Every finding on record at Diversicare of Quitman

Based on interviews, record review, and facility policy review, the facility failed to ensure residents and their resident representatives (RRs) received written notice of hospital transfers, including the reason for the transfer, in a language and manner they could understand for three (3) of four (4) residents reviewed for discharges and hospitalization. Resident #1, Resident #3, and Resident #98. Findings include:A review of the facility's policy, Transfer and Discharge, dated 11/1/2016, revealed, .(Proper Name of Facility) shall permit each Resident to remain at the Center, and not transfer or discharge the Resident from the Center except in accordance with Federal and State laws.Procedure.Notice Requirements 4. Before (Proper Name of Facility) transfers or discharges the Resident, it shall notify the Resident and the Resident's Representative of the basis for the or discharge in a language and manner they understand.5.Notice may be made as soon as practicable before a transfer or discharge when.An immediate transfer is required by the Resident's urgent medical needs.Resident #1A record review of the admission Record revealed the facility admitted Resident #1 on 3/20/2026 with current diagnoses including Diabetes Mellitus.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/24/26 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact.A record review of the Progress Notes revealed Resident #1 was transferred to the hospital on 2/12/26, 3/15/26, 4/10/26, 4/19/26, and 5/10/26. A review of Resident #1's medical record revealed there was no documentation indicating the resident or the RR received written notification of the transfers that occurred on 2/12/26, 3/15/26, 4/10/26, 4/18/26, and 5/10/26.On 5/20/26 at 8:00 AM, during an interview with the RR for Resident #1, she reported she received telephone notification regarding the hospital transfers but did not receive written notification explaining the reason for the transfers.Resident #3A record review of the admission Record for revealed the facility admitted Resident #3 on 1/15/26 and she had current diagnoses including Diabetes Mellitus.A record review of the Quarterly MDS with an ARD of 4/22/26 revealed Resident #3 had a BIMS score of 15, which indicated the resident was cognitively intact.A record review of the Progress Notes revealed Resident #3 was transferred to the hospital on [DATE], 12/19/25, and 12/25/25.A review of Resident #3's medical record revealed there was no documentation indicating the resident or the RR received written notification of the transfers that occurred on 12/1/25, 12/19/25, and 12/25/25.On 5/20/26 at 9:35 AM, during an interview with the RR for Resident #3, the representative explained that she had been notified by phone each time the resident was transferred, but she did not receive any type of written notification explaining the reason for the transfers.Resident #98A record review of the admission Record revealed the facility admitted Resident #98 on 4/1/26 and he had current diagnoses including Hemiplegia and Hemiparesis Following Cerebral Infarction.A record review of the Comprehensive MDS with an ARD of 4/8/26 revealed Resident #98 had a BIMS score of 9, which indicated the resident's cognition was moderately impaired.A record review of the Progress Notes revealed Resident #98 was transferred to the hospital on 5/2/26.A review of Resident #98's medical record revealed there was no documentation indicating the resident or the RR received written notification of the transfer that occurred on 5/2/26.On 5/20/26 at 8:57 AM, during an interview with the Business Office Manager (BOM), she reported she was responsible for sending bed-hold letters to families but was not responsible for sending written notifications explaining the reason residents were transferred to the hospital.On 5/20/26 at 9:29 AM, during an interview with the Social Services Director (SSD), she reported she was unaware she was responsible for sending written notifications to resident representatives explaining the reason for hospital transfers. The SSD explained she routinely sent notifications to the Ombudsman regarding hospital transfers and discharges.On 5/20/26 at 11:00 AM, during an interview with the RR for Resident #98, she stated she had not received any type of written notification explaining the reason for the resident's transfer to the hospital. She said that she was notified by phone on the day he was transferred and was told the reason for the transfer at that time. On 5/20/26 at 1:30 PM, during an interview with the Director of Nursing (DON), she reported the facility was expected to provide written notification to resident representatives when residents were transferred to the hospital. The DON confirmed there was no documentation indicating that written notifications of transfers were provided for Resident #1, Resident #3, or Resident #98.On 5/20/26 at 1:44 PM, during an interview with the Administrator, she reported staff were expected to follow the facility transfer notification policy and ensure resident representatives received written notification of hospital transfers.

Based on observation, interview, record review, and facility policy review, the facility failed to timely develop a comprehensive care plan with interventions related to an indwelling catheter placement for one (1) of (20) sampled residents reviewed for care planning. Resident #92. Findings include:A review of the facility's policy, Care Plans, dated 10/2025, revealed, .Care plans will be developed for all patients and residents.Care plans are developed by the interdisciplinary team.A record review of the Care Plan Report revealed Resident #92 had a care plan Focus of The resident has.Foley Catheter RT (related to) Obstructive Uropathy and Reflux Uropathy initiated on 5/4/26. The care plan included multiple interventions related to catheter care and monitoring, all initiated on 5/4/26.A record review of Section H of the Discharge - Return Anticipated Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/21/26 revealed Resident #92 did not have an indwelling catheter when discharged from the facility to an acute care hospital.A record review of the Discharge Summary from the acute care hospital, dated 2/25/26, revealed Resident #92 had instructions for .Foley (indwelling catheter) being kept in place for discharge.A record review of the facility's Progress Note, dated 2/26/26, revealed Resident #92 returned to the facility from the acute care hospital and included, Resident with Foley catheter in place.A record review of Resident #92's medical record revealed there was no documentation of physician orders related to indwelling catheter care or monitoring from the resident's return to the facility on 2/26/26 until 5/8/26, approximately ten (10) weeks after returning to the facility.A record review of the Order Summary Report revealed Resident #92 had Physician's Orders, dated 5/4/26 for a Foley catheter.A record review of the May 2026 Treatment Administration Record revealed indwelling catheter care for Resident #92 was initiated on 5/4/26. This was the first documentation identified related to catheter care, monitoring, or placement since Resident #92 returned to the facility on 2/26/26.On 5/21/26 at 10:40 AM, during an interview with the Director of Nursing (DON), she confirmed Resident #92 did not have a Foley (indwelling catheter) prior to hospitalization and the catheter was placed during the resident's February 2026 hospital stay. The DON confirmed a care plan related to the indwelling catheter was not developed until 5/4/26 despite the resident returning to the facility on 2/26/26 with the catheter in place and it had remained in place. The DON stated her expectation was for staff to develop care plans timely.On 5/21/26 at 2:30 PM, during an interview with the Administrator, she stated her expectation was for care plans to be developed timely to reflect the resident's current condition.A record review of the admission Record revealed the facility admitted Resident #92 on 5/17/21 with diagnoses including Obstructive Uropathy and Reflux Uropathy. The record further revealed an onset date of 5/4/26 for the diagnoses.A record review of the Quarterly MDS with an ARD of 5/18/26 revealed Resident #92 had a Brief Interview for Mental Status (BIMS) score of (15), which indicated the resident was cognitively intact.

Based on staff interview, record review, and facility guideline review, the facility failed to revise the comprehensive care plan to reflect Resident #29's current diabetic management orders and interventions for one (1) of (20) sampled residents reviewed for care plans. Resident #29.Findings include:A review of the facility's Care Plans guideline, dated 10/2025, revealed, .Care plans are developed.and revised as needed according to resident and patient status or change.A record review of the Care Plan Report revealed Resident #29 had a focus area for Alteration in Blood Glucose due to: Hyperglycemic Episodes, DX OF TYPE 2 DIABETES MELLITUS, initiated on 3/15/24 and revised on 6/26/24. Further review revealed interventions including ACCU Checks PRN, accuchecks bid. Notify provider if BG is less than 70 and greater than 450 mg/dL two times a day for DM, and Accuchecks PRN. Notify provider of BG 70 and >400. A comparison of the care plan interventions to the active physician orders revealed Resident #29 did not have physician orders for accuchecks as needed (PRN) or accuchecks twice daily (BID). A comparison further revealed the care plan contained conflicting blood sugar notification parameters of greater than 450 mg/dL and greater than 400; however, the active physician orders did not contain instructions regarding when nursing staff should notify the physician or nurse practitioner for abnormal blood sugar results. Further review revealed care plan interventions including ADMINISTER GLUCAGON INJECTION AS ORDERED, Glucagon HCl Injection Solution Reconstituted 1 MG (Glucagon HCl) Inject 1 mg intramuscularly as needed for hypoglycemia give if BG is less than 70 and unresponsive, and Gvoke HypoPen 1-Pack Subcutaneous Solution Auto-injector 1 MG/0.2ML (Glucagon) Inject 1 application subcutaneously as needed for Hypoglycemia / Unresponsive. A comparison of the care plan interventions to the active physician orders revealed the active physician order for Gvoke did not contain blood sugar parameters, symptom parameters, or instructions indicating the resident should be unresponsive prior to administration. A record review further revealed interventions directing staff to observe for signs and symptoms of high and low blood sugar and report signs and symptoms of advanced hypoglycemia to nursing and the physician, however there was no documentation in the medical record indicating this was being done. A record review of the Order Summary Report revealed Resident #29 had physician orders dated 3/2/26 related to Type 2 Diabetes Mellitus for NovoLOG FlexPen Subcutaneous Solution Pen-injector 100 units/mL (Insulin Aspart) with blood sugar (BS) checks three (3) times daily, Dapagliflozin Propanediol Oral Tablet 10 milligrams (mg) daily, and Lantus Subcutaneous Solution 100 units/milliliter (mL) inject 70 units subcutaneously daily. Further review revealed Resident #29 had a physician order dated 3/2/26 for Gvoke PFS Subcutaneous Solution Prefilled Syringe 1 mg/0.2 mL (Glucagon), to inject one (1) syringe subcutaneously as needed for hypoglycemia related to Type 2 Diabetes Mellitus with Diabetic Neuropathy.A review of Resident #29's medical record revealed there was no documentation indicating staff were observing Resident #29 for signs and symptoms of high and low blood sugar and reporting signs and symptoms of advanced hypoglycemia to nursing and the physician.On 5/20/26 at 1:30 PM, during an interview with Registered Nurse (RN) #1/Minimum Data Set (MDS) and care plan nurse, she stated she was responsible for revising resident care plans. RN #1 reviewed Resident #29's care plan regarding alteration in blood glucose and the current physician orders and confirmed the care plan had not been revised to reflect the resident's current physician orders. RN #1 stated she had been reviewing resident care plans and comparing them to physician orders but had not yet reviewed Resident #29's care plan. RN #1 confirmed a nurse administering medications would not have been able to accurately follow the care plan because the care plan contained conflicting instructions.On 5/20/26 at 2:00 PM, during an interview and record review with the Director of Nursing (DON), she reviewed Resident #29's physician orders and care plan and confirmed the care plan was not accurate and had not been revised to reflect the resident's current physician orders. The DON stated the nurses would have been unable to follow the care plan because it contained conflicting parameters and orders that were no longer active.On 5/20/26 at 4:30 PM, during a phone interview with Licensed Practical Nurse (LPN) #1, she stated she did not review Resident #29's care plan before, during, or after administration of glucagon on 5/19/26 because she was focused on the resident's condition and satisfied with the resident's response after the glucagon administration.A record review of the admission Record revealed the facility admitted Resident #29 on 1/19/25 with diagnoses including Diabetes Mellitus (DM).A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/31/26 revealed Resident #29 had a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact.

Based on observation, interviews, record review, and facility policy review, the facility failed to store oxygen tubing and a nasal cannula in a manner to prevent possible contamination and respiratory complications for one (1) of (1) residents reviewed for respiratory care. Resident #29. Findings include:A review of the facility's policy, Oxygen Guideline, dated 8/1/2024, revealed, .Medical oxygen.is provided in accordance with a health care provider's order and in accordance with acceptable standards of practice.A record review of the admission Record revealed the facility admitted Resident #29 on 1/19/25 with diagnoses including Diabetes Mellitus (DM).A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/31/26 revealed Resident #29 had a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact.A record review of the Order Summary Report revealed Resident #29 had a physician order dated 5/8/26 for Oxygen at 2L (liters) per nasal cannula for decreased oxygen saturation PRN (as needed) for decreased saturation.On 5/18/26 at 10:45 AM, during an observation, Resident #29 was sleeping in bed. Oxygen signage was observed on the resident's door. Resident #29 was not wearing the nasal cannula at the time of the observation. An oxygen concentrator was in the resident's room with the nasal cannula tubing lying on top of the concentrator with the nasal cannula exposed and not stored in a protective bag.On 5/20/26 at 2:45 PM, during an observation and interview, Resident #29 was in bed and stated he had not worn his oxygen in a couple of weeks. The oxygen concentrator remained in the room with the tubing lying on top of the concentrator and the nasal cannula exposed and not stored in a protective bag.On 5/20/26 at 3:00 PM, during an observation and interview with the Director of Nursing (DON), she confirmed the oxygen tubing and nasal cannula were stored with the nasal cannula exposed. The DON explained the tubing should have been stored in a bag. The DON stated she expected staff to ensure nasal cannula tubing was stored appropriately and reported Resident #29's oxygen was ordered PRN and she would have the oxygen concentrator removed from the room.

Based on interview, record review, and facility policy review, the facility failed to provide treatment and services according to professional standards of practice by failing to monitor, assess, and provide appropriate follow-up for abnormal blood sugar results, insulin holds/refusals, and glucagon administration for Resident #29 and by failing to timely implement physician orders related to indwelling catheter management for Resident #92 for two (2) of (20) sampled residents reviewed for treatment and services. Findings include: A review of the facility's policy, Medication Administration, dated 7/2023, revealed, .Policy: Medications are administered as prescribed, in accordance with good nursing principles and practices.Procedure.When PRN medications are administered, the following documentation is provided.Complaints or symptoms for which the medication was given.If a dose of regularly scheduled medication is withheld, refused.An explanatory note is entered on the reverse side of the record provided for PRN (as needed) documentation. A review of the Patient Information for GVOKE injection revealed, .GVOKE is a prescription medication used: to treat very low blood sugar (severe hypoglycemia).Tell your healthcare provider each time you use GVOKE. Resident #29 A record review of the Order Summary Report revealed Resident #29 had a physician order dated 3/2/26 for NovoLOG FlexPen Subcutaneous Solution Pen-injector 100 units/mL (Insulin Aspart) with blood sugar (BS) checks three (3) times daily. A record review further revealed Resident #29 had an order dated 3/2/26 for Gvoke PFS Subcutaneous Solution Prefilled Syringe 1 mg/0.2 mL (Glucagon), to inject one (1) syringe subcutaneously as needed for hypoglycemia related to Type 2 Diabetes Mellitus with Diabetic Neuropathy. There were no physician order parameters indicating when staff should hold the NovoLOG, notify the physician regarding abnormal blood sugar results, or administer Gvoke. A record review of the May 2026 Medication Administration Record (MAR) revealed Resident #29's NovoLOG FlexPen Subcutaneous Solution Pen-injector 100 units/mL (Insulin Aspart) had routine scheduled insulin administration at 0600 (6:00 AM), 1100 (11:00 AM), and 1700 (5:00 PM). The MAR included chart codes explaining reasons insulin was not administered, including SS (blood sugar levels indicate no insulin needed), 2 (drug refused), 3 (hold/see progress notes), and 7 (other/see progress notes). Further review of the MAR revealed that for the 0600 administration on 5/12/26, 5/14/26, and 5/19/26, chart code SS was documented indicating no insulin was required per sliding scale coverage; however, there was no actual blood sugar result documented on the MAR. A record review of the MAR revealed that for the 0600 administration on 5/15/26 and 5/18/26, chart code 2 was documented indicating the resident refused the medication. A record review of the MAR revealed that for the 1100 administration on 5/3/26, chart code SS was documented indicating no insulin coverage was required. A record review of the MAR revealed that for the 1100 administration on 5/10/26, 5/12/26, and 5/17/26, chart code 2 was documented indicating the resident refused the medication. A record review of the MAR revealed that for the 1100 administration on 5/11/26, chart code 3 was documented indicating the medication was held and to see progress notes. A record review of the MAR revealed that for the 1100 administration on 5/14/26, chart code 7 was documented indicating to see progress notes. A record review of the MAR revealed that for the 1700 administration on 5/12/26 and 5/16/26, chart code 2 was documented indicating the resident refused the medication. A record review of the MAR further revealed one (1) documented administration of PRN Gvoke solution on 5/19/26 at 6:05 AM. A record review of the progress notes and Orders - Administration Note documentation revealed there was no nursing note on 5/3/26 explaining why Resident #29's NovoLOG was not administered at the 1100 scheduled administration time. A record review of the Orders - Administration Note dated 5/10/26 at 11:15 AM revealed, NovoLOG FlexPen.Monitoring Effectiveness. There was no documentation indicating Resident #29 refused the medication, no documentation of education provided to the resident regarding negative outcomes of refusal, and no documentation indicating physician notification. A record review of the Orders - Administration Note dated 5/11/26 at 10:50 AM revealed, NovoLOG FlexPen.Monitoring Effectiveness held BG 54. There was no documentation indicating Resident #29's signs or symptoms of hypoglycemia, interventions implemented, physician or nurse practitioner notification, or follow-up monitoring after the blood sugar result of 54. A record review of the progress notes revealed there was no nursing note on 5/12/26 explaining why Resident #29's NovoLOG was not administered during the 0600 scheduled administration time when chart code SS was documented on the MAR without an actual blood sugar result recorded. A record review of the Orders - Administration Note dated 5/12/26 at 12:55 PM revealed, NovoLOG FlexPen.Monitoring Effectiveness. There was no documentation indicating Resident #29 refused the medication, no documentation of education provided to the resident regarding negative outcomes of refusal, and no documentation indicating physician notification. A record review of the Orders - Administration Note dated 5/12/26 at 4:04 PM revealed, NovoLOG FlexPen.Monitoring Effectiveness. There was no documentation indicating Resident #29 refused the medication, no documentation of education provided to the resident regarding negative outcomes of refusal, and no documentation indicating physician notification. A record review of the progress notes revealed there was no nursing note on 5/14/26 explaining why Resident #29's NovoLOG was not administered during the 0600 scheduled administration time when chart code SS was documented on the MAR without an actual blood sugar result recorded. A record review of the Orders - Administration Note dated 5/14/26 at 12:28 PM revealed, NovoLOG FlexPen.Monitoring Effectiveness. There was no documentation indicating Resident #29's signs or symptoms, interventions, physician notification, or follow-up monitoring. A record review of the Orders - Administration Note dated 5/15/26 at 5:11 AM revealed, NovoLOG FlexPen.Monitoring Effectiveness BS is 65. There was no documentation indicating Resident #29's signs or symptoms of hypoglycemia, interventions implemented, physician or nurse practitioner notification, or follow-up monitoring after the blood sugar result of 65. A record review of the Orders - Administration Note dated 5/16/26 at 5:12 AM revealed, NovoLOG FlexPen.Monitoring Effectiveness. There was no documentation indicating Resident #29 refused the medication, no documentation of education provided to the resident regarding negative outcomes of refusal, and no documentation indicating physician notification. A record review of the Orders - Administration Note dated 5/17/26 at 11:21 AM revealed, NovoLOG FlexPen.Monitoring Effectiveness refused bc (because) bs 81. There was no documentation indicating physician or nurse practitioner notification regarding the resident refusing scheduled insulin administration. A record review of the Orders - Administration Note dated 5/18/26 at 5:00 AM revealed, NovoLOG FlexPen.Monitoring Effectiveness. There was no documentation indicating Resident #29 refused the medication, no documentation of education provided to the resident regarding negative outcomes of refusal, and no documentation indicating physician notification. A record review of the Orders - Administration Note dated 5/19/26 at 6:05 AM revealed, Gvoke PFS Subcutaneous Solution Prefilled Syringe 1 MG/0.2ML Inject 1 syringe subcutaneously as needed for hypogylemia related to TYPE 2 DIABETES MELLITUS WITH DIABETIC NEUROPATHY, UNSPECIFIED (E11.40). A record review of the General Notes dated 5/19/26 at 6:05 AM revealed, Resident hypoglycemic BS66, Gvoke given. BS up to 105. There was no documentation indicating physician or nurse practitioner notification, Resident #29's signs or symptoms of hypoglycemia, or rationale for administration of glucagon rather than oral intervention. On 5/20/26 at 2:00 PM, during an interview and record review with the Director of Nursing (DON), she reviewed Resident #29's physician orders. The DON reviewed the MAR documentation and acknowledged there were entries that required further explanation, such as with chart code SS without actual blood sugar results documented, a blood sugar result of 54 without documentation of physician notification, holding and not administering insulin without physician notification, resident refusing without physician notification, and administration of glucagon on 5/19/26 without documentation indicating physician notification or the resident's signs and symptoms. She explained nurses remained responsible for administering medications according to standards of care. The DON stated nurses may have been afraid to administer insulin if the resident's blood sugar was low; however, the nurses should have contacted the physician for further orders. The DON stated nurses should monitor for signs and symptoms of hypo/hyperglycemia every shift and document. The DON stated if a fasting glucose level was low and the resident was awake, staff would typically provide food to attempt to increase the resident's blood sugar. On 5/20/26 at 4:30 PM, during a phone interview with Licensed Practical Nurse (LPN) #1, she stated Resident #29's blood sugar had been running in the lower range recently. LPN #1 stated the resident's blood sugar had been in the 70s on previous mornings and when the blood sugar registered in the 60s on 5/19/26, the resident was trembling and not himself, so she administered the glucagon to raise the resident's blood sugar quickly. LPN #1 stated she was uncomfortable with the resident's blood sugar being that low and with the symptoms the resident displayed. LPN #1 stated the resident's blood sugar increased after glucagon administration and the resident returned to his normal baseline. LPN #1 stated there were no instructions on the MAR indicating a specific blood sugar level or symptoms required before glucagon administration. LPN #1 stated she did not notify the physician or nurse practitioner because the resident's blood sugar improved and there were no MAR instructions directing her to notify the physician or nurse practitioner. On 5/21/26 at 10:15 AM, during an interview with the Nurse Practitioner (NP), she stated she preferred to be notified when a resident's blood sugar was less than 70 or greater than 400. The NP stated she would like Gvoke to be administered for blood sugar results less than 70 and believed the facility would be adding those instructions to the administration order for Resident #29. The NP explained that the facility staff should document actual blood sugar results, including an explanation of why insulin was not administered as ordered, and notify her anytime a medication is held. She also requested to be notified when residents refuse medications such as insulin so she could provide education to the residents and/or their responsible representatives. A record review of the admission Record revealed the facility admitted Resident #29 on 1/18/25 with diagnoses including Diabetes Mellitus (DM). A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/31/26 revealed Resident #29 had a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact. A review of Section N revealed Resident #29 received seven (7) insulin injections during the seven (7) day look-back period. Resident #92 A record review of Section H of the Discharge – Return Anticipated MDS with an ARD of 2/21/26 revealed Resident #92 did not have an indwelling catheter when discharged to an acute care hospital. A record review of the Discharge Summary from the acute care hospital, dated 2/25/26, revealed Resident #92 had instructions for .Foley (indwelling catheter) being kept in place for discharge. A record review of the facility's Progress Note, dated 2/26/26, revealed Resident #92 returned to the facility from the acute care hospital and included, Resident with Foley catheter in place. A record review of Resident #92's medical record revealed there was no documentation indicating indwelling catheter care or monitoring from the date the resident returned to the facility on 2/26/26 until 5/4/26, approximately ten (10) weeks after returning to the facility. A record review of the Order Summary Report revealed Resident #92 had Physician's Orders, dated 5/4/26 for a Foley catheter. A record review of the May 2026 Treatment Administration Record revealed indwelling catheter care for Resident #92 was initiated on 5/4/26. This was the first documentation identified related to catheter monitoring and placement since Resident #92 returned to the facility on 2/26/26. On 5/21/26 at 11:15 AM, during an interview with the Director of Nursing (DON), she stated the charge nurse was responsible for entering physician orders into the system following a resident's return from the hospital. The DON confirmed Resident #92's catheter was placed during the hospitalization from 2/21/26 through 2/26/26 and remained in place after the resident returned to the facility. The DON stated staff were monitoring and emptying the catheter; however, she was unable to explain why facility staff did not identify there was no documentation area for catheter monitoring or care and no physician orders related to the indwelling catheter until 5/4/26. The DON confirmed no physician orders related to the catheter, catheter monitoring, or catheter care were entered into the computer system until 5/4/26. On 5/21/26 at 2:30 PM, during an interview with the Administrator, she stated physician orders should have been entered into the system upon Resident #92's return from the hospital in February 2026. The Administrator stated the receiving nurse was responsible for entering orders and the unit manager was responsible for supervising the process to ensure orders were properly entered. The Administrator further stated if discharge orders were incomplete or were in question, nursing staff should have contacted the hospital to clarify physician instructions. A record review of the admission Record revealed the facility admitted Resident #92 on 5/17/21 with diagnoses including Obstructive Uropathy and Reflux Uropathy. The record further revealed an onset date of 5/4/26 for the diagnoses. A record review of the Quarterly MDS with an ARD of 5/18/26 revealed Resident #92 had a Brief Interview for Mental Status (BIMS) score of (15), which indicated the resident was cognitively intact.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident's call light remained accessible and within reach for one (1) of (20) sampled residents reviewed for call light accessibility. Resident #77.Findings include:A review of the facility's policy, Nurse Call Policy, dated 9/1/2014, revealed, .Guidelines.2. Each cord needs to be visible and reachable by the resident which it operates for.4. Any component that does not function should be repaired as soon as practically feasible.A record review of the admission Record revealed the facility admitted Resident #77 on 1/18/24 with diagnoses including Dementia.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/8/26 revealed Resident #77 had a Brief Interview for Mental Status (BIMS) score of (13), which indicated the resident was cognitively intact.On 5/18/26 at 11:51 AM, during an observation and interview, Resident #77's call light string was observed out of the resident's reach. Resident #77 stated the string was out of reach and she would not have been able to call for assistance if needed. The call light system required the resident to pull the string to activate the call light outside the resident's room and at the nurses' station.On 5/18/26 at 12:04 PM, during an observation and interview, Certified Nursing Assistant (CNA) #1 entered Resident #77's room and picked the call light string up from the floor. The call light string did not have a clip attached to the end. CNA #1 explained the clip must have fallen off and without a clip, the call light string would not attach to the resident's clothing or bedding. CNA #1 reported the string may have fallen out of reach while she was adjusting the bed. She was unable to recall how long the clip had been missing from the call light string. There was no clip visible on the floor or near the bed.On 5/20/26 at 2:34 PM, during an interview, CNA #2 stated staff were trained to ensure residents' call lights remained within reach when exiting resident rooms and to ensure resident needs were addressed prior to leaving the room.On 5/21/26 at 11:04 AM, during an interview, the Director of Nursing (DON) stated nursing staff were responsible for reporting equipment concerns to maintenance and could submit requests through the Technology for Equipment and Life Safety (TELS) work order system in the electronic health record.On 5/21/26 at 11:35 AM, during an interview, the Housekeeping/Maintenance Director (HM) #1 stated call light systems were checked monthly, and staff could submit maintenance requests verbally or through the TELS system. HM #1 stated no maintenance request had been verbally received or received in TELS regarding repair of Resident #77's call light and explained that maintenance requests submitted through the TELS system generated immediate notifications to his cellular phone.On 5/21/26 at 2:37 PM, during an interview, the Administrator stated staff were expected to report maintenance concerns through the appropriate process and ensure Resident #77's call light clip was replaced. The Administrator stated staff should have monitored Resident #77 more frequently until the call light clip was repaired.

Based on observation, interview, facility policy review and record review, the facility failed to implement Enhanced Barrier Precautions (EBP) and infection prevention and control practices for one (1) of six (6) sampled residents. (Resident #2) Findings include:Record review of the Infection Control Guide policy dated 2025 revealed, .Enhanced Barrier Precautions refers to the expanded use of PPE (personal protective equipment) and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing.residents with wounds.are especially high risk.On 03/17/2026 at 10:40 AM, during an observation of wound care for Resident #2, no signage for EBP was noted on the door. Licensed Practical Nurse (LPN) #1 performed wound care while wearing gloves but did not don (put on) a gown during care. The resident was noted to have a sacral wound with a large amount of grayish drainage and strong odor. LPN#1 performed hand hygiene; however, handwashing duration was observed to be approximately 10 seconds during care and 7 seconds after completion of care.On 03/17/2026 at 10:55 AM, during an interview, the Nurse Practitioner (NP) stated she was aware the resident had a draining wound and a Foley catheter but did not order EBP, stating nursing staff typically initiate those precautions. The NP confirmed the resident had been readmitted from home with a worsening pressure ulcer that progressed from stage 3 to stage 4 and that a wound culture revealed heavy growth of Escherichia coli and Proteus mirabilis, for which Ciprofloxacin was initiated.On 03/17/2026 at 11:00 AM, during an interview Registered Nurse (RN) #1, confirmed that EBP should be implemented for all wound care, especially for advanced pressure injuries, to promote healing and prevent infection. She stated the nurse providing wound care is responsible for following physician orders and applying evidence based wound care standards during each treatment. RN # 1 further stated that failure to implement EBP could result in delayed healing, worsening of the wound, or development of infection.On 03/17/2026 at 11:15 AM, during an interview, the Licensed Nursing Home Administrator (LNHA) acknowledged that based on the resident's condition, including sacral pressure injuries and documented infection requiring antibiotic therapy, the LPN should have ensured that Enhanced Barrier Precautions wound care practices were consistently implemented during each dressing change. The LNHA stated that oversight by the RN includes monitoring wound progression, ensuring orders are followed, and verifying that licensed staff are performing wound care according to current standards of practice.Record review of labs results revealed a wound culture collected on 03/10/2026 with results reported on 03/13/2026 showing heavy growth of Escherichia coli and Proteus mirabilis. On 03/17/2026 at 2:45 PM, during an interview Licensed Practical Nurse (LPN) #1 revealed she was responsible for completing wound care treatments as ordered. She stated she typically uses gloves and follows standard precautions but did not identify the requirement for additional transmission-based precautions related to wound care. LPN #1 acknowledged there was no EBP signage posted on the resident's door at the time wound care was provided. LPN #1 confirmed she did not wear a gown during the dressing change. LPN #1 stated she was not aware that a gown was required for this resident during wound care despite the presence of a Stage 3 and Stage 4 pressure injury and wound infectionRecord review of the Order Summary Report with active orders as of 3/17/26 revealed an order dated 3/12/26 for 18 French foley catheter for urinary incontinence and wound healing. An additional order dated 3/18/26 revealed Clean stage 4 pressure injury to the sacrum and 3/13/26. There was also an order dated 3/13/2026 for Ciprofloxacin 250 mg (milligrams) by mouth twice daily for 14 days.Record review of Resident # 2's admission Record revealed an admission date of 03/04/2026 with a prior admission date of 11/18/2025 with diagnoses that included cerebral infarction due to embolism of the left carotid artery.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/10/26 revealed the resident is rarely/never understood and staff completed the mental status assessment. Section M indicated the resident had unhealed pressure ulcers/injuries

Based on observation, interviews, record review, and facility policy review, the facility failed to provide supervision to prevent a resident-on-resident altercation when Resident #61 wandered into another resident's room, which resulted in Resident #61 receiving a hematoma to her forehead and an emergency department (ED) visit for one (1) of 22 sampled residents, Resident #61. Findings included: A record review of the facility's Investigation Template, dated 11/11/2024, revealed that at approximately 6:20 AM on 11/11/2024, a floor tech summoned help to Resident #91's room. Staff found water on the floor, a water pitcher spilled, and Resident #91 sitting on her bed holding her purse. Resident #91 stated she thought a man was trying to take her belongings and said she protected herself. Resident #61 was removed from the room and was noted to have a hematoma on the left side of her forehead and redness on the left side of her face. Resident #61 was assisted to her room and transported to a local hospital's ED. A record review of the local hospital's ED report, dated 11/11/2024, revealed that Resident #61 arrived at the ED at 4:51 PM and was discharged at 5:35 PM .History: Head Injury: Another resident at nursing home hit pt (patient) on head (upper eyebrow) .Review of Systems . Positive for wound (hematoma to left forehead) .Final diagnoses .Contusion of forehead, injury of head . On 12/15/2024 at 10:12 AM, during an observation of Resident #91's room where the altercation with Resident #61 occurred, there was a stop sign with a Velcro closure across the width of the door. During an interview with Resident #69 (Resident #91's roommate) she reported that she did not see the altercation between her roommate and Resident #61 because she was asleep. She reported that Resident #61 occasionally entered their room but stated the incidents decreased after the stop sign was installed. On 12/16/2024 from 9:30 AM to 10:00 AM, during an observation, Resident #61 was observed wandering throughout the facility, sleeping in hallways where she does not reside. Staff redirected her to her hallway after approximately 30 minutes. On 12/18/2024 at 9:50 AM, during an interview, the Administrator stated she was informed of the incident that occurred on 11/11/2024 by the DON and it was discussed during the facility's daily Stand-Up meeting. Staff determined interventions such as implementing stop signs and monitoring Resident #61 upon waking should be added. On 12/18/2024 at 11:13 AM, during an interview, the Floor Tech stated that on 11/11/2024 at 6:20 AM, he heard a commotion from Resident #91's room. Upon entering, he saw Resident #91 on her bed and Resident #61 in her wheelchair. He reported that a Training Center Account Manager (TCAM) assisted with removing Resident #61 and cleaning the water on the floor. On 12/18/2024 at 11:16 AM, during an interview, the TCAM stated she entered D-Hall at approximately 6:20 AM and saw the Floor Tech cleaning water. She stated she removed Resident #61 from Resident #91's room and heard Resident #91 say, Get out, get out, you don't belong in here. On 12/18/2024 at 11:40 AM, during an interview, Registered Nurse (RN) #3 stated she was informed of the incident during her medication pass. She reported the incident to the DON and Nurse Practitioner, completed an incident report, and performed neurological checks. On 12/18/2024 at 11:50 AM, during an interview, the DON stated she was informed of the incident before arriving at the facility. She ensured residents were separated, reported the incident to the State Agency, and started an investigation. She confirmed the implementation of stop signs on doors of residents who complained about Resident #61 entering their rooms. A record review of the facility's Admission Record revealed the facility admitted Resident #61 on 10/30/2020 with diagnoses including Unspecified Dementia. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/02/2024 revealed staff assessed Resident #61's cognitive status as severely impaired.

Based on observation, interviews, record review, and facility policy review, the facility failed to develop care plans related to a Continuous Positive Airway Pressure (CPAP) machine (Resident #2) and an indwelling catheter (Resident #74) for two (2) of 22 sampled residents. Findings included: A record review of the facility's policy Comprehensive Care Plan dated May 1, 2012, revealed, Standard: Social services staff and/or designee will participate in the development of a comprehensive care plan for each resident. Practice Guidelines: 1. The interdisciplinary care plan is implemented to guide healthcare center staff in the provision of necessary care and services to obtain and maintain the highest practical physical, mental, and psychosocial well-being of the resident and promotion of the resident and family in planning care . Resident #2 A record review of the Discharge Summary, dated 11/27/2024, for Resident #2 revealed, .There was concern for obstructive sleep apnea .11/25 (2024) .will have to have outpatient referral for sleep study .11/27 (2024) - sleep study referral placed and pcp (Primary Care Provider) follow-up placed, both should be addressed by facility with in a week of discharge .Other Obstructive sleep apnea syndrome Will order cpap at night .Final Active Diagnoses .Obstructive sleep apnea syndrome .Follow Up .needs sleep study referral . The medical record revealed no care plan was developed for the diagnosis of obstructive sleep apnea, including the referral for a sleep study, or the physician's orders for CPAP usage at night following the resident's return from the hospital on 11/27/2024. During an interview on 12/17/2024 at 10:00 AM, the facility's Nurse Practitioner (NP) expressed concerns about the resident's diagnosis of obstructive sleep apnea and the CPAP not being initiated as directed. She emphasized the care plan needed to be updated appropriately. During an interview on 12/17/2024 at 10:30 AM, the Director of Nursing (DON) acknowledged a breakdown in communication and emphasized the importance of verifying hospital discharge orders to support continuity of care. She confirmed the facility policy requires admitting nurses to enter all clinical data timely upon admission or readmission. During an interview on 12/17/2024 at 10:45 AM, Licensed Practical Nurse (LPN) #1 confirmed the facility failed to follow hospital discharge orders related to CPAP usage and did not develop interventions for obstructive sleep apnea in Resident #2's care plan. A record review of the Admission Record revealed the facility admitted Resident #2 on 09/25/2023 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD). Resident #74 During an observation on 12/15/2024 at 11:54 AM, Resident #74 was observed with an indwelling catheter with clear yellow urine flowing into an uncovered drainage bag. A record review of the Progress Notes revealed Registered Nurse (RN) #1 placed an 18 French indwelling catheter for Resident #74 on 08/14/2024 at 3:30 PM. A review of the Comprehensive Care Plan revealed there was no care plan with interventions developed for the indwelling catheter for Resident #74. A record review of the Admission Record revealed the facility admitted Resident #74 on 08/12/2022 with diagnoses including a Stage 4 Pressure Ulcer of the Sacral Region. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/24/2024 revealed Resident #74 had a Brief Interview for Mental Status (BIMS) score of four (4), indicating severe cognitive impairment. Further review revealed she had an indwelling catheter. During an interview on 12/16/2024 at 11:22 AM, the DON confirmed the facility failed to develop a comprehensive care plan for the catheter care. She explained the care plan ensures continuity of care and stated care plans must reflect current diagnoses to guide staff effectively. During an interview on 12/16/2024 at 11:27 AM, the Administrator confirmed the failure to develop a comprehensive care plan for the catheter. She stated care plans are essential for guiding staff on the proper care and cleaning of the catheter and emphasized the need for all care areas to be included in the care plan. On 12/18/2024 at 10:00 AM, during an interview, Registered Nurse (RN) #2 confirmed she was responsible for developing Resident #74's care plan. She acknowledged she did not see any orders for the indwelling catheter and did not inquire further. 37415

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure residents' rights to privacy by allowing wandering residents to enter resident rooms without invitation or permission (Resident #5 and Resident #57) and failing to cover a urinary drainage bag (Resident #74) for three (3) of 22 sampled residents. Findings included: A record review of the facility's policy titled Resident Rights & Quality of Life Policy, dated March 13, 2020, revealed, .All patients and residents have the right to a dignified existence, self-determination, and communication with access to people and services inside and outside the center . Procedure: A patient or resident has the right .To personal privacy and confidentiality of personal and clinical records . Resident #5 On 12/15/2024 at 10:37 AM, during an interview, Resident #5 stated that a female resident in a wheelchair often entered her room without permission, during the daytime and nighttime hours. She reported this to staff several times, but the behavior has continued. She explained she kept the door to her room closed at all times, whether she is in her room or not to prevent wandering residents from coming in. On 12/17/2024 at 12:05 PM, during an interview, Licensed Practical Nurse (LPN) #3 reported that Resident #5 often kept her door closed to prevent wandering residents from entering. She explained that while wandering residents frequently entered rooms, Resident #5 had not specifically complained to her about an individual resident. A record review of Resident #5's Admission Record revealed the facility admitted her on 08/15/2023 with diagnoses including Unspecified Mood Affective Disorder. A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/29/2024 revealed in Section C, Resident #5 had a Brief Interview for Mental Status (BIMS) score of twelve (12), indicating moderate cognitive impairment. Further review of Section F revealed it was very important to her to take care of her personal belongings and things and to have a place to lock your things to keep them safe. Resident #57 On 12/15/2024 at 10:25 AM, during an interview, Resident #57 stated that residents frequently entered his room uninvited, rummaging through his belongings. He recounted an incident in July 2024 where a resident rummaged through his snacks, causing him to fall while trying to intervene. On 12/17/2024 at 12:20 PM, during an interview, LPN #3 confirmed that Resident #57 often yelled at wandering residents to leave his room. She explained that one wandering resident had been doing so since admission but had reduced the frequency over time. A record review of Resident #57's Admission Record revealed the facility admitted him on 12/02/2022 with diagnoses including Type 2 Diabetes Mellitus. A record review of the Quarterly MDS with an ARD of 10/17/2024 revealed in Section C Resident #57 had a BIMS score of (15), indicating the resident was cognitively intact. Further review of Section F revealed it was somewhat important to have a place to lock his things and to keep them safe. Resident #74 On 12/15/2024 at 11:54 AM, during an observation, Resident #74's urinary drainage bag was uncovered and visible from the hallway because her door was open. On 12/16/2024 at 11:22 AM, during an observation and interview the Director of Nursing (DON) confirmed that Resident #74's catheter bag was not covered and emphasized the need to cover it to maintain the resident's dignity. On 12/18/2024 at 10:30 AM, during an interview the DON and Administrator acknowledged the facility had several wandering residents and confirmed staff had been educated on redirecting wandering residents to respect others' privacy. They stated that residents' rights to privacy and dignity must always be upheld. A record review of Resident #74's Admission Record revealed the facility admitted her on 08/12/2022 with diagnoses including Stage 4 Pressure Ulcer of the Sacral Region. A record review of the Quarterly MDS with an ARD of 10/24/2024, in Section C revealed a BIMS score of four (4), indicating severe cognitive impairment. Further review of Section H revealed the resident had an indwelling catheter. 37415

Based on observation, interviews, record review, and facility policy review, the facility failed to implement physician orders for the use of a Continuous Positive Airway Pressure (CPAP) machine (Resident #2) and for an indwelling catheter (Resident #74) for two (2) of 22 sampled residents. Findings included: A review of the facility's document, Standards of Practice, dated 12/19/2024 and signed by the Administrator, revealed, The expectation set forth by management is that nurses comply with current standards of practice in terms of following physician's orders . A record review of the facility's policy, Electronic Clinical Records System Timely Admission-Readmission Data Entry, undated, revealed, Guideline: The practice of the center clinicians is to enter specific patient critical and pertinent clinical data and documentation related to the patient's admission or readmission in a timely manner into the patient's electronic record . Processes: 2. Entry of Physician's Orders is the responsibility of the Health Information Management Coordinator (HIMC) and/or the admitting nurse. If Physician's Orders are entered by the admitting nurse, the HIMC is responsible to review orders entered during this stated time period for accuracy Resident #2 A record review of the Admission Record revealed the facility admitted Resident #2 on 09/25/2023, with diagnoses including Chronic Obstructive Pulmonary Disease (COPD). A record review of the Discharge Summary, dated 11/27/2024, for Resident #2 revealed, .There was concern for obstructive sleep apnea .11/25 (2024) .will have to have outpatient referral for sleep study .11/27 (2024) - sleep study referral placed and pcp (Primary Care Provider) follow-up placed, both should be addressed by facility with in a week of discharge .Other Obstructive sleep apnea syndrome Will order cpap at night .Final Active Diagnoses .Obstructive sleep apnea syndrome .Follow Up .needs sleep study referral . Review of the medical record for Resident #2 revealed the new diagnosis of Chronic Obstructive Sleep Apnea, the referral for a sleep study, or a physician's orders for the use of CPAP machine at night was not added to the resident's medical record following the return from the hospital on 11/27/2024. On 12/17/2024 at 10:00 AM, during an interview, the Nurse Practitioner (NP) expressed concerns about the resident's new diagnosis of obstructive sleep apnea and the CPAP directive. She revealed the CPAP order from 11/27/2024 was not implemented by facility staff. On 12/17/2024 at 10:30 AM, during an interview, the Director of Nursing (DON) acknowledged the importance of verifying hospital discharge orders to ensure continuity of care. She confirmed that facility policy requires admitting nurses to enter all clinical data timely. Resident #74 During an observation on 12/15/2024 at 11:54 AM, Resident #74 had a urinary drainage bag hanging at the foot of the bed uncovered. A record review of the Admission Record revealed the facility admitted Resident #74 on 08/12/2022 with diagnoses including a Stage 4 Pressure Ulcer of the Sacral Region. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/24/2024 revealed in Section C Resident #74 had a Brief Interview for Mental Status (BIMS) score of four (4), indicating severe cognitive impairment. Further review of Section H revealed she had an indwelling catheter. A record review of the Progress Notes revealed Registered Nurse (RN) #1 placed an 18 French indwelling catheter for Resident #74 on 08/14/2024 at 3:30 PM. A record review of the electronic medical record revealed there were no Physician's Orders indicating Resident #74 had an indwelling catheter. A record review of the Treatment Administration Records (TARs) from August 2024 to December 2024 revealed there was no documentation indicating the facility completed catheter care. During an interview on 12/16/2024 at 11:00 AM, Registered Nurse (RN) #1 confirmed she placed the indwelling catheter on 08/14/2024 for Resident #74, however, she was helping another nurse. She explained that she did not receive the order from the physician or the Nurse Practitioner and had assumed the other nurse had taken care of it. RN #1 acknowledged it was her responsibility to verify all orders. On 12/16/2024 at 11:27 AM, during an interview, the Administrator, who also served as the Resident Representative (RR) for Resident #74, confirmed the absence of a documented physician's order. She stated the physician's order must be documented in the resident's file and that moving forward, all orders would be written promptly upon receipt. During an interview on 12/17/2024 at 8:22 AM, the DON confirmed the lack of a documented physician's order for the indwelling catheter. She stated verbal orders must be entered into the electronic medical record and emphasized the importance of ensuring orders are recorded properly. 37415

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure sufficient nursing staff to provide nursing and related services to meet residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being for one (1) of four (4) staffing quarters reviewed. Findings included: 1) Cross Reference to F550. 2) Cross Reference to F689. A record review of the facility's policy titled Staffing Requirements for Resident Care, effective March 2023, revealed, The facility must ensure that sufficient nursing staff is present at all times to meet residents' individual care needs and maintain a safe and sanitary environment. A record review of the facility's Payroll-Based Journal (PBJ) Staffing Data Report for Quarter 4, 2024 (July 1 - September 30), revealed excessively low weekend staffing triggered alerts, indicating that submitted weekend staffing data was consistently low compared to weekday staffing data. A record review of the facility's Center Assessment Tool dated 09/23/24 revealed . Other 1.8 . When adjusting staffing for daily care needs, appropriate staff skill set are reviewed to assure that licensed and non-licensed staff are present at all times, 24/7, including nights and weekends, with skills to care for physical and psychosocial needs of patients and residents. Specific staffing needs are based upon individual patients' and residents' diagnosis, care plans, and any change of condition that may have occurred. Patients/residents who may have issues with behaviors are also taken into consideration when staffing is being reviewed . Staffing Plan. 3.2 . Our approach to determine the staffing needs to care for and support our patients and residents, along with the information provided in Section 1.8 above, begins at the bedside. The Administrator facilitates the coordination of care needed each day with the interdisciplinary team. The care team evaluates the resident/patient population and acuity as well as center layout to determine the number of team members needed to provide care and services to the patients/residents . Position Total Number Needed or Average or Range Licensed nurses providing direct care 5 on days, 4 on evenings, Nurse aides 10 on days, 8 on evenings, 7 on nights . On 12/15/2024 at 10:30 AM, during an interview with Certified Nurse Aide (CNA) #1, she reported having 16 residents to care for that day due to short staffing. She stated that staffing was inconsistent and often insufficient, particularly on weekends. She noted that completing her duties with fewer than six (6) CNAs was challenging. On 12/15/2024 at 10:45 AM, during an interview with Licensed Practical Nurse (LPN) #4, she explained that she usually worked in medical records but had been pulled to cover short staffing. She confirmed that low staffing levels had required many staff members to work extra hours. On 12/16/2024 at 10:50 AM, during an interview with LPN #3, she stated the facility had been short-staffed for several months. She reported working with six (6) CNAs on day shifts and five (5) or fewer on evening shifts, which created difficulties in completing all duties. On 12/18/24 at 10:05 AM, during an interview with the Director of Nursing (DON), she confirmed that she was aware of the low staffing issues and reported she has not been able to have the staffing she desires for the facility. On 12/18/2024 at 10:15 AM, during an interview and record review of the staffing grids with the Workforce Manager, she explained that the facility aimed to staff an average of 10 CNAs on day shifts, seven (7) CNAs on evening shifts, and five (5) CNAs on night shifts. However, staffing had fallen as low as five (5) CNAs on day shifts, four (4) CNAs on evening shifts, and three (3) CNAs on night shifts. The Workforce Manager confirmed that staffing grids for Quarter 4, 2024, showed multiple weekends with low staffing ratios. On 12/18/2024 at 10:40 AM, during an interview with the Administrator, she confirmed that the facility had consistently triggered low staffing alerts on weekends. She outlined ongoing efforts to address staffing shortages, including offering bonuses, recruiting from local vocational schools, and attempting CNA training programs, but acknowledged that staffing challenges remained unresolved.

Based on staff interviews, record review, facility investigation, and policy review, the facility failed to protect a resident from verbal abuse for one (1) of four (4) residents sampled. Resident #1 Findings include: A review of the facility's policy, Abuse, Neglect, Misappropriation Policy, dated January 2019 revealed, .Purpose: To prohibit and prevent abuse, neglect, exploitation, .Definitions .Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance . A record review of the Investigation Template, dated 10/24/2023, revealed on 10/20/23, the Administrator was in her office when she overheard Certified Nurse Assistant (CNA) #1 being disrespectful when yelling at Resident #1 to be still with profanity used. Several other residents heard the encounter with CNA #1 and Resident #1. CNA #1 admitted to using profanity to Resident #1 . Actions taken post investigation: . CNA (Proper Name) was terminated due to poor customer service . A record review of the handwritten statement, dated 10/23/23, and signed by CNA #1 indicated that CNA #1 said to Resident #1, .why don't he stay his ass at the table ., and I know I shouldn't have said that to him. On 11/27/23 at 12:15 PM, during an interview with the Administrator, she confirmed that on 10/20/23, CNA #1 used a loud tone with profanity while speaking to Resident #1. She immediately escorted CNA #1 to clock out and out of the building, placing her on suspension pending the investigation. With the assistance of Registered Nurse (RN) #1 as her witness, the Administrator discussed the incident with CNA #1. CNA #1 admitted to saying, Why don't he stay his ass at the table. The Administrator reported the incident to State Agency (SA), the Medicaid Fraud Control Unit of the Attorney General's Office (AGO), and the local police department. She stated the facility provided in-services regarding abuse prevention and dementia training to all staff and had a Quality Assurance Performance Improvement (QAPI) meeting to discuss the event and what measures would be implemented. During a phone interview on 11/27/23 at 2:10 PM, CNA #1 confirmed that she stated to Resident #1, Stay your ass at the table, because she was trying to redirect him that meal trays were being served. She stated that she couldn't believe what came out of her mouth and she knew better than to curse the resident. CNA #1 confirmed she had attended many in-services on abuse and resident rights before this incident occurred. On 11/27/23 at 2:58 PM, during an interview with Registered Nurse (RN) #1, she revealed on 10/20/23, she assisted the Administrator in escorting CNA #1 out of the building. RN #1 confirmed CNA #1 admitted to cursing Resident #1 to at the dining room table. A record review of the personnel file for CNA #1 revealed a transcript of courses attended, which included courses completed on 8/29/23 of Abuse and Neglect, Abuse Neglect Misappropriation Exploitation Policy, and Elder Justice Act Reporting Requirements. Record review of the Admission Record revealed the facility admitted Resident #1 on 6/28/21 with diagnoses including Alzheimer's Disease and Dementia. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/16/23, revealed a staff interview was required for assessment and his cognitive skills for daily decision making were severely impaired. Based on the facility's implementation of corrective actions on 10/20/23, the State Agency (SA) determined the deficiency to be Past Non-Compliance (PNC) and the deficiency was corrected as of 10/21/23, prior to the SA's first entrance on 11/27/23. Validation: On 11/28/23, the SA validated through staff interviews, record review, and facility policy review the facility began an immediate investigation when the incident occurred. A review of the emergency QAPI meeting minutes revealed the facility held a QAPI meeting on 10/21/23 at 5:16 PM, in which the Infection Preventionist (IP) was out of the facility for this emergency meeting and the Medical Director attended via phone. The SA verified through an interview with the DON and Social Services Director that they attended the QAPI meeting to discuss the situation and the facility policies related to abuse were discussed and no changes needed. The QAPI meeting concluded that the Plan of Correction was to in-service all staff, terminate the employee, and have a resident council meeting. The SA reviewed in-service sign-in sheets that began on 10/20/23 related to abuse prevention and dementia training and the Administrator conducted in-services in which she had every employee sign the policies on abuse prevention and dementia training. On 11/28/23, the SA verified the facility reported the verbal abuse to SA and the AGO on 10/20/23.

Based on observation, interviews, record review and facility policy review the facility failed to remove expired, undated, and spoiled food items from storage areas for one (1) of four (4) kitchen observations. This had the potential to affect all residents in the facility receiving food from the dietary department. Findings include: Review of facility's policy, Food and Supply Storage Procedures, undated, revealed, .Remove from storage any items for which the expiration date has expired . Review of the facility's policy, Food Storage: Dry Goods, revised ,d+[DATE], revealed, All dry goods will be appropriately stored will be appropriately stored in accordance with the FDA Food Code . 5. All packaged and canned food items will be kept clean, dry, and properly sealed. 6. Storage areas will be neat, arranged for easy identification, and date marked as appropriate. Review of facility's policy, Receiving, revised ,d+[DATE], revealed, . 5. All food items will be appropriately labeled and dated wither through manufacturer packaging or staff rotation . On [DATE] at 11:00 AM, during an initial tour of the kitchen with the facility's Cook, an observation of the dry storage area revealed, a 32-ounce bottle of liquid smoke that was opened, undated, without a top and loosely covered with plastic wrap, a one (1) gallon container of salad dressing with an expiration date of [DATE], a one (1) gallon container of barbeque sauce with an expiration date of [DATE], a 16-ounce bag of unsealed marshmallows, dated of ,d+[DATE], and a one (1) gallon container of sliced jalapeno peppers that was opened and had visible biological growth. On [DATE] at 11:47 AM, in an interview with the Cook, he stated all the staff are responsible for removing expired food. She stated the Dietary Aide is responsible for stocking the groceries when delivered and checking expiration dates prior to putting them on the shelves. On [DATE] at 12:29 PM, in an interview with the Dietary Aide, he confirmed he is responsible for checking expiration dates as he receives the food from the delivery truck but stated that all staff should check for expired foods. On [DATE] at 12:35 PM, in an interview with the Dietary Manager (DM), he revealed all staff are responsible for checking for expired foods and removing them from the shelves, as expired foods could cause foodborne illnesses. The DM also noted that when foods are opened, they should be dated and discarded according to their facility policy, which referenced the Food and Drug Administration (FDA) Food Code. On [DATE] 11:18 AM, in an interview with the Administrator, she stated dietary staff should put opened dates on food items as they are opened and make sure they are properly sealed when they are placed on the shelves. The Administrator revealed the Cook and Assistant Cook should read the labels as they pull foods from the shelves and check expiration dates, as expired foods, if contaminated, could lead to foodborne illnesses. The said she expected all dietary staff to make rounds, clean the department, and remove expired foods from the shelves.

Based on interview, observation, record review, and facility policy review, the facility failed to prevent the possible spread of infection when a nurse flushed and administered a medication via a percutaneous endoscopic gastrostomy (peg) feeding tube without wearing gloves for one (1) of three (3) residents reviewed with peg feeding tubes. Resident # 64. Findings Include: A record review of the facility's policy, Policies and Practices-Infection Control, dated 11/1/17, revealed, .This center's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and mange transmission of diseases and Infection . On 04/16/23 at 12:41 PM, during an observation and interview, Licensed Practical Nurse (LPN) #1 was in Resident #64's room using a syringe and water to flush his peg feeding tube. LPN #1 was touching the resident's feeding tube, container of water, and syringe with ungloved hands. She flushed the tube and then administered a liquid medication that she identified as Acidophilus. On 04/16/23 at 01:00 PM, in an interview with LPN #1, she explained that she usually wears gloves when flushing and administering medications through a peg feeding tube. She stated she should wear gloves to protect the resident and herself and that her actions could spread germs to the resident. On 04/19/23 at 09:20 AM, in an interview with the Director of Nursing (DON), she stated LPN #1 should have applied gloves before flushing the tube because it was standard practice and Resident #64 could get multiple infections. A record review of the Admission Record revealed the facility admitted Resident #64 on 2/1/23 and had diagnoses including Cerebral Infarction and Gastrostomy Status. Record review of the Order Summary Report with Active Orders As Of: 04/19/2023 revealed Resident #64 had a Physician's Order, dated 2/4/23, for Lactobacillus (Acidophilus) Oral Capsule .Give 2 capsule via PEG-Tube three times a day .

Based on observation, interview and record review the facility failed to provide percutaneous endoscopic gastrostomy (peg) feeding tube care in a manner to prevent complications for one (1) of three (3) residents reviewed with peg feeding tubes. Resident #64 Findings include: A record review of the facility's Care of a Gastrostomy or Jejunostomy Tube Competency Audit provided by the Director of Nursing (DON) revealed, .Cleansed skin around site with water and soap using gauze . Further review revealed the document did not contain steps for the actual cleansing procedure to include the direction of wipes and the rotation of gauze. A record review of the Order Summary Report, with Active Orders As Of: 04/19/2023 revealed Resident #64 had a Physician's Order dated 8/2/22 to Clean peg tube site with soap and water and leave open to air q (every) shift . On 04/18/23 at 2:20 PM, in an observation of Licensed Practical Nurse (LPN) #2 providing peg feeding tube care to Resident #64, she cleaned the peg feeding tube insertion site with a moistened gauze, using a circular motion wiping four (4) times around the site, without folding or rotating the position of the gauze. LPN #2 rinsed the peg feeding tube insertion site with a clean moistened gauze by folding the gauze after each wipe. She then used a clean dry gauze to dry the site, using a circular motion, wiping four (4) times around the insertion site, without folding or rotating the position of the gauze after each circular wipe. On 04/18/23 at 2:40 PM, in an interview with LPN #2, she confirmed that she cleaned around the peg tube insertion several times with the same gauze and that she should have cleaned one side of the peg site, discarded the gauze, and used a clean gauze each time for cleaning and drying the area. She stated her actions could potentially cause Resident #64 to acquire an infection. On 04/19/2 at 09:31 AM, in an interview with the DON, she stated that LPN #2 should have cleaned the peg feeding tube site by using gauze, discarding, and using a clean gauze with each wipe around the site. She stated LPN #2 had contaminated the peg feeding tube site during cleaning and her actions could put the resident at significant risk for infection. A record review of the Admission Record revealed the facility admitted Resident #64 on 02/01/23 and he had diagnoses including Cerebral Infarction, Unspecified Protein-Calorie Malnutrition, and Gastrostomy.

Based on interview, observation, record review, the facility failed to adhere to accepted standards of practice for the proper storage of a nebulizer mask for two (2) of three (3) observations. Resident # 74 Findings include: During an observation on 04/16/23 at 11:42 AM, Resident #74 was in bed, and his nebulizer mask was noted directly on the floor. There was no visible container designated to store the nebulizer tubing/mask. On 4/16/23 at 2:54 PM, Resident #74 was observed in his bed. His nebulizer mask continued to be on the floor, with no visible container to store the mask to prevent contamination. On 4/16/23 at 3:04 PM, during an interview with Licensed Practical Nurse (LPN) #2, she explained Resident #74 had scheduled nebulizer treatments, but was unsure how often. She stated that the nebulizer mask should be kept in a bag when it is not in use because of infection control. LPN #2 entered Resident #74's room and confirmed the nebulizer mask was lying on the floor. She also confirmed there was no container or designated area to store the mask to prevent contamination. She explained the nebulizer mask was contaminated and that it was not standard practice for the mask to be on the floor. LPN #2 stated that she would get a plastic bag to store the mask and a new mask for the resident's use. On 04/19/23 at 11:00 AM, during an interview with the Director of Nursing (DON), she explained all oxygen tubing and nebulizer equipment should be stored in a plastic bag while not in use. She stated any equipment noted on the floor should be thrown away and replaced and it is not the facility's normal practice or the standard for those items to be on the floor. She expected the staff to observe for any equipment not properly stored and correct the problem. A record review of the Admission Record revealed the facility admitted Resident #74 on 03/01/2023 with diagnoses including Pneumonia and Chronic Obstructive Pulmonary Disease (COPD). A record review of the Order Summary Report with Active Orders As Of: 04/19/2023 revealed Resident #74 had Physician's Orders, dated 3/1/23 for, for Budesonide Inhalation Suspension 0.5 MG(milligram)/2 ML(milliliter) .1 vial inhale orally two times a day for COPD and Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3 ML) 0.083% (Albuterol Sulfate)1 vial inhale orally every 6 hours as needed for SOB (shortness of breath).

Based on observation, interview, record review and facility policy review the facility failed to ensure recommended dental services were provided for one (1) of twenty (20) sampled residents. Resident # 79 Findings include: Review of the facility's policy, Dental/Oral Care dated December 1, 2010, revealed, Purpose To ensure residents receive care and services and attain or maintain the highest level of oral hygiene . Procedure .5. Interdisciplinary Care Team will assess for specific needs and review as indicated .7. Regular and emergency dental care will be provided by contracted services of a dentist. 8. Dentist referrals will be arranged by the Nursing Department or Social Services Departments . During an observation, on 04/16/23 at 10:33 AM, Resident #79 was lying in bed and the right side of his face was swollen. During an interview on 04/17/23 at 10:35 AM, with Resident # 79, he said he had an abscess on his right tooth and he had reported it to the nurse. The resident said that it was painful, but the facility was giving him pain medication. Record review of the facility's Progress Notes revealed an MD (Medical Doctor)/FNP (Family Nurse Practitioner) Note, dated 1/23/23 at 14:32 (2:32 PM) for Resident #79, .1. Extraction of tooth needed .3 .Plavix put on hold. Tooth extraction scheduled for Friday . Record review of the facility's Progress Notes revealed General Notes, dated 1/25/23 at 19:29 (7:29 PM) for Resident #79, .Appointment with (Proper Name of Local Dentist) January 27, 2023 for tooth extraction . Record review of Progress Notes from a local Dentist revealed Resident #79 had a dental examination on 1/27/23 and the provider documented .Felt better and he did also to send him to O.S. (Oral Surgeon) for removal of painful teeth . Record review of the facility's Progress Notes revealed General Notes, dated 2/21/23 at 14:16 (2:16 PM), revealed Resident #79, .patient c/o (complained of) tooth pain .Spoke with CN (Charge Nurse) she stated that she will talk with family member to see if they will come up with a plan to help pay for extraction . Review of General Notes, dated 2/21/23 at 14;28 (2:28 PM), for Resident #79 revealed, .Spoke with (Proper name of Resident Representative) and he said that he should have a Dental plan starting on next month. This nurse asked if he could assist him financially to have the tooth removed .He said that he would go and get him a Milk Shake if he wanted one . Record Review of a Dental Exam, dated 3/21/21, revealed, .Notes .Patient needs a referral to outside dentist for #3 Extraction. #3 has an existing root canal and crown that has present root decay and an abscess . During an interview on 04/17/23 at 02:37 PM, with Registered Nurse (RN) #1, she stated Resident # 79 was seen by the in-house dentist and received seven (7) days of antibiotics. RN #1 said the resident was sent out to a local Dentist who then referred him to an oral surgeon. His tooth was not pulled because his insurance did not cover oral surgery. RN #1 said she spoke to Resident #1's brother asking him to pay for the oral surgery, but he said that he could not pay for the tooth to be removed. During an interview on 04/19/23 at 09:45 AM, with Resident #79's brother, he said the facility called him to inform him that his brother had a bad tooth, his gums were swollen and he had been prescribed antibiotics and pain medication. The brother said he did not have the money to pay for the tooth to be removed and it wasn't covered by insurance. He stated the facility did not say they would help to get another agency to assist with the payment of getting the tooth pulled. During an interview on 04/19/23 at 11:21 AM, with the Social Worker (SW), she said she had been out sick for two (2) weeks and did not know Resident #79 did not have his tooth pulled when he went to the dentist in January. The SW expressed that she did not begin to look for a provider that would accept the resident's insurance until 4/17/23. She had found an oral surgeon and the resident was scheduled for an appointment on 5/4/23. During an interview on 04/19/23 at 01:00 PM, with the Administrator and the Director of Nursing, the DON confirmed the facility failed to send the resident to an oral surgeon because she was not aware that the resident was referred to an oral surgeon. The Administrator said she did not know the resident was referred to an oral surgeon as well. The DON said that the SW had been out sick for two (2) weeks, and no one had followed up to find a surgeon that would take the resident's insurance. A record Review of the Admission Record revealed the facility admitted Resident #79 on 8/11/22 with diagnosis of Cerebral Infarction. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/06/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #79 was cognitively Intact. Review of Section L revealed he had Mouth or facial pain, discomfort or difficulty with chewing.

Based on observation, staff interview, and facility policy review, the facility failed to prevent the likelihood of the spread of Coronavirus (COVID-19) and other infectious diseases as evidenced by the lack of proper Personal Protective Equipment (PPE) use for one (1) of two (2) dietary tours and the lack of proper hand hygiene measures one (1) of two (2) facility tours. Findings include: Review of the facility's Coronavirus (COVID-19) Precaution Plan policy, revealed, the Center COVID-19 Response Team has been activated and will utilize this COVID-19 guidance to minimize/prevent an outbreak in the Center. Healthcare providers working in facilities located in areas with moderate to substantial community transmission: wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters. Review of the facility's policy titled, Hand Hygiene, revealed, handwashing/hand hygiene shall be regarded by this Center as a means of preventing the spread of infections. An observation in the dietary department, on 09/08/2020 at 7:15 PM, revealed, Dietary Staff #1 cleaning dishes and placing them in the sink. She was not wearing face or eye protection. When Dietary Staff #1 noticed this surveyor observing her, she removed a surgical grade mask from her pocket and put it on. During an interview, on 09/08/2020 at 7:17 PM, Dietary Staff #1 removed her mask to speak to this surveyor and stated, that she was a big girl and has trouble breathing with a mask on. She stated that she had asthma when she was a child and used to use an inhaler. She stated, when working in the dietary department, she should be wearing a surgical mask and if she goes out on the floor, she should wear an N-95 mask. Dietary Staff #1 confirmed she should be wearing a mask all the time to prevent the spread of germs. An observation, on 09/08/2020 at 7:15 PM, revealed, Dietary Staff #2 at the sink in the dietary department washing dishes with no face or eye protection on. An observation, on 09/08/2020 at 7:18 PM, revealed, Dietary Staff #2 standing at an opened refrigerator, reaching in and moving items around. Dietary Staff #2 was not wearing any face or eye protection. An interview, on 09/08/2020 at 7:19 PM, with Dietary Staff #2, confirmed she should be wearing a mask. She stated that she has trouble breathing with it on. She stated she should go in the office and take it off for a break. She confirmed she was not in the office and stated, My bad. Dietary #2 stated that not wearing mask could cause her or others to get infected. An observation, on 09/08/2020 at 7:25 PM, revealed, Certified Nursing Assistant (CNA) #1 push a wheelchair bound resident to room [ROOM NUMBER]. She then walked across the hallway to the doorway of room [ROOM NUMBER] and put a glove on her right hand. CNA #1 then went to the soiled closet, got a linen and garbage container, and then got a pink pad from the clean linen and took it into room [ROOM NUMBER]. She exited room [ROOM NUMBER] and placed gloves in the trash can. She then proceeded to get a clean gown and enter room [ROOM NUMBER]. CNA #1 placed the gown on the overbed table in room [ROOM NUMBER] and assisted the resident, then picked up the gown and took it into Room # 9. CNA #1 did not wash her hands or use hand sanitizer at any time during this period of time. An interview, on 09/08/2020 at 7:30 PM with CNA #1, confirmed she should have washed her hands or used hand sanitizer when leaving resident rooms and when removing gloves. She stated that she took the gown into room [ROOM NUMBER]. CNA #1 confirmed that taking things from one room to another could spread germs. She stated she usually uses hand sanitizer all the time but doesn't know why she didn't tonight. An interview, on 09/08/2020 at 7:45 PM, with the Administrator (ADM), revealed, all staff should be wearing N-95 masks and goggles or face shield to protect themselves from each other and to protect the residents. An interview, on 09/09/2020 at 9:20 AM, with Dietary Staff #3, the Director of Culinary Services, revealed, all dietary staff should be wearing a N-95 mask and goggles or a face shield at all times. She stated this was to protect the residents and the employees, and not spread [MEDICAL CONDITION] and cause illness. She stated her staff had attended meetings to be informed of Personal Protective Equipment (PPE) to wear and have been informed when changes were made. An interview, on 09/09/2020 at 1:30 PM, with the Administrator (ADM), revealed, she felt the staff had no excuse for not wearing proper PPE and they knew to wash their hands or use hand sanitizer between each resident contact. She stated they had done so well but, felt the staff had gotten lax. She stated they were going to have to come up with a way to monitor them better. Review of the facility's in-service records, revealed, CNA #1 had received education regarding COVID Update/ Infection Control on 08/20/2020. This education included handwashing instructions for before and after resident or resident belongings contact. Review of the facility's in-service records, revealed, Dietary Staff #1 and #2 received education regarding proper PPE on 08/20/2020 and 08/27/2020.

Based on observation, staff interview, record review and facility policy review, the facility failed to ensure that Resident #68 was free from the use of a physical restraint as evidenced by failure to monitor and release her lap buddy every two (2) hours, for one (1) of three (3) residents reviewed for restraints. Findings Include: A review of the facility's Physical Restraint Application policy, dated November 2017, revealed the purpose of this procedure is to provide safety or postural support of a resident to prevent injury to himself/herself or others. The definition of a physical restraint is defined as any manual or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. The Key Procedural Points included: 7. Written policies and procedures governing the use of restraints specify which staff member may authorize the use of restraints and clearly delineate the following: a. Orders indicate the specific reason, type, and period of time for the use of the restraints. Restraints must be used only as a last resort. 8. Release for care and services as needed. During an observation, on 2/18/2020 at 8:55 AM, Resident #68 was sitting in the front lobby in her wheelchair with a lap buddy restraint secured across her lap. During a continuous observation, on 2/18/2020 from 9:10 AM until 11:40 AM, Resident #68 remained positioned in the wheelchair with the lap buddy in place for greater than two (2) hours with no staff interventions for toileting or releasing the lap buddy. During an interview, on 2/18/2020 at 3:43 PM, Licensed Practical Nurse (LPN) #1 confirmed removing the lap buddy every two (2) hours was on Resident #68's Care Plan, but she had not removed the lap buddy at all that morning. During an interview, on 2/18/2020 at 2:24 PM, Registered Nurse (RN) #1/ Staff Development Nurse stated the nursing staff and the Certified Nursing Assistants (CNAs) are the ones that have the responsibility for removing Resident #68's lap buddy every two (2) hours. During an interview, on 2/18/2020 at 3:13 PM, with the Director of Nursing (DON), she confirmed it is the responsibility of the nurses and the CNAs to remove/release restraints. The DON stated both nurses and CNAs are trained on the use of restraints. The DON confirmed when Resident #68's restraint had not been removed by a staff member every two (2) hours, Resident #68's Care Plan and Medical Doctor (MD)'s orders had not been followed. A review of Resident #68's Care Plan revealed a Focus problem was initiated, on [DATE], for the use of a lap buddy while up in the wheelchair for her safety related to falls. The Interventions included remove the lap buddy every two (2) hours and during meals. Nursing was the designated staff responsible for this intervention. A review of Resident #68's Order Summary Report revealed an order, dated [DATE], for the application of a lap buddy to the resident's wheelchair while she was up in the wheelchair for safety related to (r/t) falls. Further review of the orders revealed an order, dated [DATE]20, to remove the lap buddy every two hours and during meals. Review of the Face Sheet revealed Resident #68 was admitted by the facility, on 11/3/2017, with the included [DIAGNOSES REDACTED]. Review of Resident #68's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/1/2020, and Quarterly MDS with an ARD of 12/12/2019, revealed the resident's Basic Interview for Mental Status (BI[CONDITION]) score was 99, which indicated the interview was not completed. The resident's Cognitive Skills For Daily Decision Making was coded a 3, which indicated the resident never or rarely made decisions. Further review of the MDS revealed Resident #68 was coded for the use of a trunk restraint device daily when up in chair or out of bed. The MDS also revealed Resident #68 required extensive assistance with transfers and bed mobility, was totally dependent on staff with one person physical assist with locomotion on and off the unit, extensive assistance with one person physical assist with dressing and eating, extensive assistance with two person physical assist with toileting, and was totally dependent on staff with one person physical assist with personal hygiene and bathing. The wheelchair was coded as the resident's mobility device. Resident #68 did not have Range of Motion (ROM) deficits of any of her extremities.

Based on observation, staff interview, record review, review of manufacturer's User Guide, review of the Centers for Disease and Control (CDC) Guidelines, and facility policy review, the facility failed to follow standard precautions for infection control during the performance of the routine testing of blood sugars. The facility staff did not clean or disinfect a multi-person use glucometer before, after, or between residents for three (3) of five (5) residents observed who receiving finger stick blood glucose monitoring (Acu-checks), Residents #211, #361, and #365. Residents #211, #361 and #365, all had orders for, and received Acu-checks routinely before meals and at bedtime (AC&HS). Records revealed each of the residents had a current care plan in place to receive the Acu-checks as ordered. Records revealed no current issues with infectious-based diseases of these three (3) residents. Of the 33 residents who received Acu-checks, one (1) resident (on admission to the facilty) had an infectious-based disease. The facility's failure of not following standard precautions for infection control by not providing a clean barrier to place the glucometer, and not disinfecting the glucometer between residents, placed these and other residents who received Acu-checks (33 total residents) in a situation which caused a likelihood of serious injury, harm, impairment, or death, related to the spread of blood-borne pathogens due to cross-contamination with the multi-resident use of the glucometer. The situation was determined to be an Immediate Jeopardy (IJ), which began on 3/12/19, when the facility failed to follow standard precautions of infection control while performing Acu-checks without providing a clean barrier or cleaning/disinfecting the Glucometer before, or after use between three (3) residents. The SA notified the Administrator on 3/13/19, of the IJ. An acceptable Removal Plan was received on 3/14/19, in which the facility alleged all actions were completed on 3/13/19, and the IJ was removed as of 3/14/19. The SA validated the Removal Plan and determined the IJ was removed on 3/14/19, prior to exit. The scope and severity for CFR(s) 483.80 (a)(1)(2)(4)(e)(f), was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of the Center for Disease Control and Prevention guidelines, last updated 6/8/17, regarding shared blood glucose meters, revealed if blood glucose meters were shared, the device should be cleaned and disinfected after every use, per manufacturer instructions, to prevent carry-over of blood and infectious agents. A review of the Infection Prevention and Control Program, dated (MONTH) (YEAR), revealed a section titled, Infection Control Monitoring. The objectives of the policy included providing a safe sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections. The section for Standard Precautions, revealed staff was to ensure that reusable equipment is not used for the care of another resident until it has been appropriately cleaned and single use items are properly discarded. A review of the Facility Policy about Diabetic Care titled, Obtaining a Fingerstick Blood Glucose Level, dated (MONTH) (YEAR), revealed staff were to maintain clean technique, provide a clean barrier, and clean the glucose monitor with approved disinfectant before and after each resident use. A review of the Manufacturer's User Guide for the EvenCareG2 glucose monitor (used by the facility), revealed if the meter is used by a second person, the meter should be disinfected, prior to use. The User Guide listed the appropriate cleansing agents for the monitor. An observation on 03/12/19 at 10:30 AM, revealed Licensed Practical Nurse (LPN) #1 picked up a glucometer from the surface of the medication cart, that was not on a barrier, and entered Resident #365's room to perform an Acu-check. LPN #1 entered the room and placed the glucometer on Resident #365's over bed table without a barrier and without cleaning or disinfecting the glucometer. LPN #1 completed a finger stick Acu-check on Resident #365. After completing the Acu-check on Resident #365, LPN #1 placed the glucometer back on the over bed table with no barrier and without disinfecting it. LPN #1 discarded her gloves, picked up the glucometer, left the room, and placed the glucometer on the surface of the medication cart, without a barrier. LPN #1 then gathered supplies to perform more finger stick Acu-checks, including two (2) plastic cups which contained the lancet, alcohol wipe, and a wadded up Kleenex tissue. LPN had used her bare un-washed hands to wad the Kleenex up and place in the plastic cups. LPN #1 picked up the glucometer without cleaning it, and entered the shared room of Resident #211 and Resident #361. LPN #1 used hand sanitizer and gloved. LPN #1 did not clean or disinfect the glucometer. LPN #1 laid the glucometer down on Resident #211's night stand without a barrier, then removed a tissue from a cup and placed it on the over bed table. LPN # 1 reached over, picked up the glucometer and placed the glucometer on the tissue without disinfecting it. LPN #1 then performed the finger stick Acu-check on Resident #211. After completing Resident #211's Acu-check, LPN #1 picked up the glucometer and proceeded to the other side of the room to do perform an Acu-check on Resident #361. LPN #1 placed the glucometer on Resident #361's night stand without cleaning or disinfecting it. LPN #1 used hand sanitizer, gloved, placed a tissue on the over bed table, picked up the glucometer and placed it on the tissue, without disinfecting it. After completing the Acu-check, LPN #1 removed and discarded her gloves, picked up the glucometer and exited the room. LPN #1 placed the glucometer back on top of the medication cart, without a barrier and without being disinfected after use between the three (3) residents. During an interview, on 03/12/19 at 02:10 PM, Licensed Practical Nurse (LPN) #1 confirmed she had been trained in nursing school on cleaning the glucometer. LPN #1 stated she didn't even think about cleaning the glucometer between the three (3) residents while being observed. LPN #1 stated she used to clean the glucometer and place barriers down when she first started at the facility about three (3) years ago, but thought she had become complacent after working in the facility over a period of time. LPN #1 confirmed she had not used barriers or cleaned/disinfected the glucometer as required, before use, after use, or between the three (3) residents. A review of Facility Documentation titled Medication Checklist dated 11/4/15, revealed LPN #1 received training on this date; on equipment cleaned before and after use, as well as infection control techniques being followed during administration of all medications. A review of facility document titled, Skills Technique- Operation of Equipment Verification revealed, LPN #1 was checked-off on Blood Glucose Monitor Cleaning on 10/22/15. A review of facility computer documentation titled Preventing Medical Errors and Adverse Events revealed License Practical Nurse (LPN) #1 completed this course on 12/11/18. A review of facility document dated 3/13/19, titled Current Acu-check list, revealed 33 residents in facility received Acu-checks. A review of a facility document, Resident's Diagnoses, identified two (2) residents, on admission, with a [DIAGNOSES REDACTED]. An interview on 03/13/19 at 10:23 AM, with LPN #2, Staff Development Nurse, revealed she did one on one (1:1) training after the orientation process to ensure skills were performed correctly. LPN #2 stated her observations included monitoring how staff handled medications, performance of finger-stick Acu-checks, including glucometer cleaning before and after use, and adhering to infection control standards. LPN #2 stated she performed the same training for all nurses. An Interview on 03/13/19 at 02:22 PM, with the Facility Administrator, revealed, We called Licensed Practical Nurse (LPN) #1 into the facility for an in-service. LPN #1 verified to us she did not clean the glucometer or place a barrier down. We wrote LPN #1 up as a Category one (1) Violation 11 offense. The violation noted, Conduct that would be widely regarded as improper in a work group. The Administrator stated, We suspended her until the investigation is complete. An interview on 03/13/19 at 02:35 PM, with the Facility Administrator revealed, Our best practice is to have two (2) glucometer machines on every cart so that while one is drying from being disinfected, you can pull the other cleaned glucometer out and use it. This is not in our policy, but it is our Best Practice. We did not change any policies. An interview on 03/13/19 at 03:30 PM, with Director of Nursing (DON), revealed it was expected for nurses to follow standard precautions when performing any care with residents to protect both the resident and staff. The DON stated LPN #1 was called in for an in-service on cleaning of the glucometer and using barriers. The DON stated the LPN was able to demonstrate correct infection control technique. The DON stated LPN #1 was asked why she hadn't cleaned the glucometer when observed by the Surveyor, and LPN #1 stated she didn't know, but just didn't. In an interview on 03/13/19 at 04:08 PM, the Facility's Medical Director revealed there were policies in place for infection control related to the use of barriers and cleaning and disinfecting glucometers. The Medical Director stated LPN #1 failed to follow facility policy and practice for standard precautions of infection control when she didn't use the barriers or disinfect the glucometer. In an interview on 03/14/19 at 09:55 AM, the Facility Administrator revealed she considered LPN #1 not cleaning the glucometer or using a barrier an infection control issue. An interview on 03/14/19 at 09:57 AM, with LPN #4, Infection Control Nurse/Care Plan Nurse, revealed, In my opinion, not cleaning the glucometer between each resident and not using a barrier is an infection control issue. The glucometer should be cleaned between each resident with Micro-kill wipes which are supposed to be on each medication cart. We use the Manufacture recommendations on how to clean the glucometer. During an interview, on 03/14/19 at 02:55 PM, the DON revealed LPN #1 should have used a barrier to place the glucometer when doing the Acu-checks. The DON stated, It is an infection control issue. Review of Resident #211's medical record revealed the facility admitted the resident on 3/7/19, with [DIAGNOSES REDACTED]. Current (MONTH) 2019 physician's orders included orders for Acu-checks before meals and at hour of sleep (AC&HS). The current comprehensive care plan included the Acu-check orders of AC&HS. Review of Resident #361's medical record revealed the facility admitted the resident on 10/23/12, with [DIAGNOSES REDACTED]. Current (MONTH) 2019 physician's orders and care plan included Acu-checks AC&HS. Review of Resident #365's medical record revealed the facility admitted the resident on 10/21/14, with [DIAGNOSES REDACTED]. Current (MONTH) 2019 physician's orders and care plan included Acu-checks AC&HS. The facility submitted an acceptable Removal Plan on 3/14/14, for the Immediate Jeopardy. Review of the facility's removal plan revealed the facility took the following actions to remove the Immediate Jeopardy: 1. On 3/13/19 at 11:10 AM, the ADM called a mandatory meeting with the nursing staff to notify Immediate Jeopardy had been called. Nurses on duty were instructed to clean all glucometers on medication carts and follow current policies regarding cleaning glucose meter with approved disinfectant before and after each resident use. 2. On 3/13/19 at 11:20 AM, the Staff Developer and Assistant Director of Nursing (ADON) initiated an all licensed nursing staff in-service, including a skills checkoff list, for each nurse in regards to glucometer infection control protocol and safety. 3. On 3/13/19 at 12:00 PM, an emergency Quality Assurance (QA) meeting was held with the Medical Director, ADM, DON, ADON, Infection Control Officer, Business Office Manager, Housekeeping Supervisor, Laundry Supervisor, Life Enrichment Director, Minimal Data Sets (MDS) Nurse Coordinators, Restorative Nurse, Maintenance Director, Admission/Marketing Nurse, Medicare Nurse, and Food Service Director to discuss the events after Resident #211, #365, & #361 was exposed to the surface of the glucometer and the importance of following the policy for infection control protocol and safety in regards to glucometers. The QA Committee also reviewed policies on infection control, care planning, manufacturer guidelines for the blood glucose monitoring system/micro-kill bleach germicidal bleach wipes, and infection control protocol safety in relation to glucose monitoring systems with no changes to any of the current policies and no further recommendations. 4. On 3/13/19 at 12:30 PM, the Care Plan Coordinator revised all diabetic care plans to include the proper cleansing of the glucometer machines for 33 of 33 residents that require accuchecks. 5. On 3/13/19 at 01:00 PM, the Staff Developer in-serviced all licensed nursing staff on infection control, care planning, manufacturer guidelines for the blood glucose monitoring system/micro-kill bleach germicidal bleach wipes, and infection control protocol safety in relation to glucose monitoring systems. The facility currently has 33 licensed nursing staff members. No nursing staff will be allowed to work until they have completed this in-service. 6. On 3/13/19 at 01:45 PM, the ADM completed an associate memorandum, which is part of the Human Resource Personnel Procedure for a Category I Offense, #11 Conduct that would be widely regarded as improper in a work group with LPN #1. LPN #1 was suspended until further investigation. 7. On 3/13/19 at 03:00 PM, Resident #211, #365, & #361 were assessed for exposure complications by DON and ADON with no complications noted. 8. The facility alleges that all corrective actions to removed the IJ were completed on 3/13/19, and the IJ removed on 3/14/19. The SA validated through observation, interview, and record review, that the facility completed the following actions to remove the IJ: 1. The State Agency (SA) validated through interview and documentation that on 3/13/19, nursing staff were instructed to clean all Glucometers and instructions provided for proper cleaning and disinfection of the Glucometer before and after use. 2. The SA validated through sign-in sheet review, skills check-off sheet review, and interview, that all license nursing staff received an in-service on 3/13/19, regarding cleaning of the glucometer and the placement of barriers. 3. The SA validated through interview and document review, that the facility had a QA meeting, which included the Medical Director, ADM, DON, ADON, Infection Control Officer, Business Office Manager, Housekeeping Supervisor, Laundry Supervisor, Life Enrichment Director, Minimal Data Sets (MDS) Nurse Coordinators, Restorative Nurse, Maintenance Director, Admission/Marketing Nurse, Medicare Nurse, and Food Service Director on 3/13/19, which included review of policy and infection control standards. The Administrator, Director of Nursing, and the Medical Director were interviewed and able to describe what they had done to ensure the implementation of the Removal Plan and how they would ensure on-going compliance. 4. The SA validated through record review and interview with the Care Plan Coordinator that on 3/13/19, all Diabetic Care Plans were revised to include the cleaning of the glucometer. 5. The SA validated through interview with the Staff Development Coordinator and record review of an in-service sign in sheet that on 3/13/19, 33 nursing staff were in-serviced on cleaning of the glucometer with Micro-kill wipes and infection control protocol safety in relation to glucose monitoring. An observation on 3/15/19, with two (2) nurses on the 7p-7a shift revealed the nurses performed the cleaning of the glucometer and the placement of a barrier with no problems noted. 6. The SA validated through interview and record review that LPN #1 received a memorandum for improper conduct on 3/13/19, and was suspended related to not cleaning the Glucometer as required. 7. The SA validated that Resident #211, Resident #365 and Resident #361 received an assessment on 3/13/19, with no issues noted. An interview with the Medical Director on 3/14/19 at 02:58 PM, revealed his plan was to obtain a base line [MEDICAL CONDITION] Panel on the 33 residents receiving Acu-checks and then repeat the [MEDICAL CONDITION] Panel on those residents in six (6) weeks to identify any issues that could arise from not cleaning glucometers. 8. The SA validated that all corrective actions were completed on 3/13/19, and the IJ removed on 3/14/19.

Based on observation, staff interview, review of the Mississippi Board of Nursing Administrative Code, and facility policy, the facility failed to follow professional standards of practice for standard precautions of infection control during the performance of the routine testing of blood sugars (Acu-checks). The facility failed to ensure the use of a barrier on which to place the glucometer, and failed to clean/disinfect the glucometer before, between, and after use, for three (3) of five (5) residents observed, who received Acu-checks, Residents #211, #361, and #365. This practice had the potential and likelihood to pose a threat of bloodborne cross-contamination between 33 residents who received Acu-checks. Review of the medical records for Residents #211, #361 and #365, revealed they all had orders and received Acu-checks routinely before meals and at bedtime. Records revealed each of the residents had a current care plan in place to receive the Acu-checks as ordered. Records revealed no current issues with infectious-based diseases of these three (3) residents. Of the 33 residents who received Acu-checks, one (1) was admitted with an infectious-based disease. The failure to follow standard precautions for infection control, by not cleaning the glucometer and not using a barrier, placed Residents #211, #361, and #365 and other residents at risk, who required Acu-checks, in a situation for the likelihood of severe injury, harm, impairment or death related to the risk of spread of blood borne pathogens and cross-contamination. The situation was determined to be an Immediate Jeopardy (IJ), which began on 3/12/19, when the facility failed to follow standard precautions while performing Acu-checks without cleaning or disinfecting the Glucometer before, or after use between three (3) residents. The SA notified the Administrator on 3/13/19, of the IJ. An acceptable Removal Plan was received on 3/14/19, in which the facility alleged all actions were completed on 3/13/19, and the IJ was removed as of 3/14/19. The SA validated the Removal Plan and determined the IJ was removed on 3/14/19, prior to exit. The scope and severity for CFR(s) 483.21 (b)(3)(i) Services Provided to Meet Professional Standards (F658), was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: A review of the Mississippi Board of Nursing Mississippi Administrative Code, dated 3/16/12, revealed a Licensed Practical Nurse (LPN) would be responsible for knowledge of and compliance with the laws and regulations governing the practice of nursing in the state of Mississippi. A review of the Mississippi Board of Nursing Position Statement, titled Blood Borne pathogens, with a revision date of 4/6/2000, revealed the Board had regulations in place to recognize the Centers of Disease Control (CDC) and Prevention Guidelines as the accepted standard of nursing practice and to require all nurses to practice accordingly. In accordance with CDC guidelines in the provision of nursing care, all nurses should adhere to standard precautions, including the use of protective barriers and comply with current guidelines for disinfection and sterilization of reusable devices. A review of the Center for Disease Control and Prevention guidelines, last updated 6/8/17, regarding shared blood glucose meters, revealed if blood glucose meters were shared, the device should be cleaned and disinfected after every use, per manufacturer instructions, to prevent carry-over of blood and infectious agents. A review of the Facility Policy titled, Obtaining a Fingerstick Blood Glucose Level, dated (MONTH) (YEAR), revealed staff were to maintain clean technique, provide a clean barrier, and clean the glucose monitor with approved disinfectant before and after each resident use. An observation on 03/12/19 at 10:30 AM, revealed Licensed Practical Nurse (LPN) #1 picked up a glucometer from the surface of the medication cart, that was not on a barrier, and entered Resident #365's room to perform a finger stick Acu-check. LPN #1 placed the glucometer on the resident's over bed table without a barrier. LPN #1 used hand sanitizer on her hands and donned gloves, picked up the glucometer and performed the Acu-check on the resident without disinfecting the glucometer. After completion of the Acu-check, LPN #1 placed the glucometer back on the over bed table without a barrier and did not disinfect the glucometer. LPN #1 discarded her gloves, picked up the glucometer, left Resident #365's room, then placed the glucometer on the surface of the medication cart without a barrier or disinfecting it. LPN #1 gathered supplies to perform Acu-checks, picked up the glucometer then entered the shared room of Resident #211 and Resident #361. LPN #1 placed the glucometer on the bed side table of Resident #211, used hand sanitizer and donned gloves, placed a tissue on the overbed table, placed the glucometer on the tissue without disinfecting the device, then performed a finger stick Acu-check on Resident #211. After completion of the finger stick Acu-check for Resident #211, LPN #1 went to Resident #361 to perform an Acu-check. LPN #1 placed the glucometer on Resident #361's night stand without a barrier. LPN #1 used hand sanitizer, gloved and then placed a tissue on the resident's over bed table, pick up the glucometer and placed it on the tissue without disinfecting it. After completing the Acu-check, LPN #1 removed and discarded her gloves, picked up the glucometer, exited the room, then placed the glucometer back on top of the medication cart without a barrier and without being disinfected after use. An interview on 03/12/19 at 02:10 PM with Licensed Practical Nurse (LPN) #1 confirmed she had not disinfected the glucometer between residents and had not used a barrier. When asked why she had not cleaned the glucometer, LPN #1 shrugged her shoulders and stated she did not even think about doing it. LPN #1 stated she had been trained, but had not been observed or checked off for performing finger stick Acu-checks since being employed by the facility about three (3) years ago. LPN #1 stated she had cleaned the glucometer and used barriers when she first started at the facility then stated, I guess working over a period of time you get complacent. LPN #1 stated she worked on an as needed basis (PRN) as she is taking RN classes. LPN #1 confirmed not following the standards of practice. A review of LPN #1's facility training records revealed LPN #1 initialed having skills training during her orientation for skills including standard precautions on 10/12/15, and blood glucose monitor cleaning on 10/22/15. LPN #1 had been checked off on a facility form titled Medication Pass Checklist, dated 10/2/2015, which included equipment being cleaned before and after use and infection control techniques being followed during administration of all medications. An interview on 03/13/19 at 03:30 PM, with the Director of Nursing (DON), revealed she believed a nurse should know as a nurse to clean the glucometer before and after use for each resident. The DON stated LPN #1 did not seem concerned about infecting the residents. The DON stated anytime a nurse interacts with residents they should follow infection control procedures. An interview on 03/14/19 at 08:25 AM, with the Director of Nursing (DON), revealed, Licensed Practical Nurse (LPN) #1 did not meet the Standards of Practice for Nursing, in her opinion. An interview on 03/14/19 at 09:55 AM, with the Facility Administrator, revealed she did not think LPN #1 followed standards of nursing practice by her not cleaning the glucometer and the administrator thought the nurse had been trained appropriately. An interview on 03/14/19 at 09:57 AM, with Licensed Practical Nurse (LPN) #4, the Infection Control Nurse/Care Plan Nurse, revealed it was her opinion failing to clean the glucometer and failure to use a barrier was an infection control issue. She stated it was expected the glucometer be cleaned between each resident with Micro-kill wipes which were kept on each medication cart. She stated LPN #1 did not follow the standard practice of nursing by failing to follow standard precautions. Review of Resident #211's medical record revealed he was admitted [DATE], with [DIAGNOSES REDACTED]. Current (MONTH) 2019 physician's orders included orders for Acu-checks before meals and at hour of sleep (AC&HS). The current comprehensive care plan included the Acu-check orders of AC&HS. Review of Resident #361's medical record revealed the facility admitted the resident on 10/23/12 with diagnoses, which included Diabetes Mellitus type 2, [MEDICAL CONDITION], and right lower extremity amputation. Current (MONTH) 2019 physician's orders and care plan included Acu-checks AC&HS. Review of Resident #365's medical record revealed the facility admitted the resident on 10/21/14, with diagnoses, which included Cerebral Infarct, Diabetes and [MEDICAL CONDITION]. Current (MONTH) 2019 physician's orders and care plan included Acu-checks AC&HS. The facility submitted an acceptable Removal Plan on 3/14/14, for the Immediate Jeopardy. Review of the facility's removal plan revealed the facility took the following actions to remove the Immediate Jeopardy: 1. On 3/13/19 at 11:10 AM, the ADM called a mandatory meeting with the nursing staff to notify Immediate Jeopardy had been called. Nurses on duty were instructed to clean all glucometers on medication carts and follow current policies regarding cleaning glucose meter with approved disinfectant before and after each resident use. 2. On 3/13/19 at 11:20 AM, the Staff Developer and Assistant Director of Nursing (ADON) initiated an all licensed nursing staff in-service, including a skills checkoff list, for each nurse in regards to glucometer infection control protocol and safety. 3. On 3/13/19 at 12:00 PM, an emergency Quality Assurance (QA) meeting was held with the Medical Director, ADM, DON, ADON, Infection Control Officer, Business Office Manager, Housekeeping Supervisor, Laundry Supervisor, Life Enrichment Director, Minimal Data Sets (MDS) Nurse Coordinators, Restorative Nurse, Maintenance Director, Admission/Marketing Nurse, Medicare Nurse, and Food Service Director to discuss the events after Resident #211, #365, & #361 was exposed to the surface of the glucometer and the importance of following the policy for infection control protocol and safety in regards to glucometers. The QA Committee also reviewed policies on infection control, care planning, manufacturer guidelines for the blood glucose monitoring system/micro-kill bleach germicidal bleach wipes, and infection control protocol safety in relation to glucose monitoring systems with no changes to any of the current policies and no further recommendations. 4. On 3/13/19 at 12:30 PM, the Care Plan Coordinator revised all diabetic care plans to include the proper cleansing of the glucometer machines for 33 of 33 residents that require accuchecks. 5. On 3/13/19 at 01:00 PM, the Staff Developer in-serviced all licensed nursing staff on infection control, care planning, manufacturer guidelines for the blood glucose monitoring system/micro-kill bleach germicidal bleach wipes, and infection control protocol safety in relation to glucose monitoring systems. The facility currently has 33 licensed nursing staff members. No nursing staff will be allowed to work until they have completed this in-service. 6. On 3/13/19 at 01:45 PM, the ADM completed an associate memorandum, which is part of the Human Resource Personnel Procedure for a Category I Offense, #11 Conduct that would be widely regarded as improper in a work group with LPN #1. LPN #1 was suspended until further investigation. 7. On 3/13/19 at 03:00 PM, Resident #211, #365, & #361 were assessed for exposure complications by DON and ADON with no complications noted. 8. The facility alleges that all corrective actions to removed the IJ were completed on 3/13/19, and the IJ removed on 3/14/19. The SA validated through observation, interview, and record review, that the facility completed the following actions to remove the IJ: 1. The State Agency (SA) validated through interview and documentation that on 3/13/19, nursing staff were instructed to clean all Glucometers and instructions provided for proper cleaning and disinfection of the Glucometer before and after use. 2. The SA validated through sign-in sheet review, skills check-off sheet review, and interview, that all license nursing staff received an in-service on 3/13/19, regarding cleaning of the glucometer and the placement of barriers. 3. The SA validated through interview and document review, that the facility had a QA meeting, which included the Medical Director, ADM, DON, ADON, Infection Control Officer, Business Office Manager, Housekeeping Supervisor, Laundry Supervisor, Life Enrichment Director, Minimal Data Sets (MDS) Nurse Coordinators, Restorative Nurse, Maintenance Director, Admission/Marketing Nurse, Medicare Nurse, and Food Service Director on 3/13/19, which included review of policy and infection control standards. The Administrator, Director of Nursing, and the Medical Director were interviewed and able to describe what they had done to ensure the implementation of the Removal Plan and how they would ensure on-going compliance. 4. The SA validated through record review and interview with the Care Plan Coordinator that on 3/13/19, all Diabetic Care Plans were revised to include the cleaning of the glucometer. 5. The SA validated through interview with the Staff Development Coordinator and record review of an in-service sign in sheet that on 3/13/19, 33 nursing staff were in-serviced on cleaning of the glucometer with Micro-kill wipes and infection control protocol safety in relation to glucose monitoring. An observation on 3/15/19, with two (2) nurses on the 7p-7a shift revealed the nurses performed the cleaning of the glucometer and the placement of a barrier with no problems noted. 6. The SA validated through interview and record review that LPN #1 received a memorandum for improper conduct on 3/13/19, and was suspended related to not cleaning the Glucometer as required. 7. The SA validated that Resident #211, Resident #365 and Resident #361 received an assessment on 3/13/19, with no issues noted. An interview with the Medical Director on 3/14/19 at 02:58 PM, revealed his plan was to obtain a base line [MEDICAL CONDITION] Panel on the 33 residents receiving Acu-checks and then repeat the [MEDICAL CONDITION] Panel on those residents in six (6) weeks to identify any issues that could arise from not cleaning glucometers. 8. The SA validated that all corrective actions were completed on 3/13/19, and the IJ removed on 3/14/19.