDACTED]. The MDS Coordinator reviewed the care plan and stated, I don't see it. The MDS Coordinator was asked if she would expect it to be care planned. The MDS Coordinator stated, Yes.

Based on policy review, medical record review, observation and interview, the facility failed to follow care plan interventions for Activities of Daily Living (ADLs) for 1 of 30 (Resident #76) sampled residents of the 45 residents included in the survey. The findings included: 1. The facility's TURNING & REPOSITIONING PROGRAM policy documented .2. Charge Nurse is responsible for visually observing and assisting with turning and positioning as needed .5. All Residents (unless reasons documented in the care plan) are to face the same direction at the same time . Medical record review revealed Resident #76 was admitted to the facility 7/15/16 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the Brief Interview of Mental Status (BIMS) score was left blank, indicating severe cognitive impairment. Admission Minimum Data Set (MDS) assessment dated [DATE] documented the BIMS was left blank, indicating severe cognitive impairment. Resident #76 was severely cognitively impaired and was totally dependent for Activity of Daily Living (ADL) care. The Care Plan for Resident #76 dated 7/15/16 documented, .self-care deficit related to independently perform ADL's related to cognitive and functional limitations. 1. Goal was resident will be clean, dressed and free of odor . Interventions .staff was to provide necessary privacy, turn and reposition at least every two hours .and provide needed assistance with ADLs. 2. Resident requires Contact Isolation secondary to[DIAGNOSES REDACTED] ([MEDICAL CONDITION]). Staff was to follow contact isolation precautions before and after each interaction of care. 3. Incontinent of B & B (Bowel and Bladder.) .Staff was to provide privacy when providing incontinence care .check resident and provide care as needed q 2 h (every two hours) and PRN (whenever necessary) .Clean and dry thoroughly & change soiled clothing .Keep linens and pads clean and dry .Apply moisture barrier as needed. The updated Daily Care Guide documented, .CONTACT ISOLATION .2 person assist with Marissa lift .Get dressed daily and up in chair .Incontinent of B & B . Medical record review revealed Resident #76 was placed on contact isolation for ESBL (Extended-Spectrum beta-Lactamase) in urine on 7/24/16 and contact isolation for [MEDICAL CONDITION] on 12/1/16. Nurses notes from 9/2/16 through present documented resident required extensive assist with all activity of daily living functions. Observations in Resident #76's room on 1/11/17 at 9:00 AM, Certified Nursing Assistant (CNA)s #4 & #8 entered Resident #76's room after donning gloves and applying mask and gown. The CNA's did not close the door or pull the privacy curtain but proceeded to pull the covers back from Resident #76 and remove her brief. The surveyor asked the CNA's was there anything else they should have done before exposing the resident and CNA #4 stated, We should have pulled the curtain. CNA #4 pulled the curtain at that time but the resident was already exposed. When the CNAs pulled back the bed linen, Resident #76's brief was heavily soiled with urine and liquid formed feces. Interview with the Director of Nursing (DON) on 1/18/17 at 2:19 PM, in the conference room, the DON was asked what is the expectation of staff when providing incontinence or peri care for a resident in contact isolation. The DON stated staff should follow the isolation protocol, wash their hands, put on gloves, gown and mask as indicated. The DON was asked if it was acceptable for staff to provide peri care with the door open and the privacy curtain not pulled. The DON stated No, it is not acceptable. Observations in Resident #76's room on 1/15/17 beginning at 2:20 PM, the surveyor noted a foul smell. The surveyor asked Licensed Practical Nurse (LPN) #2 what CNA was assigned to Resident #76. LPN #2 stated (CNA #4). LPN #2 changed her response after CNA #4 stated she was not assigned Resident #76 since 10 AM. LPN #2 then stated CNA #1 had Resident #76. At 2:25 PM, CNA #1 stated Ma'am, she (LPN #2) just told me I had her (Resident #76). I have not done anything for this lady today. I have not been in this room. CNA #1 entered Resident #76's room, donned gloves, pulled curtain and proceeded to uncover Resident #76. CNA #1 removed a wedge cushion from the left side of resident. Observations of Resident #76 after removing the covers revealed Resident #76 had feces on the top sheet, feces oozing from the adult brief from the front and from behind. There was noted dried and liquid feces in the vaginal area, buttocks and thigh areas. CNA #1 stated, I need to get some help. CNA #1 removed her gloves and went out into hall. CNA #1 did not wash her hands before leaving the room. CNA #1 returned to outside of Resident #76's room with CNA #2. Surveyor asked CNA #1 if Resident #76 was in contact isolation. CNA #1 stated, I didn't know, I never had her before. I just passed right by this isolation cart. CNA #1 was asked if she should do anything else other than wear gloves when changing the brief or providing care for Resident #76. CNA #1 stated, Yes, I should have put on a gown and a mask too. Interview with CNA #1 on 1/15/17 at 2:50 PM, across from Resident #76's room CNA #1 again confirmed she had not provided care for Resident #76 because she thought her assignment was the same as the day before when the assignment changed. CNA #1 stated, I have always stopped at room [ROOM NUMBER], I have never had room [ROOM NUMBER] (Resident #76's room) .we had 5 CNA's until a few minutes ago when I was told I had room [ROOM NUMBER] (Resident #76's room). CNA #1 stated, I did not get an updated Daily Care Guide on this lady, either. Interview with CNA# 4 on 1/15/17 at 3:10 PM, in the hall between east and central halls by the time clock. CNA #4 was asked about her assignment this shift. CNA #4 stated, We started out with 6 CNA's on this hall but they pulled one. We, CNA #2 and me found out about 10 AM. We were walking by the nurses' station and LPN #1 told us. CNA #4 was asked if there were any other CNA's around when she and CNA #2 were told about the assignment change. CNA #4 stated, No, not at that time. CNA #4 was asked if she provided any care for Resident #76 before the assignment changed, CNA #4 stated, Yes ma'am, I did oral care, changed her brief and provided peri-care, and I repositioned her between 8:30-9:00 this morning. Interview with LPN #2 on 1/15/17 at 3:22 PM, in the east dining room, LPN #2 was asked to clarify the CNA assignment for today (1/15/17, 7-3 shift). LPN #2 stated, We started off with 6 CNAs at 7 AM. The nurse (LPN #5) on the west hall apparently pulled CNA #7 and failed to notify either nurse on the east hall of the change . LPN #2 was asked if Resident #76 had received care that day, LPN # 2 stated, Yes. LPN #2 was asked who provided the care. LPN #2 stated, CNA #4 did something for her this morning. LPN #2 stated, She had been in Resident #76's room at 7:30AM, 8:00AM, 11:30 AM, and between 1-1:30 PM, to give tube feeding, meds stuff like that. LPN #2 was asked if she turned and repositioned Resident #76, LPN #2 stated, No. LPN #2 was asked if she noticed Resident #76 lying in the same position for greater than 5 hours. LPN #2 stated, I guess I didn't notice. Interview with CNA #6 in the front parking lot on 1/17/17 at 7:10 AM, CNA #6 was asked if she cared for Resident #76 last night (1/16/17) on the 3rd shift. CNA #6 stated, Yes, I just turned her before leaving for the day. CNA #6 was asked if she worked Saturday night 1/14/17. CNA #6 stated, No, I was off. CNA #6 was asked what time last rounds are performed by the 11-7 shift. CNA #6 stated, We start around 6 and finish around 7, sometimes a little later .I usually do everything for (named Resident #76) just before I leave around 7, when I have her. Interview with the Director of Nursing (DON) on 1/18/17 at 2:19 PM, in the conference room, the DON was asked what is the expectation of staff when providing incontinence or peri care for a resident on contact isolation. The DON stated, Staff should follow the isolation protocol, wash their hands, put on gloves, gown and mask as indicated. The DON was asked if staff did not provide care for Resident #76 for 5 hours or greater, did staff provide adequate ADL care and care per the resident's care plan. The DON stated, No, they did not. The facility failed to provide Activity of Daily Living (ADL) Care related to incontinence care, turning and repositioning, and privacy per the resident's care plan.

Based on policy review, medical record review, observation and interview, the facility failed to ensure Activities of Daily Living (ADL) assistance related to incontinence care, turning and repositioning, and privacy were provided for 1 of 3 (Resident #76) residents reviewed requiring assistance with ADLs. The findings included: 1. The facility's TURNING & REPOSITIONING PROGRAM policy documented .2. Charge Nurse is responsible for visually observing and assisting with turning and positioning as needed .5. All Residents (unless reasons documented in the care plan) are to face the same direction at the same time . 2. Medical record review revealed Resident #76 was admitted to the facility 7/15/16 with [DIAGNOSES REDACTED]. The Care Plan for Resident #76 dated 7/15/16 documented, .self-care deficit related to independently perform ADL's related to cognitive and functional limitations. 1. Goal was resident will be clean, dressed and free of odor . Interventions .staff was to provide necessary privacy, turn and reposition at least every two hours .and provide needed assistance with ADLs. 2. Resident requires Contact Isolation secondary to[DIAGNOSES REDACTED] ([MEDICAL CONDITION]). Staff was to follow contact isolation precautions before and after each interaction of care. 3. Incontinent of B & B (Bowel and Bladder.) .Staff was to provide privacy when providing incontinence care .check resident and provide care as needed q 2 h (every two hours) and PRN (whenever necessary) .Clean and dry thoroughly & change soiled clothing .Keep linens and pads clean and dry .Apply moisture barrier as needed. Admission Minimum Data Set (MDS) assessment dated [DATE] documented the BIMS was left blank, indicating severe cognitive impairment. Resident #76 was severely cognitively impaired and was totally dependent for Activity of Daily Living (ADL) care. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the Brief Interview of Mental Status (BIMS) score was left blank, indicating severe cognitive impairment. The updated Daily Care Guide documented, .CONTACT ISOLATION .2 person assist with Marissa lift .Get dressed daily and up in chair .Incontinent of B & B . Medical record review revealed Resident #76 was placed on contact isolation for ESBL (Extended-Spectrum beta-Lactamase) in urine on 7/24/16 and contact isolation for [MEDICAL CONDITION] on 12/1/16. Nurses notes from 9/2/16 through present documented resident required extensive assist with all activity of daily living functions. Observations in Resident #76's room on 1/11/17 at 9:00 AM, Certified Nursing Assistant (CNA)s #4 & #8 entered Resident #76's room after donning gloves and applying mask and gown. When the CNAs pulled back the bed linen, Resident #76's brief was heavily soiled with urine and liquid formed feces. Observations in Resident #76's room on 1/15/17 beginning at 2:20 PM, the surveyor noted a foul smell. The surveyor asked Licensed Practical Nurse (LPN) #2 what CNA was assigned to Resident #76. LPN #2 stated (CNA #4). LPN #2 changed her response after CNA #4 stated she was not assigned Resident #76 since 10 AM. LPN #2 then stated CNA #1 had Resident #76. At 2:25 PM, CNA #1 stated Ma'am, she (LPN #2) just told me I had her (Resident #76). I have not done anything for this lady today. I have not been in this room. CNA #1 entered Resident #76's room, donned gloves, pulled curtain and proceeded to uncover Resident #76. CNA #1 removed a wedge cushion from the left side of resident. Observations of Resident #76 after removing the covers revealed Resident #76 had feces on the top sheet, feces oozing from the adult brief from the front and from behind. There was noted dried and liquid feces in the vaginal area, buttocks and thigh areas. CNA #1 stated, I need to get some help. CNA #1 removed her gloves and went out into hall. CNA #1 did not wash her hands before leaving the room. CNA #1 returned to outside of Resident #76's room with CNA #2. Surveyor asked CNA #1 if Resident #76 was in contact isolation. CNA #1 stated, I didn't know, I never had her before. I just passed right by this isolation cart. CNA #1 was asked if she should do anything else other than wear gloves when changing the brief or providing care for Resident #76. CNA #1 stated, Yes, I should have put on a gown and a mask too. Interview with CNA #1 on 1/15/17 at 2:50 PM, across from Resident #76's room CNA #1 again confirmed she had not provided care for Resident #76 because she thought her assignment was the same as the day before when the assignment changed. CNA #1 stated, I have always stopped at room [ROOM NUMBER], I have never had room [ROOM NUMBER] (Resident #76's room) .we had 5 CNA's until a few minutes ago when I was told I had room [ROOM NUMBER] (Resident #76's room). CNA #1 stated, I did not get an updated Daily Care Guide on this lady, either. Interview with CNA #4 on 1/15/17 at 3:10 PM, in the hall between east and central halls by the time clock. CNA #4 was asked about her assignment this shift. CNA #4 stated, We started out with 6 CNA's on this hall but they pulled one. We, CNA #2 and me found out about 10 AM. We were walking by the nurses' station and LPN #1 told us. CNA #4 was asked if there were any other CNA's around when she and CNA #2 were told about the assignment change. CNA #4 stated, No, not at that time. CNA #4 was asked if she provided any care for Resident #76 before the assignment changed, CNA #4 stated, Yes ma'am, I did oral care, changed her brief and provided peri-care, and I repositioned her between 8:30-9:00 this morning. Interview with LPN #2 on 1/15/17 at 3:22 PM, in the east dining room, LPN #2 was asked to clarify the CNA assignment for today (1/15/17, 7-3 shift). LPN #2 stated, We started off with 6 CNAs at 7 AM. The nurse (LPN #5) on the west hall apparently pulled CNA #7 and failed to notify either nurse on the east hall of the change . LPN #2 was asked if Resident #76 had received care that day, LPN #2 stated, Yes. LPN #2 was asked who provided the care. LPN #2 stated, CNA #4 did something for her this morning. LPN #2 stated, She had been in Resident #76's room at 7:30AM, 8:00AM, 11:30 AM, and between 1-1:30 PM, to give tube feeding, meds stuff like that. LPN #2 was asked if she turned and repositioned Resident #76, LPN #2 stated, No. LPN #2 was asked if she noticed Resident #76 lying in the same position for greater than 5 hours. LPN #2 stated, I guess I didn't notice. Interview with CNA #6 in the front parking lot on 1/17/17 at 7:10 AM, CNA #6 was asked if she cared for Resident #76 last night (1/16/17) on the 3rd shift. CNA #6 stated, Yes, I just turned her before leaving for the day. CNA #6 was asked if she worked Saturday night 1/14/17. CNA #6 stated, No, I was off. CNA #6 was asked what time last rounds are performed by the 11-7 shift. CNA #6 stated, We start around 6 and finish around 7, sometimes a little later .I usually do everything for (named Resident #76) just before I leave around 7, when I have her. Interview with the Director of Nursing (DON) on 1/18/17 at 2:19 PM, in the conference room, the DON was asked what is the expectation of staff when providing incontinence or peri care for a resident on contact isolation. The DON stated, Staff should follow the isolation protocol, wash their hands, put on gloves, gown and mask as indicated. The DON was asked if staff did not provide care for Resident #76 for 5 hours or greater, did staff provide adequate ADL care and care per the resident's care plan. The DON stated, No, they did not. The facility failed to to provide Activity of Daily Living (ADL) Care related to incontinence care, turning and repositioning, and privacy.