Every finding on record at Greystone Nursing and Rehab, LLC

Based on observation, record review, and interview the facility failed to ensure cross contamination did not occur during the serving of lunch trays and beard coverings were worn at all times in the kitchen. These are our findings: On 06/18/2024 at 11:40 AM, the Surveyor observed two Dietary Aides making the House Supplement. Dietary Aide # 4 was scooping ice cream into the mixer, while Dietary Aide #5 added a nutritional supplement and half and half into the mixer. Dietary Aide #5 had a full beard, including a mustache, that appeared two to three inches long and was preparing food for the residents without the use of a beard covering. The Surveyor observed Dietary Aide #5 leave, putting the half and half back into the fridge, before coming back to help Dietary Aide #4 finish the House Supplement and start the mixer. On 06/18/2024 at 12:00 PM, the Surveyor observed Dietary [NAME] #3 leaning over the steam table setting up for lunch service, when two beads of clear liquid fell off their nose and into the regular lima beans. On 06/18/2024 at 12:10 PM, the Surveyor observed lunch service, with the lima beans being plated for the residents. On 06/18/2024 at 12:30 PM, the Surveyor observed the dining room area, where residents were eating the lima beans and the rest of the lunch served. On 06/19/2024 at 1:58 PM, during an interview the Dietary Manager stated that beard restraints should be worn at all times or hair could fall into the food, its gross. The Dietary Manager then stated that bodily fluids should not be added to the food, as it is disgusting for it to happen. The Dietary Manager stated that the air conditioner was being worked on that day, and it was at least 80 degrees Fahrenheit (F) in the kitchen. On 06/20/24 at 8:25 AM, during a phone interview Dietary [NAME] #3 stated that bodily fluids should not be added into the food, as it is cross contamination like if you put your finger in the food. A review of the facility policy Dress Code stated, Food employees wear a hair covering which covers all hair completely. [NAME] guards but be used for employees with facial hair.

Based on observation, record review and interview, the facility failed to ensure call lights were answered in a timely manner for 2 (Resident #33 and #16) of 2 sample mix residents. The findings are: 1. On 06/18/2024 at 9:30 AM, observed Resident #33's call light turned on. a. Resident #33's Care Plan dated 05/25/2022 revealed the resident had an Activity of Daily Living (ADL) self-care performance deficit and was to be encouraged to use the bell to call for assistance. b. On 06/18/2024 at 9:38 AM, observed Licensed Practical Nurse (LPN) #1 sitting at the nurse's station. Certified Nursing Assistant (CNAs) were observed on the hallway. c. On 06/18/2024 at 9:42 AM, the Surveyor was asked by another resident for assistance to turn off a beeping noise. LPN #1 was notified that the resident needed assistance to turn a beeping noise off. After assisting the resident, observed LPN #1 return to the nurse's station without answering the call light for Resident #33. d. On 06/18/2024 at 9:44 AM, observed CNA #2 answer the call light for Resident #33. e. During an interview on 06/18/2024 at 9:45 AM, CNA #2 said call lights are usually answered within five to ten minutes. CNA #2 said usually another CNA will help, if the CNAs are busy or the nurses will assist. f. During an interview on 06/18/2024 at 9:46 AM, LPN #1 said call lights are usually answered in less than five minutes and said the nurses and other staff can assist. LPN #1confirmed call lights should not go off for fifteen minutes. g. The facility provided an Inservice Education Report dated 03/05/2024 that noted, Call Lights: Must be answered in a timely manner. Do not turn a call light off until the task the resident needs done is completed. 49689 2. On 06/19/2024 at 9:48 AM, observed Resident #16's call light was on. LPN #1 was sitting behind the nurse's station. a. On 06/19/2024 at 9:56 AM, observed LPN #6 walk by Resident #16's room to assist another resident. LPN #6 returned to the nurse's station after assisting the other resident. Resident #16's call light continued to light up, indicating a need for assistance. b. On 06/19/2024 at 9:59 AM, another staff member answered Resident #16's call light as two CNAs left the room across the hall with a sit to stand lift. 3. On 06/19/2024 at 10:00 AM, the bathroom call light came on for Resident #16's room and two minutes later, LPN #6 walked past the bathroom call light without answering it. a. On 06/19/2024 at 10:05 AM, a CNA answered the bathroom light for Resident #16's room. b. On 06/19/2024 at 2:34 PM, during an interview LPN #6 stated the call light should be answered in a timely manner, and that any staff member can answer the call light. LPN #6 stated that the resident might need to go to the restroom, and we do not want them to get up or fall.

Based on observation and record review, the facility failed to ensure dietary staff washed their hands between dirty and clean tasks and before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practice had the potential to affect 67 residents who received meals from the kitchen (total census:68), as documented on a list provided by the Dietary Supervisor on 04/20/23 at PM. The findings are: 1. On 04/19/23 at 8:46 AM, Dietary Employee (DE) #1 picked up the water hose with his bare hand, used it to spray off leftover food items from the dishes, contaminating his hands. He placed dishes in the dirty racks and pushed them into the dish washing machine to wash. After the dishes stopped washing, DE #1 moved to the clean side in the dishwasher area and picked up a clean dishes stacked them on the cart with his fingers touching the inside of the dishes to be used in portioning food items to be served to the residents for lunch. 2. On 04/19/23 at 8:49 AM, DE #2 held the glove box and removed gloves. She placed gloves on her hands, contaminating the gloves. She then picked up utensils at the tips that goes into the mouth and placed them in a drawer for the residents on isolation to be used for eating their meals. 3. On 04/19/23 at 9:32 AM, DE #1 turned on the sink faucet and washed his hands. He then, turned off the faucet with his bare hands contaminating his hands. Without washing his hands, he picked up clean dishes and placed them on the cart to be used in portioning food items to be served to the residents for lunch. 4. On 04/19/23 at 9:41AM, DE #1 turned on the sink faucet and washed his hands. He then, turned off the faucet with his bare hands contaminating his hands. Without washing his hands, he picked up clean dishes and placed them on the cart to be used in portioning food items to be served to the residents for lunch. 5. On 04/19/23 at 9:52 AM, DE #3 picked up a pot of Italian vegetables from the stove and placed it on the counter. Without washing her hands. She attached a clean blade to the base of the blender to be used in pureeing food items to be served to the residents who received pureed diets. 6. On 04/19/23 at 10:06 AM, DE #2 washed her hands. She then pulled her blouse down contaminating her hands. She removed containers of whip topping from the refrigerator and placed them on the counter. She picked up plates from under the counter and placed them on the counter. At 10:14 AM, without washing her hands, she placed gloves on her hands, contaminating the gloves. She picked up apple pie from a rack and placed it on the counter. Holding the apple pie with her contaminated gloved hand, she cut and placed each slice of pie into individual plates to be served to the residents for lunch. 7. On 04/19/23 at 11:39 AM, DE #1 had gloves on his hands. He pushed a rack out of the way, picked up a rack that contained clean utensils and opened the door leading to the Dining Room. He placed the rack that contained utensils from the kitchen outside window counter facing the steam table inside the kitchen. He went back to the kitchen, picked up napkins and placed them on the counter. Without removing his gloves and washing his hands, he picked up utensils by the tips and wrapped them. The Surveyor immediately asked, What should you have done after touching dirty objects and before handling clean equipment? He stated, I should have removed the gloves and washed my hands. 8. The facility policy titled, Hand Washing , provided the Dietary Supervisor on 04/20/23 at 11:45 AM documented, .Purpose: To remove contamination . during food preparation, when switching between raw food and working with ready-to-eat food, before donning gloves for working with food, after engaging in other activities that contaminate the hands. after engaging in other activities that contaminate the hands .

Based on observation, interview, and record review, the facility failed to provide nail care for 2 (Residents #16 and #18) of 10 (Residents #1, #4, #14, #16, #17, #18, #20, #53, #57 and #165) sampled residents who required assistance with Activities of Daily Living (ADL) as documented on a list provided by the Director of Nursing (DON) on 04/20/23 at 3:13 PM. The findings are: 1. Resident #16 had diagnoses of Multiple Sclerosis, Unspecified, Osteoarthritis, and Hidradenitis Suppurativa (skin condition). The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/04/23 documented the resident scored 6 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required extensive physical assistance of one person with personal hygiene and was totally dependent of two plus persons physical assistance for bathing. a. A Care Plan with a revision date of 08/09/18 documented, .The resident has an ADL self-care performance deficit . Bathing/Showering: Check nail length and trim and clean on bath day and as necessary . b. A Bathing Task Schedule provided by the DON on 04/21/23 at 10:21 AM documented, .Last Revision Date: 3/29/2021 .Date Initiated: 10/3/2018 . Description: ADL - Bathing Mon [Monday], Wed [Wednesday], FRI [Friday] DAY & [and] PRN [as needed] . c. On 04/17/23 at 9:38 AM, Resident #16 was lying in bed. On the resident ' s right hand, she had three out of five fingernails 1/4 inch long beyond the tip of the finger and had a light brown substance under them. The right thumbnail was greater than 1/4 inch in length beyond the tip of the thumb. d. On 04/18/23 at 2:10 PM, Resident #16 was lying in bed, the fingernails on the right hand remained long, jagged, and uneven with a medium brown and medium orange colored substance under them. The right thumbnail remained greater than 1/4 inch in length beyond the tip of the thumb. e. On 04/19/23 at 10:45 AM, Resident #16 was lying in bed. The fingernails on the right hand remained long, jagged, and uneven. The Surveyor was unable to visualize four fingers on her left hand, as they were folded under the palm. The left thumbnail was visible with the length greater than 1/4 inch beyond the tip of the thumb. An orange and medium brown substance was under the left thumbnail and around the cuticle. 2. Resident #18 had diagnoses of Osteomyelitis, Unspecified, Chronic Kidney Disease, Stage 3, and Gout. The Annual MDS with an ARD of 01/24/23 documented the resident scored 13 (13-15 indicates cognitively intact) on a BIMS and required extensive physical assistance of one person with personal hygiene and was totally dependent of two plus persons physical assistance for bathing. a. A Bathing Task Schedule provided by the DON on 04/21/23 at 10:21 AM documented, .Last Revision Date: 12/1/2021 .Date Initiated: 1/12/2020 . Description: ADL - Bathing M [Monday], W [Wednesday], FRI [Friday] DAY & PRN . b. A Care Plan with a revision date of 01/31/23 documented, .The resident has an ADL self-care performance deficit . Check nail length and trim and clean on bath day and as necessary. c. On 04/17/23 at 8:33 AM, Resident #18 was lying in bed, the fingernails on her right hand were uneven and 1/4 inches in length beyond the tip of the finger with a medium brown substance under the nails. The fingernails on her left hand were uneven and 1/4 inches in length beyond the tip of the fingers with a medium brown substance under the nails. d. On 04/18/23 at 1:52 PM, Resident #18 was in lying bed. The fingernails on her right hand remained long and uneven with jagged edges with a medium brown substance under the nails. e. On 04/19/23 at 10:54 AM, Resident #18 was lying in bed. The fingernails on her left hand were more than 1/4 inch in length beyond the tip of the finger with uneven, jagged edges. The left thumbnail had pointed edges on both the right and left edges of the thumbnail. f. On 04/19/23 at 11:01 AM, the Surveyor asked Licensed Practical Nurse (LPN) #1 to look at Resident #18 ' s nails and describe what she saw. LPN #1 answered, Oh my gosh, we need to trim your nails, they are jagged and very sharp. The Surveyor asked LPN #1 to describe what she saw under the surface of the nails. She answered, It looks like a little dirt, but it doesn't look like BM [bowel movement]. g. On 04/19/23 at 11:02 AM, Certified Nursing Assistant (CNA) #3 walked into Resident #18's room and observed her fingernails with LPN #1. CNA #3 stated She just got out of the shower, but they are dirty and jaggedly looking. I will be sure and do an inservice with the shower girls, so they don't forget to check the fingernails. h. On 04/19/23 at 11:45 AM, the Surveyor asked the Administrator for the facility's nailcare policy. i. On 04/19/23 at 12:15 PM, the Administrator informed the Surveyor the facility had no policy for nail care.

Based on observation, and interview, the facility failed to store nebulizer masks in a manner that would prevent contamination for 1 (Resident #54) of 8 (Residents #10, #16, #20, #23, #51, #53, #54 and #165) sampled residents who utilized nebulizers to receive medication in the facility as documented on a list provided by the Director of Nursing (DON) on 04/20/23 at 2:20 PM. The findings are: 1. Resident #54 had diagnoses of Dysphagia, Pharyngoesophageal Phase, Esophageal Obstruction, and Gastrostomy. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/22/23 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and required extensive physical assistance of 2 plus persons for bed mobility, transfer, and toilet use and used a wheelchair. a. A Care Plan with a revision date of 03/31/23 did not address nebulizer treatment. b. A Physician ' s Orders dated 04/05/23 documented, Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 3 ml inhale orally every 4 hours as needed . c. The April 2023 Medication Administration Record (MAR) documented, Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML [milligrams per milliliter] (Ipratropium-Albuterol) 3 ml [milliliters] inhale orally every 4 hours as needed . -Order Date- 04/05/2023 . The medication was last given on 04/17/23 at 6:55 AM. d. On 04/17/23 at 10:49 AM, Resident #54 was lying in bed. A nebulizer was resting on the bedside table with the tubing and a mask attached. The nebulizer mask was lying on the bedside table without a bag covering it. The Surveyor asked Resident #54 if she used the nebulizer herself, or if staff typically handled it for her. She stated, No, they do, they give me my medicine with it. e. On 04/18/23 at 12:52 PM, Resident #54 was sitting in a chair with her eyes closed. The nebulizer mask remained on the bedside table, not in a bag. f. On 04/20/23 at 12:01 PM, the Surveyor asked Licensed Practical Nurse (LPN) #2 to explain the policy and procedure for the storage of updraft masks when not in use. She stated, They should either be stored in a bag or attached to the machine to keep them clean. g. On 04/20/23 at 12:30 PM, the Surveyor asked the DON to provide the facility's policies and procedures relating to the use and storage of nebulizers. She stated, We don't have one, we just follow the orders. h. On 04/20/23 at 12:50 PM, the Surveyor asked the DON to explain the procedure the nursing staff would be expected to follow in relation to the care of nebulizer masks when they were not in use. She stated, They should be cleaned and then stored in a bag.

Based on observation, interview, and record review, the facility failed to store an oxygen nasal cannula in a clean, safe manner, allowing the nasal prongs of the cannula to touch the bathroom floor in 1 (Resident #53) of 9 (Residents #4, #10, #16, #20, #27, #51, #53, #165 and #166) sampled residents who received oxygen therapy as documented on a list provided by the Director of Nursing (DON) on 04/20/23 at 3:00 PM. The findings are: Resident #53 (R#53) had diagnoses of Chronic Respiratory Failure with Hypoxia, Chronic Diastolic (Congestive) Heart Failure (CHF), and Type II Diabetes Mellitus. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/26/23 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). a. The Physician Order dated 06/16/22 documented, Oxygen @ [at] 2 L/M [liters per minute] via NC [nasal canula] as needed . b. The Care Plan with a revision date of 12/07/22 documented, The resident has altered respiratory status/difficulty breathing . with PRN [as needed] oxygen . OXYGEN SETTINGS: O2 via nasal CANNULA @ 2L [liters] PRN [as needed]. c. On 04/18/23 at 1:58 PM, Resident #53 was lying in bed with his eyes closed. In the bathroom there was a wheelchair pushed up against the vanity. On the wheelchair was a portable oxygen tank with the oxygen tubing hanging over the top of the backrest on the wheelchair and through the space between the seat and backrest. The nasal prongs of the cannula and tubing were 2 inches from floor. d. On 04/19/23 at 11:58 AM, Resident #53 was lying in bed awake. The Surveyor asked if her wheelchair, in the bathroom, was placed there by staff. She answered, The staff puts it there to make more space in my room. The Surveyor asked if she put the oxygen on by herself, or if the staff puts in on her. She answered, The staff puts it on me and takes it off when I use the restroom, because I get short of breath. e. On 04/19/23 at 11:59 PM, Resident #53 ' s wheelchair was in the bathroom positioned against the vanity. Oxygen tubing was draped over the back of the chair and had dropped between the space between the seat and the back of the chair. The nasal prongs of the oxygen cannula were in contact with the bathroom floor. Certified Nursing Assistant (CNA) #1 and CNA #2 assisted Resident #53 into the restroom and positioned her on the toilet. CNA #1 placed the nasal prongs of the oxygen tubing from the wheelchair, which had touched the floor, inside Resident #53's nose. f. On 04/20/23 at 8:50 AM, the Surveyor asked the DON what should happen if a residents oxygen tubing with nasal prongs falls on the floor. She answered, It is dirty it should be replaced. The Surveyor asked what could happen to the resident if dirty tubing and prongs are not replaced after coming in contact with the floor. She answered, Infection can happen. g. On 04/20/23 at 8:55 AM, the Surveyor asked the Infection Preventionist (IP) what should happen if a residents oxygen tubing with nasal prongs falls on the floor. She answered, It should be replaced. The Surveyor asked what can happen if it isn't replaced. She answered, A respiratory infection.

Based on record review and interview, the facility failed to ensure documentation of the provision of written information regarding the right to formulate an advanced directive was readily available for review in the residents' clinical record, to protect resident rights for 6 (Residents #35, #48, #51, 5, 59, and #63) sampled residents whose clinical records were reviewed for advanced directive information. This failed practice had the potential to affect 41 residents who did not have an advanced directive, as documented on the Resident Census and Conditions of Residents form dated 10/5/2020. The findings are: 1. Resident #59 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/17/2020 documented the resident scored 11 (8-12 indicates moderate impairment) on a Brief Interview for Mental Status. a. On 10/7/2020 at 10:00 a.m., the resident's clinical record contained no documentation related to an Advance Directive. b. On 10/7/2020 at 10:10 a.m., Advance Directive documents were provided by the Administrator. She was asked where the documents had been located. She stated, They were in the Business Office, in their paper record. She was asked, Are you aware the Advance Directive must be in the Active Record? She stated, Oh, okay. I'll have them scanned into the (computerized record). 2. Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Quarterly MDS with an ARD of 9/23/2020 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS). a. On 10/7/2020 at 10:00 a.m., the resident's clinical record contained no documentation related to an Advance Directive. 3. Resident #5 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 7/11/2020 documented the resident scored 12 (8-12 indicates moderate impairment) on a BIMS. a. As of 10/7/202 at 10:11 a.m., the resident's clinical record contained no documentation related to an Advanced Directive. The clinical record contained documentation related to cardiopulmonary resuscitation. 4. Resident #51 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 9/9/2020 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS. a. On 10/6/2020 at 1:42 p.m., the Advanced Directive Care Plan was blank. The resident's clinical record contained no documentation related to an Advanced Directive. b. On 10/7/2020 at 10:14 a.m., the Social Services Director provided the Advanced Directive Care Plan containing the General Durable Power of Attorney for Healthcare which had been signed on 5/26/2020. The Advanced Directive Care Plan containing the General Durable Power of Attorney was located in the Business Office and had no reference to the Advanced Directive. 5. Resident #48 had [DIAGNOSES REDACTED]. a. On 10/5/20 at 8:22 p.m., the resident's clinical record only contained documentation indicating Cardiopulmonary Resuscitation was chosen on 12/5/2016. The clinical record contained no documentation related to an Advanced Directive. b. On 10/7/2020 at 10:18 a.m., the Social Services Director provided the Acknowledgment of Advance Directive information which had been signed 12/5/2016 and was located in the Business Office 6. Resident #35 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 8/24/2020 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS. a. On 10/5/2020 at 9:00 p.m., the resident's clinical record only contained a Do Not Resuscitate Directive dated 5/22/2014. The clinical record contained no documentation related to an Advanced Directive. b. On 10/7/2020 at 10:17 a.m., the Social Services Director provided the Advanced Care Plan containing the Advance Directive signed 5/29/2019 which had been located in the Business Office.

Based on record review and interview, the facility failed to ensure Comprehensive Care Plans were accurate, complete, updated, and revised to reflect the resident's current care needs and address the necessary services to be furnished to attain or maintain the highest practicable level of well-being and minimize the potential for complications for 1 (Resident #23) of 1 sampled resident who required [MEDICAL TREATMENT] services; for 1 (Resident #46) of 1 sampled resident who required a mechanical lift for transfer, and for 1 (Resident #27) of 1 sampled resident who required hospice services. This failed practice had the potential to affect all 67 residents who resided in the facility, according to the Resident Census and Conditions of Residents form dated 10/5/2020. The findings are: 1. Resident #23 had a [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/9/2020 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and required [MEDICAL TREATMENT] services. a. As of 10/6/2020 at 11:00 a.m., the emergency shunt interventions for bleeding was not addressed in the resident's Care Plan. b. The Physician order [REDACTED].Check bruit and thrill of fistula to left arm every shift . [MEDICAL TREATMENT] on Tuesday, Thursday, Saturday for [MEDICAL TREATMENT] . c. On 10/7/2020 at 2:08 p.m., the Minimum Data Set (MDS) Consultant was asked, Should the [MEDICAL TREATMENT] shunt risk and interventions necessary be Care Planned? She stated, They are. We monitor the thrill and bruit. She was asked, What about shunt malfunction and / or bleeding? She stated, I'll have to look, but I'm almost certain it's there. At 2:45 p.m., the Director of Nursing (DON) stated, The Care Plan was updated today with the risk of bleeding. 2. Resident #46 had [DIAGNOSES REDACTED]. bed mobility, dressing, and toilet use; and required extensive one-person assistance personal hygiene. a. On 10/5/2020 at 1:40 p.m., the resident was being assisted from his wheelchair to his bed by Certified Nursing Assistants (CNAs) #1 and #2 using a mechanical lift. b. The Care Plan dated 9/3/2020 contained no documentation of interventions regarding mechanical lift use to transfer resident. c. On 10/8/2020 at 10:35 a.m., the Minimum Data Set (MDS) Coordinator was asked if she was aware the mechanical lift used for (Resident #46) was not Care Planned. The MDS Coordinator stated, I was not aware of that, but I will fix it. 3. Resident #27 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set with an Assessment Reference Date of 8/10/2020 documented the resident scored 4 (0 to 7 indicates severely impaired) on a Brief Interview for Mental Status; required limited two-person assistance for toilet use; required limited one-person assistance for bed mobility, transfer, locomotion, dressing, and personal hygiene; and required supervision with set up help for eating. a. A physician's orders [REDACTED]. b. As of 10/8/2020 at 10:30 a.m., the resident's Care Plan dated 8/24/2020 contained no documentation regarding hospice. c. On 10/8/2020 at 10:36 a.m., the MDS Coordinator was asked if she was aware Hospice care was not documented in the resident's Care Plan. The MDS Coordinator stated, I was not aware of that. She was asked if she knew how many days the facility had to do a Significant Change MDS after Hospice was initiated. She stated, Um, either 10 or 14. I'm not real sure.

Based on observation, record review, and interview, the facility failed to ensure a resident with Physician Ordered blood sugar monitoring and Aspiration Pneumonia received care and treatment in accordance with professional standards of nursing practice and the Physician's Plan of Care by failure to ensure the physician was consistently notified regarding blood sugar results as ordered to enable the physician to evaluate whether a change in treatment was needed; and failed to ensure interventions / measures were put in place for a resident with Aspiration Pneumonia to prevent further potential complications or injury for 1 (Resident #51) of 1 sampled resident. These failed practices had the potential to affect 9 residents who had documented parameters for physician notification, according to the list provided by the Administrator on 10/8/2020 at 1:13 p.m. The findings are: 1. Resident #51 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 9/6/2020 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status; required limited one-person assistance with bed mobility, transfers, toilet use; and required supervision with set up help with eating. a. The physician's orders [REDACTED].check the blood sugar before meals and at bedtime . contact physician if (results are) less than 60 or greater than 250 . b. The Medication Administration Record [REDACTED] 1.) On 9/5/2020 at 6:30 a.m., blood sugar results of 257; 2.) On 9/8/2020 at 8:00 p.m., blood sugar results of 289; 3.) On 9/17/2020 at 6:30 a.m., blood sugar results of 265; and., 4.) On 9/30/2020 at 6:30 a.m., blood sugar results of 262. As of 10/6/2020 at 2:00 p.m., the Progress Notes dated 9/5/2020, 9/8/2020, 9/17/2020, and 9/30/2020 contained no documentation regarding physician notification of the resident's blood sugar results. c. The MAR indicated [REDACTED]. [MEDICATION NAME]-pot Clavulate 875-125mg (milligrams) related to Pneumonitis Due to Inhalation of Food and Vomit for 5 days . d. A Progress Note dated 8/31/2020 at 1:34 p.m. documented, .Resident was transferred out to (hospital name) . Abnormal vitals (vital signs) / labs (laboratory results), and diaphoretic. Resident was sent back at approximately 12:45 p.m. with a dx (diagnosis) of Pneumonia. During my assessment after arrival via (ambulance name) the resident showed s/sx (signs / symptoms) of continued AMS (altered mental status), diaphoretic. APRN (Advanced Practice Registered Nurse) assessed alongside and advised for send out to (hospital name) ER (emergency room ) for further eval. (evaluation) . A Progress Note dated 9/1/2020 at 1:28 p.m. documented, .Resident currently admitted to ICU (Intensive Care Unit) at (hospital name), (name) RN (Registered Nurse) who stated the following: Upon admission to the ER (emergency room ) resident presented with 101.6 temp (temperature), and Bacterial Pneumonia. The resident was admitted to ICU (Intensive Care Unit) and began on IV (intravenous) abx (antibiotics). Faxed over most recent lab (laboratory) results for hospital review . e. The hospital Discharge Notice dated 9/4/2020 documented, .Aspiration Pneumonia . The hospital Progress Note dated 9/4/2020 documented, .Sepsis / suspected Aspiration Pneumonia . The hospital imaging documented, .Small Right Trace Left Pleural Effusion with scattered focal ground glass opacities in the superior posterial left lobe. Multiple reticulated ular opacities are also seen involving the posterior right upper lobe and superior right lower lobe. Predominantly Bibasilar Pneumonia . f. On 10/7/2020 at 9:00 a.m., the new Director of Nursing (DON) was asked to find out how the Aspiration Pneumonia was addressed by the facility. At 9:46 a.m. the DON stated, The former DON took report from the hospital. She wrote the Aspiration Pneumonia note, but it wasn't discernable, so it was not addressed. She was asked, If this happened when you were the DON, what would you do? She stated, I would have had Speech Therapy conduct a swallow study and the resident would have documentation about eating and drinking capabilities. g. On 10/8/2020 at 10:40 a.m., the Minimum Data Set (MDS) Coordinator was asked, Where should the documentation for physician notification about blood sugar parameters be documented? She stated, In the Progress Notes. h. On 10/8/2020 at 11:15 a.m., the DON was asked, Where should physician notification regarding blood sugars be documented at? She stated, In the Progress Notes.

Based on observation, record review, and interview, the facility failed to ensure medications were administered only in the presence of documented indications for use and specific targeted behaviors were monitored, documented, and evaluated for causative factors for 1 (Resident #4) of 3 (Residents #4, #27 and #43) sampled residents who had physician's orders [REDACTED].#2 on 10/6/2020. The findings are: Resident #4 had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set with an Assessment Reference Date of 7/10/2020 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status; was totally dependent on two-plus person assistance with bed mobility, transfer, dressing, toilet use, and bathing; was totally dependent on one-person assistance with eating and personal hygiene; and received an antipsychotic, antidepressant, and antianxiety medication 7 out of the last 7 days. a. A physician's orders [REDACTED].[MEDICATION NAME] Tablet 1 MG (milligram) Give 1.5 tablet via PEG (percutaneous endoscopic gastrostomy) tube . Unspecified Dementia with Behavioral Disturbance . A physician's orders [REDACTED].[MEDICATION NAME] Tablet 2 MG Give 1 tablet via PE[DEVICE] in the evening related to Unspecified Dementia with Behavioral Disturbance . b. The resident's Care Plan with a revised date of 7/27/2020 documented, .The resident is / has potential to be verbally aggressive (i.e. (such as) yelling, cursing, verbally threatening, etc. (et cetera)) due to poor impulse control related to her medical [DIAGNOSES REDACTED]. Monitor / document for side effects and effectiveness . The resident uses [MEDICAL CONDITION] medications [MEDICATION NAME] r/t (related to) Behavior management due to the [DIAGNOSES REDACTED]. c. On 10/5/2020 at 11:30 a.m., Resident #4 was lying in her bed. When greeted, she opened her eyes and looked at the Surveyor. Little other movement was attempted. d. The Progress Notes dated 1/7/2020, 3/19/2020, and 3/29/2020 documented the resident was noted to have yelled out. e. On 10/7/2020 at 2:00 p.m., the Director of Nursing was asked where the behavior documentation would be found in the resident's clinical record? She stated, It should be in the Progress Notes under 'Behavior'. The DON was asked to check the resident's clinical record and verify if there was any other documentation. f. On 10/7/2020 at 2:10 p.m., the DON stated, I couldn't find any other Behavior Documentation except for 1/7/2020, 3/19/2020 and 3/29/2020. She was asked, Should the resident be on an antipsychotic medication without an appropriate diagnosis? She stated, No, it should not be used. She was asked, The resident's behavior, from what was reviewed in the record, stemmed from pain, correct? She stated, Correct. I will work on getting that removed. I have sent a message to the physician. She was asked, Did you see the resident? She stated, Yes. She doesn't do anything. She was asked, With no behavior documentation, is there a documented reason or [DIAGNOSES REDACTED].? She stated, No. She needs to be off of it.

Based on record review and interview, the facility failed to ensure a Significant Change Minimum Data Set (MDS) was completed within 14 days after a significant change in status to determine if any changes in care were necessary for 1 (Resident #10) of 4 (Residents #4, #10, #27 and #51) sampled residents who had a significant change in condition in the past 6 months. This failed practice had the potential to affect 11 residents who had a significant change in condition in the past 6 months, according to a list provided by the Administrator on 10/8/2020. The findings are: Resident #10 had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/28/2020 documented the resident scored 3 (0-7 indicates severe impairment) on a Brief Interview for Mental Status and received Hospice services. a. The physician's orders [REDACTED].Admit to (Name) Hospice r/t (related to) [MEDICAL CONDITION] . b. The resident's Care Plan with a revised date of 8/24/2020 documented, .The resident has a terminal prognosis r/t (related to) Heart Failure . c. As of 10/7/2020 Resident #10's MDS contained no documentation indicating a Significant Change in Status MDS was in progress or completed after the resident was admitted to hospice services on 3/20/2020. (The Surveyor took a snip picture at this time.) d. On 10/8/2020 at 10:40 a.m., Licensed Practical Nurse (LPN) #1, MDS Perspective Payment System Coordinator, was asked, When someone goes on Hospice, how long does the facility have to complete a Significant Change in Status Assessment? She stated, I have no idea. She was informed the Significant Change in Status MDS should be completed within 14 days of the significant change.

Based on record review and interview, the facility failed to ensure the Minimum Data Set assessments accurately reflected residents' current status to provide accurate information and facilitate the ability to develop a Care Plan and provide necessary care and services for 1 (Resident #48) of 16 (Residents #48, #59, #63, #4, #10, #11, #58, #51, #23, #35, #5, #46, #60, #9, #6, and #27) sampled residents whose MDS assessments were reviewed. This failed practice had the potential to affect all 67 residents who resided in the facility, according to the Resident Census and Conditions of Residents form dated 10/5/2020. The findings are: 1. Resident #48 had [DIAGNOSES REDACTED]. a. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 9/2/2020 documented a [DIAGNOSES REDACTED]. b. The Resident Assessment Instrument documented Active [DIAGNOSES REDACTED]. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current status. c. On 10/8/2020 at 10:40 a.m., the Minimum Data Set (MDS) Coordinator was asked, Is Section I supposed to contain all the [DIAGNOSES REDACTED].? She stated, No, only what is current.

Based on observation, record review, and interview, the facility failed to ensure the results of all surveys, including the most recent Annual survey and the Plan of Correction, were posted in a readily accessible location for residents and visitors without having to ask a staff person for 1 of 1 facility, in order to allow residents and other concerned parties to be informed regarding any identified deficient practices. This failed practice had the potential to affect all 67 residents who resided in the facility, according to the Resident Census and Conditions of Residents form dated 10/5/2020. The findings are: 1. The Centers for Medicare and Medicaid Services (CMS) Interpretive Guidelines documented, .'Results of the most recent survey' means the Statement of Deficiencies (Form CMS-2567) and the Statement of Isolated Deficiencies generated by the most recent standard survey and any subsequent extended surveys, and any deficiencies resulting from any subsequent complaint investigation(s). 'Made available for examination' means that survey results and approved plan of correction, if applicable, are available in a readable form, such as a binder, large print, or are provided with a magnifying glass, have not been altered by the facility unless authorized by the State agency, and are available to residents without having to ask a staff person. 'Place readily accessible to residents' is a place (such as a lobby or other area frequented by most residents) where individuals wishing to examine survey results do not have to ask to see them . 2. Survey records from the Office of Long Term Care (OLTC) documented the most recent standard (Annual Recertification) survey conducted at this facility was completed on 5/9/2019. 3. On 10/7/2020 at 1:35 p.m., the facility Survey Binder located in the front lobby area did not contain the results of the last Annual Recertification Survey dated 5/9/2019. a. On 10/7/2020 at 1:36 p.m., the Nurse Consultant was asked to find the Annual Recertification Survey in the Survey Binder. She stated, It's not in here. b. On 10/7/2020 at 2:18 p.m., the Annual Recertification Survey with the Plan of Correction was located on the facility's computer system and was placed in the facility Survey Binder.

Based on observation, record review, and interview, the facility failed to ensure written notification of transfer / discharge was provided to the Ombudsman when residents transferred to the hospital and / or discharged as required to protect resident rights for 2 (Residents #35, and #67 ) sampled residents who were transferred and / or discharged in the past 6 months. This failed practice had the potential to affect 33 residents who were transferred or discharged in the past 6 months, according to a list provided by the Administrator on 10/8/2020 at 10:14 a.m. The findings are: 1. Resident #35 had [DIAGNOSES REDACTED]. A Discharge Return Anticipated Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/14/2020 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status. a. On 10/7/2020 at 1:27 p.m., The Administrator was asked for the Ombudsman Log for June 2020. The Administrator stated, I have to be honest. We haven't been notifying the Ombudsman. 2. Resident #67 was admitted on [DATE] with [DIAGNOSES REDACTED]. a. The Care Plan dated 8/16/2020 documented, .The resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) R (right) total knee replacement. The resident will remain free of complications related to immobility . including contractures, thrombus formation, skin breakdown, fall related injury through the next review date . b. A physician's orders [REDACTED].Send to (hospital) via ambulance due to [MEDICAL CONDITION] . b. A Nurse's Note dated 8/18/2020 documented, .Resident was sent to the hospital due to abnormal labs and is not going to return to the facility at this time . c. A Discharge Return Not Anticipated Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/18/2020 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and required limited one-person assistance with bed mobility and transfer.

Based on record review and interview, the facility failed to ensure a written discharge summary was completed and included a recapitulation of the resident's stay that consisted of a concise summary of the stay, course of treatment, a reconciliation of medications, and discharge plans to provide necessary medical information and recommended follow-up care for the continuing care provider for 1 (Resident #67) of 1 sampled resident who was discharged in the past 90 days. This failed practice the potential to affect 33 residents who were transferred / discharged in the past 90 days, as documented on a list provided by the Administrator on 10/8/2020 at 10:14 a.m. The findings are: Resident #67 was admitted on [DATE] with [DIAGNOSES REDACTED]. a. The Care Plan dated 8/16/2020 documented, .The resident has an ADL (activities of daily living) self-care performance deficit related to right total knee replacement . The resident will remain free of complications related to immobility, including, contractures, thrombus formation, skin breakdown, fall related injury through the next review date . b. A physician's orders [REDACTED].Send to (hospital) via ambulance due to [MEDICAL CONDITION] . c. A Nurse's Note dated 8/18/2020 documented, .Resident was sent to the hospital due to abnormal labs and is not going to return to the facility at this time . d. A Discharge Return Not Anticipated Minimum Data Set (MDS) with an Assessment Reference Date of 8/18/2020 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS); required limited one-person assistance with bed mobility and transfer. e. As of 10/8/2020 at 10:15 a.m., the resident's clinical record contained no documentation related to a Discharge Summary. f. On 10/8/2020 at 10:25 a.m., the Director of Nursing (DON) was asked, When a resident is transferred to the hospital, who completes their Discharge Summary? The DON stated, If the resident goes to the hospital, the Nurse will do it.

Based on record review and interview, the facility failed to ensure physician's orders were obtained prior to performing COVID-19 testing for 15 (Residents #51, #23, #35, #5, #44, #5, #3 #56, #9, #48, #30, #59, #4, #10, and #11) sampled residents who had testing for COVID-19. This failed practice had the potential to affect 67 residents who resided in the facility, according to the Resident Census Listing provided by the Administrator on 10/6/2020. The findings are: 1. On 9/28/2020, Resident #29 was tested for COVID-19. The clinical record for Resident #29 contained no physician's order for COVID-19 testing. 2. On 9/28/2020, Resident #30 was tested for COVID-19. The clinical record for Resident #30 contained no physician's order for COVID-19 testing. 3. On 10/5/2020, Resident #51 was tested for COVID-19. The clinical record for Resident #51 contained no physician's order for COVID-19 testing. 4. On 10/5/2020, Resident #44 was tested for COVID-19. The clinical record for Resident #44 contained no physician's order for COVID-19 testing. 5. On 10/5/2020, Resident #56 was tested for COVID-19. The clinical record for Resident #56 contained no physician's order for COVID-19 testing. 6. On 10/5/2020, Resident #23 was tested for COVID-19. The clinical record for Resident #23 contained no physician's order for COVID-19 testing. 7. On 10/5/2020, Resident #35 was tested for COVID-19. The clinical record for Resident #35 contained no physician's order for COVID-19 testing. 8. On 10/5/2020, Resident #5 was tested for COVID-19. The clinical record for Resident #5 contained no physician's order for COVID-19 testing. 9. On 10/5/2020, Resident #3 was tested for COVID-19. The clinical record for Resident #3 contained no physician's order for COVID-19 testing. 10. On 10/5/2020, Resident #48 was tested for COVID-19. The clinical record for Resident #48 contained no physician's order for COVID-19 testing. 11. On 10/5/2020, Resident #9 was tested for COVID-19. The clinical record for Resident #9 contained no physician's order for COVID-19 testing. 12. On 10/9/2020, Resident #59 was tested for COVID-19. The clinical record for Resident #59 contained no physician's order for COVID-19 testing. 13. On 10/9/2020, Resident #4 was tested for COVID-19. The clinical record for Resident #4 contained no physician's order for COVID-19 testing. 14. On 10/9/2020, Resident #10 was tested for COVID-19. The clinical record for Resident #10 contained no physician's order for COVID-19 testing. 15. On 10/9/2020, Resident #11 was tested for COVID-19. The clinical record for Resident #11 contained no physician's order for COVID-19 testing. 16. On 10/9/2020 at 8:38 a.m., the Director of Nursing was asked, Should residents have a physician's order for the testing of COVID-19? She stated, Yes, they should. She was asked, Does (Resident #48 and #5) have physician's orders? She stated, No. I'll have to review to see what happened.

Based on record review and interview, the facility failed to ensure residents were provided with the opportunity to formulate advanced directives other than code status, to enable them to make advance decisions regarding which measures should be provided or withheld in the event of their incapacitation for 3 (Residents #20, #4, and #219) of 20 (Residents #20, #4, #219, #1, #8, #14, #16, #19, #22, #23, #35, #38, #40, #43, #52, #59, #68, #69, #221, and #319) sampled residents whose clinical records were reviewed for advanced directive information. This failed practice had the potential to affect all 73 residents who resided in the facility, according to the Resident Census Report provided by the Administrator on 5/9/19 at 12:50 p.m. The findings are: 1. Resident #20 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/22/19 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). a. A physician's orders [REDACTED].Do Not Resuscitate . b. A facility form titled Acknowledgement of Receipt of Advance Directive Information provided by the Social Services Director on 5/8/19 at 2:05 p.m., was signed by the Resident #20 and dated 5/22/14. The form documented, .(Initials) . I have chosen to formulate and issue the attached Advance Directive . Please indicate on the line what Advance Directives have been issued or formulated, such as Advance Care Plan and / or DNR (Do Not Resuscitate) . (DNR) . c. As of 5/8/19 at 2:45 p.m., the resident's clinical record contained no Advance Directive for review. The Social Services Director stated, The resident does not have any other paper work that I could find. 2. Resident #4 was admitted to facility on 8/14/18 and had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 4/24/19 documented the resident scored 11 (8-12 indicates moderate cognitive impairment) on a BIMS. a. A physician's orders [REDACTED].Do Not Resuscitate . b. The Care Plan with a revised date of 2/1/19 documented, .The resident's code status is Do Not Resuscitate (DNR) . c. A facility form titled Acknowledgement of Receipt of Advance Directive Information provided by the Social Services Director on 5/8/19 at 2:05 p.m., documented, .(Initials) . I have chosen to formulate and issue the attached Advance Directive. (Please indicate on the line what Advance Directives have been issued or formulated, such as Advance Care Plan and / or DNR (Do Not Resuscitate) . (Blank) . The form was signed by the resident and dated 7/24/18, however, it was blank. The Social Services Director stated, The resident does not have any other paper work that I could find. d. As of 5/8/19 at 2:45 p.m., the resident's clinical record contained no Advanced Directive for review. The Social Services Director stated, The resident does not have any other paper work that I could find. 3. Resident #219 admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date of 5/1/19 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status. a. The Baseline Care Plan dated 4/24/19 documented, .Code Status . DNR (Do Not Resuscitate) . The Care Plan dated 4/29/19 documented, .The resident's code status is Do Not Resuscitate . DNR . b. A physician's orders [REDACTED]. c. A facility form titled An Acknowledgement of Receipt of Advance Directive Information provided by the Social Services Director on 5/8/19 at 1:45 p.m. documented, . (Initialed) .I have chosen to formulate and issue the attached advance directive .(Please indicate on the line what Advance Directives have been issued or formulated, such as Advance Care Plan and / or DNR (Do Not Resuscitate) . (Blank} . The form was not completed and was initialed and dated 4/24/19. There was no advance directive attached. d. As of 5/8/19 at 2:45 p.m., the resident's clinical record contained no Advanced Directive for review. e. On 5/8/19 at 1:45 p.m., the Social Services Director was asked about the resident's Advance Directive. The Social Services Director stated, He just got here and he actually declined it, but I have nothing documented to show that he did decline it. I have talked with my Nurse Consultant, and she told me I have to document what they want to do.

Based on observation, record review, and interview, the facility failed to ensure nursing staff washed their hands and changed gloves after touching dirty supplies and before continuing with wound care to prevent potential infection for 1 (Resident #221) of 2 (Residents #221 and #36) sampled residents who had physician's orders [REDACTED]. Resident #221 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date of 5/1/19 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status, had a pressure ulcer; had one or more unhealed pressure ulcers; had one Stage 3 pressure ulcer that was present upon admission; had one unstageable pressure ulcer that was present upon admission; and had Moisture Associated Skin Damage. a. A Weekly Wound Observation dated 4/24/19 documented, .Left lateral ankle . admitted with . unstageable .0.9 cm (by) 0.9 cm (by) 0.4 cm . b. A Weekly Wound Observation dated 4/24/19 documented, .Top of Left foot . admitted with . Stage 3 .13.5 cm (by) 9.5 cm (by) 0.5 cm . c. A Weekly Wound Observation dated 5/1/19 documented, .Top of Left Foot . admitted with . Stage 3 .6.8 cm (by) 8.8 cm (by) 0.4 cm . d. A Weekly Wound Observation dated 5/1/19 documented, .Left lateral ankle . admitted with . unstageable . 0.9 cm (by) 1 cm (by) 0.4 cm . e. A physician's orders [REDACTED].Stage 3 wound to top of left foot. Clean with wound cleanser, pat dry. Place black foam onto wound bed, secure with vac (vacuum) dressing. Connect to wound vac q M (Monday) W (Wednesday) F (Friday) and prn (as needed) for stage 3 wound . There was no end date or stop date on this order. A physician's orders [REDACTED].Clean unstageable wound to left lateral ankle with wound cleanser, pat dry, apply small piece of black foam to wound bed and apply drape, bridge to wound on top of left foot and connect to wound vac (every) Mon W F until resolved every day shift . A physician's orders [REDACTED].Wound Vac to wounds on Left foot 150 mmhg/ml (millimeters of mercury per milliliter), continuous suction. Check that vac is functioning properly and in place q shift . for wounds . f. On 5/8/19 at 1:59 p.m., the Treatment Nurse provided the wound treatments with the assistance of Certified Nursing Assistant (CNA) #1. Both staff washed their hands and donned gloves. The Treatment Nurse removed the resident's old dressing, then changed gloves. She cleaned the wound with 4 by 4's with wound cleanser and placed the soiled 4 by 4's into a cup and placed the cup in a trash bag. With gloved hands, she picked up the trash bag and shook the trash to the bottom of the bag. With the same contaminated gloves, she picked up another cup with dry gauze in it and patted the wounds dry. She did remove her gloves, sanitized her hands, and donned new gloves before proceeding with the remainder of the wound treatment. Upon completion of the treatment the nurse and CNA removed the trash and washed their hands. The Treatment Nurse did not date or initial the resident's wound dressing. g. On 5/8/19 at 2:33 p.m., the Treatment Nurse was asked, When should you sanitize your hands and change your gloves during treatments? She stated, Sanitize after every glove change. Change gloves so you don't contaminate the wound. Clean inside of the wound and change gloves, clean periwound and change gloves. If they have more than one wound change, between those too. She was asked, Did you do that today? She stated, I think so. I tried to. She was asked, Should you have changed gloves and sanitized your hands between cleaning the wound with 4 by 4's soaked in wound cleanser, and touching the red trash bag, shaking it down, and then with the same gloves, picking up dry 4 by 4's and patting the wound dry? She stated, I thought I took my gloves off and sanitized after I shook the bag down. No? I knew not to touch that bag. She was asked, When should you initial and date the dressing? She stated, After dressing changes. She was asked, What are the potential outcomes for not sanitizing hands and changing gloves between dirty and clean tasks? She stated, Contamination of the wound and infection. h. On 5/8/19 at 3:23 p.m., the Director of Nursing (DON) was asked, When should a nurse change gloves and sanitize her hands during a treatment? She stated, Anytime they have to touch something that is not clean, and between taking the old off, sanitizing and putting the rest of it back on. Or, if they touch anything not clean. i. A facility policy titled Pressure Injury, Prevention and Management provided by the Administrator on 5/9/19 at 2:51 p.m. documented, .Aseptic treatment will be observed during dressing change procedure unless otherwise specified by physician .

Based on record review and interview, the facility failed to ensure residents and/or their representatives were notified in writing of transfers to the hospital and / or facility-initiated discharges, as required to protect resident rights for 3 (Residents #24, #61, and #32) of 3 sampled residents who were transferred and / or discharged from the facility in the past 90 days. This failed practice had the potential to affect 26 residents who had been transferred / discharged from the facility in the past 90 days, according to a list provided by the Administrator on 7/26/18 at 1:24 p.m. The findings are: 1. Resident #24 had [DIAGNOSES REDACTED]. A Physician's Telephone Order dated 7/24/2018 at 17:30 (5:30 p.m.) documented, .Send Resident to emergency room for Eval (evaluation) / Tx (Treatment) R/T (related to) [MEDICAL CONDITION] . There was no documentation in the clinical record to indicate a written notice of transfer was provided to the resident or responsible party. 2. Resident #61 had [DIAGNOSES REDACTED]. A Physician's Telephone Order dated 7/23/18 at 1:33 a.m., written on a Laboratory Note, documented, .New order to send to ER (emergency room ) for eval (evaluation) r/t (related to) Fx (fracture) . There was no documentation in the clinical record to indicate a written notice of transfer was provided to the resident or responsible party. 3. Resident #32 had [DIAGNOSES REDACTED]. A Physician's Telephone Order dated 7/18/18 at 17:42 (5:42 p.m.) documented, .New Orders Rec'd (received) to transfer to (local hospital) for further evaluation . There was no documentation in the clinical record to indicate a written notice of transfer was provided to the resident or responsible party. 4. On 7/27/18 at 8:44 a.m., the Administrator was asked if the facility had provided written notification of transfer to the residents, resident representatives and Ombudsman. He stated, I send the notices to the Ombudsman. We have not been sending them to the resident or representatives. We have a letter drafted to send residents and representatives, and the Social person will start sending those out now.

Based on observation, record review, and interview, the facility failed to ensure a leaking air conditioning unit was promptly repaired to prevent potential falls related to wet floors for 1 (Resident #69) of 2 (Residents #69 and #15) sampled residents who resided in the affected room on the 200 Hall; failure to ensure the wall above the head of a resident's bed was free of a sharp object that could cause skin tears or other injuries for 1 (Resident 4) of 1 (Resident #34) sampled residents who resided in the affected room on the 300 Hall; and, failure to ensure geri chair arm rests were free from torn and jagged edges to prevent potential injury / skin tears for 1 (Resident #48) of 3 (Residents #10, #13 and #48) sampled residents who required a geri chair. The failed practices had the potential to affect 2 residents who resided in the affected room on the 200 Hall, 1 resident who resided in the affected room on the 300 Hall and 3 residents who required geri-chairs, as documented on lists provided by the Administrator on 7/26/18. The findings are: 1. Resident #34 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/11/18 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS), and was dependent on two person assistance for bed mobility, transfer, toilet use and personal hygiene. a. The resident's Care Plan with a revised date of 1/28/18 documented, .The resident is / has potential to be physically aggressive related to Dementia . The resident has potential for impairment to skin integrity r/t Immobility . Identify / document potential causative factors and eliminate / resolve where possible . b. On 7/23/18 at 12:05 p.m., Resident #34 was lying in the bed. Approximately 2 and one-half feet above the head of the resident's bed was a sharp, jagged picture hook protruding from the wall. c. On 7/24/18 at 1:41 p.m., Resident #34 was lying in the bed. The sharp, jagged picture hook was still protruding from the wall above the resident's bed. d. On 7/25/18 at 8:56 a.m., the resident was lying in the bed. The bed was pushed up against the wall. The sharp, jagged, picture hook was protruding from the wall above the resident's head of the bed. e. On 7/25/18 at 9:05 a.m., the Director of Nursing (DON) was asked to accompany the surveyor to Resident #34's room. The resident was lying in the bed with her arm up over her face. The DON was asked, do think that sharp metal hook has the potential to cause a skin tear? She stated, Yes. I don't even know where that picture went to. 2. Resident #69 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD 7/13/18 documented the resident scored 7 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status (BIMS), and required supervision with one person assistance for bed mobility, transfer, dressing, toilet use and personal hygiene, was independent with set up help for walking in room, required limited one person assistance with locomotion off unit, had no falls, and used a walker and wheelchair for mobility. a. The Resident Care Plan with a revised date of 7/17/18 documented, .The resident is at risk for falls r/t (related to) Confusion, Gait / balance problems . Vision / hearing problems . The resident will be free of falls through the review date . Review information on past falls and attempt to determine cause of falls . Record possible root causes . Alter / remove any potential causes if possible . b. On 7/23/18 at 10:58 a.m., Resident #69's wall air conditioner unit had two wash basins sitting on the floor, on a blanket, under the air conditioner unit. The front wash basin was three-fourths full of water, which was dripping from the air conditioner unit into the wash basin. c. On 7/23/18 at 2:45 p.m., Resident #69 was sitting in her recliner by the air conditioner unit. There were 2 wash basins under the air conditioner unit, on a blanket, catching the dripping water. The wash basin was almost full of dripping water from the unit. d. On 7/24/18 at 9:28 a.m., Resident #69 was sitting in her recliner in her room by the air conditioner unit. There were 2 wash basins under the air conditioner unit. One of the wash basins was almost full of water, with approximately 1/4 inch of available space before running over the top of the basin. e. On 7/24/18 at 9:30 a.m., Resident #69 had a bruise under her chin, and a bruise to her right hand. The resident stated she had a fall 3 days ago, and showed the Surveyor a knot on her head. f. On 7/25/18 at 8:22 a.m., Resident #69 had 2 wash basins sitting under the air conditioner unit sitting on a towel. The air conditioner unit was dripping water into the basins. There were two towels by the basin. g. On 7/25/18 at 2:32 p.m., the Director of Nursing (DON) was asked, do you think those basins on the floor are a potential hazard? She stated, Yes. h. On 7/26/18 at 2:03 p.m., the Director of Nursing was asked to accompany the surveyor to the resident's room. Two wash basins were sitting on the floor, on a towel, under the air conditioner unit, with water dripping into the basins. The DON was asked if she still considered the wash basins, towels and water to be hazards. The DON stated, Yes. The water dripping in the basin is what makes the water splash in the floor. She keeps it so cold that it freezes the unit. We have an air conditioning man coming. 3. Resident #48 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/28/18 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS) and was dependent on two person assistance for bed mobility, transfer, toilet use and personal hygiene. a. The Care Plan dated 3/29/18 documented, .Geri chair utilized . Transfer . The resident is totally dependent on (2) staff for transferring . Transfer .The resident requires Mechanical Lift (Hoyer) with (2) staff assistance for transfers . b. On 7/24/18 at 11:32 a.m., Resident #48 was being transferred Certified Nursing Assistant (CNA) #5 from a geri-chair to his bed. The upholstery to the outer edges of both of the armrests of the geri chair was cracked / split and had jagged edges which were 5 to 8 inches in length. The resident was in the same geri chair on 7/23/18 at 5:30 p.m., 7/24/18 at 10:03 a.m., 7/24/18 at 11:32 a.m., and 7/24/18 at 1:35 p.m. c. On 7/26/18 at approximately 1:55 p.m., the Activity Director was asked a question and stated, If a geri chair has broken, jagged upholstery, then it should be reported to the Charge Nurse or Maintenance, and not be used. Residents could get skin tears big time or snag on a lift during transfer. They can get hurt. d. On 7/26/18 at approximately 2:00 p.m., Certified Nursing Assistant (CNA) #5 was asked about the geri chair with broken, jagged upholstery. She stated, I would tell the Charge Nurse and not use the geri chair, so they (residents) don't get hurt. They could get a skin tear, almost anything, injury, same thing with using the lift to transfer residents. The lift pad sling could snag on it and the resident could get hurt. e. On 7/26/18 at 2:11 p.m., the Director of Nursing (DON) was asked about the geri chair with broken, jagged upholstery. The DON stated, The staff should notify their department head, or me, and get the geri chair repaired. This could cause skin tears or injuries.