Every finding on record at Groveton Nursing Home

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 1 medication storage rooms reviewed for labeling and storage.1.The facility failed to label and remove a vial of expired Tuberculin (TB) testing solution on 9/8/2025 from the refrigerator in the medication room.2. The facility failed to remove expired insulin for Resident #16 from the refrigerator in the medication room on 9/8/2025.These failures could place residents at risk for improper glucose monitoring and could result in residents not receiving the intended therapeutic effects of their medications causing a health decline.Findings include:Record review of an admission Record for Resident #16 dated 9/9/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of encephalopathy (a condition where the brain does not function properly), type 2 diabetes, and dementia. Record review of active physician orders dated 9/9/2025 for Resident #16 indicated there was not an order for the insulin lispro kwik pen. Record review of a Consultant Pharmacist Medication Room Report dated 8/25/2025 indicated the medication room was checked and a vial of tuberculin/aplisol was missing the date opened on the opened vial in the medication fridge.Record review of a Quarterly MDS dated [DATE] for Resident #16 indicated she had moderate impairment in thinking with a BIMS score of 9. She received 7 days on insulin injections during the look back period.Record review of a care plan revised 4/24/2025 for Resident #16 indicated she had diabetes with interventions to administer medications as ordered by the doctor and monitor/document for side effects and effectiveness.During an observation and interview on 9/8/2025 at 10:15 AM in the medication room with MA D. The refrigerator had a vial of aplisol (TB) 5 units/1 ml that was dated 7/25/2025 by the pharmacy. The vial did not have a cap on top and did not have an open date noted on the vial. An insulin lispro Kwikpen for Resident #16 was also in the refrigerator dated 7/14/2025 with an expiration date for December 2026. The label on the insulin pen for Resident #16 indicated directions were prn. MA D said the nurses were responsible for checking medications that were stored in the refrigerator.During an observation and interview on 9/8/2025 at 10:30 AM, LVN C said she nurses were responsible for checking the refrigerators in the medication room daily and they were to check the temperatures and check for expired medications. LVN C looked at the TB vial and said it did not have an open date to indicate when it was accessed, and it had been used. She said the vial of TB was received on 7/25/2025 from the pharmacy and said it should be discarded. She said she was not sure how long they were to keep the TB once it had been accessed. She observed the insulin for Resident #16 and said it should be discarded. She said it was only good for 30 days. She said medications could be ineffective if given past their expiration dates.During an interview on 9/9/2025 at 1:45 PM, the ADON said the nurses were responsible for checking the medication room daily for expired medications. She said medications should have an open date when they were opened such as vaccines or insulin. She said if there were not any open dates on medications, residents could get sick from taking medications that could be ineffective. She said insulin pens were good for 28 or 29 days and then should be discarded depending on the brand once opened. She said TB was good for 30 days once it was opened and should have an open date when accessed. During an interview on 9/9/2025 at 1:49 PM, the DON said the nurses were responsible for checking the medication room daily. She said medications should have open dates such as insulin and vaccines. She said insulin was good for 28 days once opened and TB was good for 30 days and then should be discarded. She said if residents took medications that were given past their dates, they could be ineffective. She said she planned to in-service the nursing staff on medication storage with vaccines and insulins. She said she would monitor to make sure medications were dated and removed it they were supposed to be. During an interview on 9/9/2025 at 1:54 PM, the Administrator said the nurses were responsible for checking the medication rooms. She said if residents were given medications that were not labeled with an open date, the medications given might not be effective. She said she expected her staff to check the medications and label them with open dates to make sure the medications were not expired.Record review of a package insert for aplisol (tuberculin) undated indicated, .aplisol vials in use more than 30 days should be discarded .Record review of a package insert for insulin lispro undated indicated, .16.2 Storage and Handling-In-use insulin lispro and insulin lispro Kwik pens must be used within 28 days or be discarded, even if they still contain insulin lispro.Record review of a facility policy titled Storage of Medications revised 8/2020 indicated, .Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. 3. Expiration Dating (Beyond-Use Dating) 5. When the original seal of a manufacturer's container or vial is initially broken, the container or vial is initially broken, the container or vial will be dated. a. The nurse shall place a date opened sticker on the medication and record the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days from opening, unless the manufacturer recommends another date or regulations/guidelines require different dating. b. If a vial or container is found without a stated date opened, the date opened will automatically default to the date dispensed and the expiration date will be calculated accordingly, unless otherwise indicated in a facility-specific policy .

Based on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident's #14) and 2 of 4 staff (CNA A and NA B) reviewed for infection control. The facility failed to ensure CNA A and NA B performed hand hygiene and observed EBP by not following the instructions on the posted signage on Resident #14's door requiring the use of gown and gloves when providing care to Resident #14 on 9/08/25 and did not clarify with nursing staff when there was no PPE bin. This failure could place residents at risk of exposure to infectious diseases due to improper infection control practices.Findings included: Record review of Resident #14's facility face sheet dated 09/09/25 revealed Resident #14 was an [AGE] year-old female that admitted to the facility on [DATE] with diagnosis of diabetes.Record review of Resident #14's Quarterly MDS assessment dated [DATE] revealed Resident #14 had a BIMS of 15 indicating intact cognition and was always incontinent and was dependent on staff for toileting. Record review of Resident #14's comprehensive care plan dated 9/9/2024 revealed Resident #14 had an ADL Self Care Performance Deficit and required staff times two for toileting assistance.During an observation on 09/08/25 at 9:50 AM Resident #14 had a sign on her door for EBP indicating gloves and a gown were required for care.During an observation on 09/08/25 at 2:07 PM CNA A and NA B performed incontinent care to Resident #14. Neither performed hand hygiene before applying gloves nor placed PPE for EBP. CNA A opened Resident #14's brief and cleaned front to back using wipes. NA B assisted resident to right side and Resident #14's buttocks, and peri area were cleaned with wipes front to back by CNA A. The soiled brief was removed by CNA A. Using the same soiled gloves a clean brief was applied by CNA A, and Resident #14 was rolled back to her left side and brief secured. The linen and bed were repositioned by CNA A wearing the same soiled gloves. Both removed their gloves, placed them in a bag and left the room without performing hand hygiene. During an interview on 09/08/25 at 2:12 pm CNA A said she had started at the facility a week ago but had been a CNA for many years. She said she should have performed hand hygiene when she entered the room, between soiled and clean task and before leaving the room. She said she was nervous. She said she did not see the sign on the door and there was no cart by the door, so she was not aware the resident required EBP. She said when a resident required EBP you were to wear gloves and a gown with care. She said by not following infection control infections could spread. During an interview on 09/08/25 at 2:18 pm NA B said she saw the sign for EBP but there was not a PPE cart outside the door, so she proceeded without asking. She said she should have applied PPE and performed hand hygiene when she entered the room and before leaving the room. She said not following the infection control procedures infections could spread. During an interview on 09/08/25 at 2:44 PM LVN C said that Resident #14 was no longer on EBP, and the PPE was removed but not the sign. She said the staff should still recognize the sign and follow the guideline or ask before providing care. She said not following EBP could cause infections to spread. During an interview on 09/09/25 at 1:45 pm the DON said she was the infection prevention nurse and responsible for the oversight of the infection control program. She said all staff were trained on infection control measures including hand hygiene and EBP on hire and annually and she monitors randomly as needed to ensure the staff were following the program. She said that not following the infection control program could possibly cause transmission of infections. During an interview on 09/09/25 at 1:50 pm the Administrator said the DON was responsible for the infection control program. She said the staff were monitored randomly but trained on hire and annually. She said she expected all staff to follow the infection control protocols to prevent the spread of infections in the facility. Record review of CNA proficiency Audit dated 4/28/25 indicated NA B successfully completed skills for infection control for hand hygiene, incontinent care and infection control practices. Record review of CNA proficiency Audit dated 9/02/25 indicated CNA A successfully completed skills for infection control for hand hygiene, incontinent care and infection control practices. Record review an undated facility policy titled Perineal Care indicated, .1. place equipment on the bedside table, 2. wash and dry hands, 7. put on gloves, 10. remove gloves, 11. wash and dry hands .Record review of a facility policy titled Handwashing/Hand Hygiene dated October 2023 indicated, .hand hygiene is the primary means to prevent the spread of infections. Indications for Hand Hygiene: 1. a. immediately before touching a resident, d. after touching a resident, immediately after glove removal .Record review of a facility policy titled Enhanced Barrier Precautions dated 4/1/24 indicated, .1. Prompt recognition of need: a. all staff receive training on enhanced barrier precautions and are expected to comply with all designated precautions. c. the facility will have discretion on how to communicate which residents require EBP as long as the staff are aware of which residents require EBP .

Based on record review and interviews the facility failed to ensure the arbitration agreement contained all the required elements for 1 of 1 facility reviewed for Arbitration Agreements.The facility did not ensure the arbitration agreement granted the resident or his/her representative the right to rescind the agreement within 30 calendar days of signing.This failure could place the residents or the residents' responsible parties in binding agreements not fully understood, have a loss of their legal rights, and cause negative psychological issues. Findings included:Record review of an Arbitration Agreement dated November 2024 indicated the agreement did not grant the resident or his/her representative the right to rescind the agreement within 30 calendar days of signing.During an interview on 9/9/25 at 9:17 am Administrator said she was responsible for the arbitration agreements, and she had not had anyone enter into a binding agreement. She said it was something new for her since the facility was under new ownership since December of last year. She said she was not aware of the requirements of the arbitration agreement. She said the agreement was supplied by corporate office and she would have it corrected. She said the facility did not have a policy regarding arbitration agreements.

Based on observation, interview, and record review the facility failed to ensure the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 2 (Resident #1) residents at risk for elopement reviewed for supervision. The facility failed to ensure the front lobby door alarm was functioning properly. On 4/8/2025 Resident #1 eloped from the facility and was found lying outside of the facility on the sidewalk where she had fallen and sustained a right hip fracture. An IJ was identified on 6/2/25. The IJ began on 4/8/2025 and was removed on 4/16/2025. The facility took action to remove the IJ before the survey began. While the IJ was removed on 4/16/2025, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm potential for minimal harm because all staff had not been trained on supervising residents to prevent elopement. This failure could place residents at risk of not being properly supervised resulting in injury or death. Findings included: 1.Record review of the electronic face sheet for Resident #1 indicated Resident #1 originally admitted to the facility on [DATE] with the most recent readmission on [DATE] with diagnoses that included: dementia (decline in cognitive function), muscle weakness, and urinary tract infection. Record review of Resident #1's annual MDS assessment dated [DATE] indicated a BIMS score of 02, which indicates severe cognitive impairment. It also indicated Resident #1 was not assessed for walking 10 feet due to medical condition or safety concerns. Record review of Resident #1's care plan dated 4/9/2025 indicated: Risk for injury: Fall occurred on 4/8/2025 during elopement attempt interventions included: Educate on the importance of maintaining a safe environment, free of potential fall hazards. Record review of Resident #1's elopement risk assessment dated [DATE] indicated an elopement score of 02 which was of moderate risk category. Record review of Resident #1's elopement risk assessment dated [DATE] indicated an elopement score of 07 which was of high-risk category. Record review of the facility's incident report for Resident #1 dated 4/8/2025 at 1:28am completed by the LVN A indicated: This nurse was alerted by another resident that he could hear crying from outside his window. This nurse and one aide to check out the calls and resident was observed laying on back on sidewalk with left knee bent. Resident asked staff not to touch her because of pain 10/10 in right hip. Resident had no visible injuries and denies hitting head. 911 called. Administrator notified. Responsible party called. Record review of hospital records dated 4/8/2025 indicated Resident #1 had a acute comminuted displaced right intertrochanteric fracture with apex lateral angulation (right hip fracture). Resident #2 was admitted to the hospital and underwent surgical repair. 2. Record review of the electronic face sheet for Resident #2 indicated Resident #2 originally admitted to the facility on [DATE] with the most recent admission on [DATE] with diagnoses that included: type 2 diabetes (high blood sugar), weakness, and unsteadiness of feet. Record review of Resident #2's admission MDS assessment dated [DATE] indicated a BIMS score of 12, which indicates moderate cognitive impairment. Record review of Resident #2's care plan dated 10/6/2022 indicated: Resident #2 had an ADL self-care performance deficit with interventions that included: Transferring requires 1 staff assistance for safety. During an interview on 6/2/2025 at 10:34 am, LVN C said the lobby door alarm could not be heard about halfway down the long hall or if they were in a resident room or if a resident had a TV on that was loud. She said she came in the next morning after the incident with Resident #1. She said the nurse was LVN A that was there when it happened. During an interview on 6/2/2025 at 12:13pm Resident #2 said on the night Resident #1 fell outside he woke up about 1:15am and heard yelling help me. He said it took him a minute to realize it was not the lady next door and that it was coming from outside. He said he turned on his call light and after 5-10 minutes when no one came he took his grabber tool and started banging on the wall. He said after about 5 minutes later someone finally came and he told them about the yelling outside. He said he did not hear any alarms going off at that time. He said he found out the next day that a lady had fallen outside. He said he found out a few days later that the door alarm was not working that night and had not been working for at least about a week. During an interview on 6/2/2025 at 12:48 pm CNA D said when she got to work on the evening shift 4/7/2025 Resident #1 was focused on going home. She said Resident #1 wanted to call her family member because she was confused. She said she convinced Resident #1 to stay at the facility and she took her to her room about 11:15pm. She said she went down to check on Resident #1 again at 11:30-11:45pm and the resident was asleep. She said her and the other CNA was making their round. She said about 12:30-1:00am the other aide came and told her Resident #1 got outside. She said Resident #2 had started banging on the wall and when the nurse went to see why he was banging on the wall that was when they discovered that Resident #1 had gotten outside and fell. So she ran outside, the nurse and other aide was outside. She said when she went outside the alarm was not sounding and she had to put in the code to get out of the door. She said the nurse told her the doors were still not fixed. She said the doors had been messed up for about 2 weeks or longer. She said they tested the door alarm by the loading dock, she set the alarm off and she never heard the door alarm. She said the nurse took a video of the door not working and sent it to the Administrator. She said the Administrator told them they should have been doing every 15 minute checks. She said she told the Administrator about a week prior to the incident that the door was messed up and was told there was an order in for it to be fixed. She said she reported it again that the door was not working right. She said they checked the front door that night the door was in maintenance mode and the alarm was not going off. She said that next morning after the incident the Administrator had the Maintenance Director check the door because it was not working right. She said she knew when Resident #1 fell the door had been messed for at least 2 weeks. During an interview on 6/2/2025 at 1:12 pm the Maintenance Director said there was a programming issue with the doors. He said sometimes the door would secure and sometimes it would not. He said when he checked the doors the next morning after the incident, they were alarming. He said when he started checking the doors regularly that's when they figured out the doors were not working properly. He said he had not had any problems with the doors since the company came out and reprogrammed the doors on 4/8/2025. During an interview on 6/2/2025 at 1:35 pm, the Administrator said it was reported to her about a week prior to Resident #1's fall that the lobby door was not functioning properly. She said she had the previous Maintenance Director show the Current Maintenance Director how to reset the door codes. She said on 4/8/2025 after Resident #1's fall she had a company come out to service the doors and the doors were in maintenance mode. She said the company was able to reprogram the doors at that time which fixed the problem with the doors. She said the other resident that was an elopement risk had not been exit seeking but was placed on 15 minute checks to increase supervision. During an interview on 6/2/2025 at 2:00 pm, CNA B said she had worked a double shift on the day that Resident #1 got out of the facility and fell outside. She said earlier that day Resident #1 had been exit seeking and wandering in the facility. She said LVN A had notified Resident #1's family that she had been exit seeking and even asked for a family member to come and sit with the resident. She said Resident #2 started banging on his wall and LVN A went to check on him and he told her about the yelling coming from outside. She said LVN A and her went to go check on Resident #1 and outside and that was when they discovered she had gotten out of the facility and fell. She said when her and LVN A went outside the lobby door was not alarming, but they did have to put in the code to get outside. She said the door had not been functioning properly for about a week and knew that LVN A had reported that the door was not functioning properly. During an interview on 6/2/2025 at 2:12 pm the ADON said she knew there was a problem with the doors the day before Resident #1 got outside and fell. She said her and the Administrator checked the doors before they left on 4/7/25 and all doors were working properly so she thought the doors were fixed. Record review of the facility's Elopement and Wandering Residents policy dated 1/1/2023 indicated: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk . Record review of an in-service titled Resident Rights dated 4/8/2025 with 37 employee signatures. Record review of in-service titled Elopement and Wandering Residents dated 4/8/2025 with 36 employee signatures. Record review of in-service titled Abuse/Neglect dated 4/8/2025 with 36 employee signatures. Record review of in-service titled Accidents/Incidents and Supervision dated 4/8/2025 with 39 employee signatures. Record review of in-service titled Fall Prevention Program dated 4/8/2025 with 37 employee signatures. Record review of in-service titled Exit Doors and Alarms dated 4/8/2025 with 37 employee signatures. Record review of in-service titled Elopement Binder dated 4/16/2025 with 44 employees educated. Record review of invoice from the repair company dated 4/8/2025 at 9:31am indicated when codes were changed the exit code was put as the maintenance bypass (no alarm). Verified codes in system did what they were supposed to be. All doors working properly. Record review of Daily Door Log dated 4/8/2025 through 5/30/2025 indicated the Maintenance Director had checked doors daily to ensure proper functioning. Record review of Daily Door Log dated 4/8/2025 through 6/2/2025 indicated the nurses had checked the doors every shift to ensure proper functioning. Record review of Resident #1's electronic medical record indicated Resident #1 discharged from the facility on 5/9/2025. During an observation of the doors on 6/2/2025 at 10:30 am the door handle was pushed, and the door began a 15 second count down, the door released and the alarm sounded appropriately. During interviews between 6/2/2025 at 8:45 am through 6/3/2025 at 11:00 am staff were able to appropriately verbalize the elopement procedures and knew appropriate interventions for wandering residents, abuse/neglect procedures, resident rights, fall prevention procedures, exit door and alarms, the elopement binder and daily door checks: Administrator, DON, ADON, LVN A, CNA B, LVN C, CNA D, MA E, CNA F, and the Maintenance Director. On 6/2/25 at 4:26 pm the Administrator, and DON were informed of IJ. The IJ began on 4/8/2025 and removed on 4/16/2025. The facility took action to remove the IJ before the survey began. While the IJ was removed on 4/16/2025, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm potential for minimal harm because all staff had not been trained on supervising residents to prevent elopement.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents reviewed for infection control. (Resident #5) The facility failed to ensure CNA A did not leave a trash bag containing a used brief on the floor of Resident #5's room on 8/5/24. The facility failed to implement enhanced barrier precautions for Resident #5 on 8/6/24. These failures could put residents at risk of infections and decreased quality of life. Findings include: Record review of a facility face sheet dated 8/6/24 for Resident #5 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: Extended Spectrum Beta Lactamase (ESBL) Resistance and urinary tract infection. Record review of a Quarterly MDS assessment dated [DATE] for Resident #5 indicated that she had a BIMS score of 3, which indicated that she had severe cognitive impairment. She was always incontinent of bowel and bladder. She required moderate to total assistance with toileting and personal hygiene. Section I (Active Diagnoses) indicated that she had a multi-Drug resistant organism (MDRO). Record review of an Order Report Summary dated 8/6/24 for Resident #5 indicated that she did not have an order for enhanced barrier precautions. Record review of a comprehensive care plan dated 4/30/24 for Resident #5 indicated that she had a focus of Resident is on enhanced barrier precautions Interventions included .Gloves and gown should be donned if any of the following activities are to occur: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high-contact activity ad .Posting at the resident room entrance indicating the resident is on enhanced barrier precautions Comprehensive care plan also indicated that she had a focus f .The resident has Urinary Tract Infection, placed on Macrobid 100mg daily for prophylactic colonized ESBL with interventions includig .Continue enhanced barrier precautions dated 6/15/24. Record review of hospital records for Resident #5 from admitted [DATE] red .Microbiology: UA revealed quite significant pyuria with urine cultures growing out an ESBL producing E. coli. ad .Assessment and Plan of Treatment: UTI with an ESBL producing gram-negative rod Record review of Resident #5's electronic medical record dashboard on 8/6/24 indicated that she had enhanced barrier precautions. Record review of an undated list of residents on enhanced barrier precautions provided by the DON indicated that Resident #5 was not on the list. During an observation on 8/5/24 at 9:23 a.m., a clear plastic trash bag was noted on the floor in Resident #5's room. It contained what appeared to be a used brief. Residents room did not have signage indicating that she was on enhanced barrier precautions. During an interview on 8/5/24 at 9:26 a.m., LVN B said the trash bag should not have been left in Resident #5's room on the floor. She said residents could be at risk of infection if proper infection control measures were not followed. During an interview on 08/06/24 at 02:15 p.m., CNA A said she had taken care of Resident #5 yesterday morning. She said she had changed her and went to get the barrel and got distracted. She said she had left the trash bag in there and she was upset about it. She said she'd been trained on infection control. She said she would do better in the future. She said she was unaware that resident was to be on EBP until today. She said Resident #5 did not have the sign or PPE there until earlier today. She said it was not there during incontinent care this morning. She said residents could be at risk of developing infections if proper infection control measures were not followed. During an observation on 08/06/24 at 10:05 a.m., CNA A and CNA C were both present in Resident #5's room to provide incontinent care. Both washed their hands in the bathroom and applied gloves. Had supplies set up on an overbed table in the room. CNA C pulled the covers down and opened the resident's brief and placed it between her legs. CNA A rolled the resident onto her right side and CNA C removed the brief and placed it in the trash. CNA C removed her gloves and placed them in the trash and washed her hands. CNA C placed gloves on both hands, placed a towel underneath the resident's buttocks. CNA A placed a towel over the resident to cover her. Both CNAs removed their gloves and placed them in the trash, sanitized their hands and applied gloves. CNA C removed a wipe from the plastic bag and wiped across the lower abdomen and placed the wipe in the trash. CNA C removed another wipe and wiped down the middle of the vagina from front to back and placed the wipe in the trash. CNA C removed another wipe from the plastic bag and wiped both inner thighs and placed the wipe in the trash. CNA C removed her gloves and placed them in the trash, washed her hands and applied gloves. CNA A rolled the resident onto her right side and CNA C removed a wipe from the plastic bag and wiped the resident's rectal area from front to back. CNA C removed the towel that was underneath the resident's buttocks and removed her gloves. CNA C sanitized her hands and put on gloves. CNA C placed a brief and secured it in place. Both repositioned the resident in bed, removed their gloves and washed their hands. During an interview on 8/6/24 at 3:40 p.m., CNA C said they had an in-service some months ago by the Administrator on EBP. She said they were told which residents were on EBP and they also had notes on the resident doors along with PPE in drawers outside of their rooms in the hallways. She said when a resident was on EBP that meant the staff had to wear a gown and gloves while providing incontinent care. She said the residents that were on EBP included Resident #5. During an interview on 8/6/24 at 3:45 p.m., LVN B said the residents that were on EBP included Resident #5,who was placed on EBP earlier that day. She said anyone with a history of ESBL colonization, anyone with wounds, foley catheters, have MRSA or any opening to the body that could cause infection would be placed on EBP. During a joint interview on 08/07/24 at 11:47 a.m., the DON said that going forward they would review all hospital records when residents come back from hospital and take appropriate actions with MDROs. DON and Administrator said they would be providing education to all the staff, and they would be doing a PIP and QAPI. DON said they would be reviewing CMS guidelines to ensure they follow the appropriate infection control practices. DON said residents could be at risk of an outbreak of proper procedures were not followed. Record review of a CNA Proficiency Audit for CNA A dated 4/16/24 indicated she had been trained on infection control awareness, including universal precautions, with perineal care. Record review of a facility policy titled Enhanced Barrier Precautions undated read: 1.EBP are indicated for residents with any of the following: Colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply (see MDRO list on page 3) .; 2.Resident status: Colonized with a CDC-targeted MDRO without a chronic wound, indwelling medical device or secretions that are unable to be covered or contained. Use EBP: Yes .; 3.Donning PPE for Residents on EBP Based on activity provided / assistance while in resident room: providing hygiene .Don gloves and gown: yes .; 4. (from page 3, referenced above) .List of colonized MDRO to utilize EBP: .ESBL-producing Enterobacterales .; 5.Communication to staff: The facility will utilize postings outside the room and Point Click Care to communicate to staff if a resident requires EBP . Record review of a facility policy titled Perineal Care Female dated 2003, with a revision date of December 8, 2009, read .Closing steps .discard disposables per facility policy . Record review of CMS Memo titled Center for Clinical Standards and Quality/Quality, Safety & Oversight Group Ref: QSO-24-08-NH read .The recommendations now include the use of EBP during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply .

Based on observation, interview, and record review the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity for 1 of 4 (Resident #34) residents reviewed for dignity in that: The facility failed to ensure Resident #34's urinary drainage bag had a dignity/privacy cover while out of his room. This deficient practice could place residents in the facility at risk for a diminished quality of life, loss of dignity and self-worth. Findings: Record review of facility face sheet dated 5/23/2023 indicated Resident # 34 was admitted on [DATE] with diagnosis aftercare following digestive system surgery, urinary tract infection, and obstructive uropathy (blockage of urinary tract). Record review of Quarterly MDS dated [DATE] indicated Resident # 34 had a BIMS of 11 indicating moderately impaired cognition and required indwelling urinary catheter. Record review of care plan with review date of 05/01/2023 indicated Resident # 34 had an indwelling foley catheter, and approach was to position catheter bag in a privacy bag. Record review of order summary report dated 5/23/2023 indicated Resident # 34 had an order dated 10/08/2022 to ensure foley catheter bag was in a privacy bag while in bed or wheelchair. During an observation on 05/22/23 at 11:52 AM Resident # 34 was lying in bed with a foley catheter attached to bedframe. The catheter drainage bag was without a privacy cover. During an observation on 05/23/23 at 9:48 AM Resident # 34 was ambulating in the hallway with COTA and rehab director using a walker. His foley catheter drainage bag was attached to the walker with dark yellow urine in the bag without a privacy covering. During an interview on 05/23/23 at 9:59 AM Resident # 34 stated he was not aware his catheter bag had to be covered but could see how that would be important to protect his privacy. He had nothing further to comment regarding his catheter. During an interview on 05/23/23 at 10:25 AM the COTA stated that a residents privacy and dignity was maintained by not discussing their health openly, closing doors, and pulling privacy curtains. She stated foley catheter drainage bags should also be covered to maintain resident privacy and dignity. She stated she had been trained on privacy covering of catheter bags and should have put a cover on the walker before getting Resident # 34 up to walk. She stated that by not covering it could affect a residents dignity. During an interview on 05/23/23 at 2:12 PM the rehab director stated that resident privacy and dignity was maintained by protecting resident information. She stated that Resident # 34's catheter drainage bag should have been covered when he was up walking with therapy in the hallway. She stated she had been trained on dignity and that by not covering the bag it could cause the resident embarrassment. She stated she would make sure there was a privacy cover for future therapy sessions. During an interview on 05/23/23 at 2:20 PM LVN B stated that when a resident has a urinary catheter they are to have a privacy cover over the drainage bag and the nurse was responsible for monitoring that it was there. She stated when she last checked he had a privacy bag on his bed and wheelchair but was not aware Resident #34's drainage bag was exposed during therapy. She stated the drainage bag is covered for dignity and privacy reasons and if it was not covered it could cause resident embarrassment. During an interview on 05/23/23 at 2:22 PM the DON stated she was responsible for all nursing oversight and expects that residents with an indwelling catheter to have a privacy cover in place at all times. She stated all staff had been trained on privacy and dignity. She stated by not covering the drainage bag it could affect the residents dignity. During an interview on 05/24/23 at 8:25 AM the administrator stated that she was responsible for ensuring privacy and dignity for all residents at the facility. She stated all staff are trained on resident rights on hire, annually, and as needed. She stated the risk of not maintaining a residents dignity could be belittlement. She stated here expectation was that all residents rights are honored, and dignity maintained. Record review of the facility's policy titled Resident Rights dated 11/28/2016 indicated, .facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents reviewed for infection control. (Resident #20) CNA A and CNA B did not wash or sanitize her hands when changing gloves while performing incontinent care to Resident #20. This failure could place residents at risk of exposure to communicable diseases and infections. Findings included: Record review of an Admission Record for Resident #20 dated 3/23/2022 indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a Significant Change MDS Assessment for Resident #20 dated 2/10/2022 indicated she had severe cognitive impairment with a BIMS score of 3. She required extensive assistance with a 2 person assist with bed mobility, transferring, dressing, and toilet use. Skin condition indicated she had 1 unstageable wound and she is always incontinent of bowel/bladder. Record review of a Care Plan for Resident # 20 with a date of 4/2/2021 indicated a focus that she had a potential for pressure injury development. Record review of a Care Plan for Resident #20 dated 2/13/2022 indicated a focus that she has an indwelling foley catheter related to pressure ulcer un-staged wound to right hip. Interventions included to ensure tubing is anchored to the resident's leg or linens so that tubing is not pulling on the urethra. During an observation on 3/21/2022 at 3:27 PM, CNA A and CNA B were getting supplies for Resident # 20 outside in the hallway to perform incontinent care. Both CNA A and B washed their hands in the resident's bathroom prior to providing care. Both placed gloves on their hands. Resident # 20 was lying in bed on her left side. Covers were removed and a clear dressing with a white gauze underneath was visible to the resident's right buttock. Contractures were noted to Resident #20's left hand and both lower extremities. Resident #20 had a foley catheter that was anchored to the bed frame on the left side of bed. CNA A and CNA B pulled Resident #20's brief down and CNA A removed wipes from the container with her left and used her right hand to wipe fecal material from the front of Resident #20's perineal area to her rectum. CNA B was assisting with holding Resident #20's legs and with turning and repositioning. CNA A removed her gloves and placed them in the trash. CNA A did not wash or sanitize her hands after removing gloves. CNA A donned another pair of clean gloves and removed wipes from container and continued to clean rectum area from front to back. CNA A removed gloves and placed them in the trash. CNA A did not wash or sanitize her hands after removing gloves. CNA A donned (put on) another pair of clean gloves and cleaned rectal area with more wipes. CNA A removed her gloves and placed them in the trash. CNA A did not wash or sanitize her hands after removing gloves. CNA A donned another pair of clean gloves. CNA B removed the linens from the bed and rolled them underneath resident's buttocks. CNA A checked to be sure Resident #20's rectum was cleaned before placing clean linens on the bed and a clean brief on the resident. CNA A placed clean linens on the mattress and put them on top of the old linens and soiled brief. CNA A and CNA B rolled Resident #20 to her right side and removed the linens and brief and then positioned her on her back. CNA B placed the soiled brief in the trash and linens in a plastic bag. CNA B removed her gloves and placed them in the trash. CNA B did not wash or sanitize her hands after removing her gloves. CNA B donned clean gloves and assisted with placing clean linens on the mattress. CNA A removed a wipe from the container and cleaned Resident #20's perineal area and wiped from front to back. CNA A removed her gloves and placed them in the trash. CNA A did not wash or sanitize her hands after removing her gloves. CNA A donned clean gloves and CNA B positioned Resident #20 on her right side and covers placed on top of the resident. CNA A and CNA B removed their gloves and placed them in the trash, and both washed their hands in the resident's bathroom. During an interview on 3/21/2022 at 3:40 PM, CNA A said she had been employed at the facility for 6 years. When asked if she would have done anything differently with the incontinent care provided, she said she would have cleaned around Resident #20's foley catheter because they had just changed her brief and she forgot to do it when she was cleaning her. She said she didn't realize she did not wash her hands with glove changes. She said she was nervous, and she also had COVID a few months ago and her brain was not working like it should at times. She said she had been checked off for incontinent care during her annual competency skills check. She said she was trained to wash her hands or sanitize them before and after wearing gloves. During an interview on 3/21/2022 at 3:42 PM, CNA B said she had been employed at the facility for a couple of weeks and had only had her CNA certification for about a year. When asked if she would have done anything differently with the incontinent provided. CNA B said she would have washed or sanitized her hands with each glove change. She said she was nervous as well and had never been observed by a surveyor providing incontinent care. During an interview on 3/22/2022 at 3:45 PM, the DON said she if a staff member does not perform hand hygiene/washing with glove changes they could cause an infection, transfer of bacteria, and increased risk of [CONDITION(S)] to the residents. She said they started competency check offs with everyone employed for incontinent and foley catheter care yesterday. She said staff were usually assigned to the same hall and the DON and ADON conduct random monitoring to ensure the needs of the residents were being met. She said all staff that use gloves should wash or sanitize their hands with gloves changes. She said all staff would be in-serviced on hand washing/hygiene along with CNA A and B would be checked off on incontinent care again. Record review of a facility polity with a revised date of 2/13/2007 titled Catheter Care indicated, .5. Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. Keep tubing off floor and minimize friction or movement at insertion site. 14. Hold catheter tubing to one side and support against leg to avoid traction or unnecessary movement of the catheter while washing perineum. 16. Gently wash, rinse and dry around the juncture of the catheter and meatus. If using Pre-moistened no-rinse disposable wash cloths, rinsing is not required. 17. Then wash the catheter from the meatus down the tube about 3 inches . Record review of a facility policy dated 2019 titled Fundamentals of Infection Control Precautions indicated, .1. Hand Hygiene continues to be the primary means of preventing the transmission of infection. Before and after assisting a resident with personal care, after removing gloves or aprons; and after completing duty. Except for situation where hand washing is specifically required, antimicrobial agents such as ABHR are also appropriate for cleaning hands and can be used for direct resident care. Wearing gloves does not replace the need for hand washing .

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions in the kitchen. The facility did not operate the dish machine according to facility policy. Findings included: During an observation and interview on 09/30/19 at 10:25 a.m., the dietary manager demonstrated use of dish machine on four attempts. The highest temperature was 104 degrees F. The high temperature dish machine did not reach the manufacture's recommended of 120 degrees F. The dietary manager said the dish machine should reach the manufacturer's recommended temperature. The High Temperature Dish Machine Log indicated the dish machine was last tested on [DATE]. A policy from the Dietary Services Policy and Procedure Manual dated 2012 indicated Prior to washing the soiled dishes after a meal, the dish machine should be tested for proper temperature and PPM of sanitizing solution. The dish machine may need to be run empty for a few cycles to ensure the proper temperature is attained.

Based on observation, interview and record review the facility failed to ensure appropriate treatment and services for incontinence were provided for 1 of 16 residents reviewed for catheters. (Resident #6) The facility did not obtain a physician's orders [REDACTED].#6. Resident #6 received intermittent in and out catherization during the night. This failure could place residents who are incontinent at risk for infections. Findings included: Physician orders [REDACTED].#6 was an [AGE] year-old male re-admitted [DATE] with [DIAGNOSES REDACTED]. The orders did not contain an order for [REDACTED].>A physician order [REDACTED]. A physician's progress noted dated 08/22/19 indicated Resident #6 had an indwelling catheter for retention. The note indicated eventually the resident would go back to in and out catheterization. An MDS dated [DATE] indicated Resident #6 had no cognitive impairment and he did not have intermittent catheterizations performed. A care plan dated 06/21/19 indicated Resident #6 had monthly urinary tract infections. The care plan did not address intermittent catheterizations. A treatment administration record dated (MONTH) 2019 for Resident #6 did not included intermittent catheterizations. Progress notes for Resident #6 indicated an in and out catheterization was completed on the following dates: *09/03/19 at 8:41 PM, completed by RN C with 750 cc of urine *09/16/19 at 10:15 PM, completed by RN C with 350 cc of urine *09/25/19 at 9:30 PM, completed by RN C with 850 cc of urine. Prior to catheterization urinated 450 cc of urine. *09/26/19 at 9:16 PM, completed by RN C with 750 cc of urine. Prior to catheterization voided 250 cc of urine. *09/27/19 at 9:35 PM, completed by LVN B with 750 cc of urine. *09/28/19 at 9:32 PM, completed by LVN B, per request, with 1000 cc of urine. *09/29/19 at 9:51 PM, completed by LVN B, per request, with 975 cc of urine. Prior to catheterization voided 350 cc of urine. During an observation and interview on 09/30/19 at 9:56 AM, Resident # 6 was sitting in his room in a recliner. He said he used the toilet during the day but at night they used a tube to empty his bladder. During an interview on 09/30/19 at 2:36 PM, LVN A said LVN B reported performing and in and out catheterization on Resident #6 for the past two nights. She said his urine retention was worse with the urinary tract infection. During an interview on 09/30/19 at 3:55 PM, the DON said Resident #6 was hospitalized (MONTH) 15, 2019 and all his previous orders were discontinued. She said Resident #6 was readmitted [DATE]. She said prior to hospitalization [DATE], Resident #6 had orders for intermittent catherization. During an interview on 10/02/19 at 2:20 PM, LVN B said she should have checked for an order before performing the in and out catheterization. A physician's orders [REDACTED].

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food under sanitary conditions in the kitchen. The facility did not date or label food properly in the refrigerator and pantry. A scoop was left in the sugar. Cook A did not use the dish machine to sanitize cooking equipment. Cook B did not wear a beard protector while working in the kitchen. Findings included: 1. During an observation on 10/22/2018 at 9:35 AM, Cook A was in the kitchen without a beard protector. During an interview on 10/22/2018 at 9:40 AM, Cook A said he was supposed to wear a beard protector while in the kitchen. During an observation of the pantry at 9:46 AM, an open box of quick grits was inside a zip lock bag. There was no label or date on the bag. A plastic container used for a scoop was in the sugar. During an observation on 10/22/2018 at 9:50 AM, scrambled eggs were thawing in a clear plastic bag in the refrigerator. There was no label or date on the bag. During an interview on 10/22/2018 at 9:55 AM, the DM said staff should label, date, the food when it was opened. She satff knew to wear beard covers in kitchen. The Food and Drug Administration Code 2013 accessed 10/26/18 at http://www.fda.gov/Food/GuidanceRegulation/RetailFoodProtection/FoodCode/ucm 8.htm indicated the following: .Hair Restraints 2-402.11 Effectiveness. (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES . A policy for Dry Storage and Supplies dated 2012 indicated .Dry bulk foods (e/g/ flour, sugar) are to be stored in seamless metal or plastic containers with tight covers or bins which are easily sanitized. Containers are labeled. Scoops should not be left in food containers or bins . Opened containers of food are stored in closed containers with tight covers and dated as to when opened . 2. During an observation on 10/23/2018 at 11:35 AM, Cook B washed the blender container in the two-compartment sink, rinsed with running water, then used the sanitizer hose to spray sanitizer directly onto the blender container for approximately 3 seconds, then rinsed under running water Cook B then prepared to place green beans in the blender. During an interview on 10/23/2018 at 11:45 AM, Cook B said that was the way she usually washed the blender container in the two-compartment sink. During an interview on 10/23/2018 at 11:50 AM, the DM said staff was to run the blender container through the dish machine before using it. A policy for Equipment Sanitation indicated .If a three-compartment sink is not available, the dishes can be washed in a two-compartment sink, and then transported to the dish machine and run through the machine to sanitize using the chlorine sanitizer that must reach 50 ppm and water temperature of at least 120 degrees .

Based on observation, interview and record review the facility failed to ensure residents had the right to examine the results of the most recent survey of the facility in a place readily accessible to residents and family and have reports of surveys from the 3 preceding years available. The facility did not keep the survey results in a place that was readily accessible to residents and family or that 3 preceding years of survey results were available. The survey results were kept in a binder on the lower shelf of an end table in the reception area. Resident #s 1,2, 4, 11, 12 and 19 said they were not aware of where the survey results were kept. Findings included: During an observation on 10/22/18 at 12:30 PM, the survey results were kept in a green binder with Survey results written on the cover. The survey binder was placed on the lower shelf of an end table in the reception area and not visible unless you were looking down to find binder. During an interview on 10/22/18 at 1:31 PM, the administrator said the survey results were kept in the reception area. The administrator said the binder contained survey results from (YEAR) and (YEAR) surveys. She said the binder did not contain the survey results of the past year. During an interview on 10/23/18 at 11:15 AM, Resident #s 1, 2, 4, 11, 12 and 19 said they were not aware of where the facility kept the survey results binder. They said the results might be posted on the wall beside the business office.

Based on observation, interview, and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition. The facility did not ensure the stove was in working order. Two of four stove burners did not light. This failure could place the census of 38 residents at risk for injury. Findings included: During an observation on 12/5/17 at 8:52 a.m., two of four stove burners did not light automatically. During an interview on 12/5/17 at 8:52 a.m., the dietary manager said the burners should light when the knobs were turned on. The CMS 672 dated 12/4/17 indicated a census of 38 residents.

Based on observation, interview and record review, the facility failed to ensure medications were secured on 1 of 5 medication carts reviewed for pharmacy services. (Hall 100 medication cart) The facility did not ensure medications were secured on the Hall 100 medication cart. LVN A locked the cart, but left the keys to the cart laying on top of it. This failure could place 26 residents who resided on Hall 100 at risk of a drug diversion. Findings included: During an observation on 12/06/17 at 2:06 p.m., LVN A locked the Hall 100 medication cart, entered a resident's room, and closed the door behind her. She left the keys on the top of the medication cart, unattended. During an interview on 12/06/17 at 2:08 p.m., LVN A said normally, she did not leave her keys on top of the medication cart. LVN A said they were heavy referring to her keys. During an interview on 12/0617 at 3:30 p.m., the DON said the nurses should lock the medication cart, and keep the keys with them. An undated Medication Carts policy noted, .The carts are to be locked when not in use or under the direct supervision of the designated nurse . A handwritten statement on the policy noted, .Keys kept on person not on top of cart . The facility 802 dated 12/06/1717 indicated 26 residents resided on Hall 100.

Based on observation and interview, the facility failed to maintain essential equipment in safe operating condition for the facility. The gasket on the walk-in freezer was missing causing heavy ice build-up. This failure could place 34 residents who ate meals prepared in the kitchen at risk for poor food quality. Findings included: During an observation on 01/03/2017 at 10:05 a.m., the walk-in freezer threshold gasket was missing. There was a heavy build-up of ice on the food,ceiling, and floor. The FSS said this had been happening for a long time and the administrator were aware of the ice build-up. During an interview on 01/05/2017 at 3:20 p.m., the maintenance man said he was aware the walk-in freezer had ice build-up, but did not know the gasket was missing. The CMS 672 dated 05/18/2015 indicated there are 34 residents who received meals prepared in the kitchen.

Based on interview and record review the facility failed to provide an on -going program for planned activities in accordance with the comprehensive assessments to meet the needs and interest of 9 of 9 residents reviewed for activities. (Resident #s 8, 9, 10, 20, 21, 30, 32, 35, and 37) Resident #s 8, 9,10, 20, 21, 30, 32, 35, and 37 said the facility did not provide activities on weekends. This failure could place14 residents who participates in activities at risk for of deminished social interactions and a decreased quality of life. Findings included: During a group interview on 01/03/2017 at 2:00 p.m., Residents #s 8, 9, 10, 20, 21, 30, 32, and 35 complained there were no activities on the weekends. The activity calendar for January 1-31 2017 indicated the following activities were scheduled on the weekends: morning pledge and prayer, family visits, dominoes, church, and coloring. 1. Physicians orders dated 12/27/2016 indicated Resident #8, admitted [DATE], with [DIAGNOSES REDACTED]. A care plan revision date 09/11/2017 indicated Resident #8 .will express satisfaction with activities and level of activity indolent . During interview on 01/04/2017 at 2:10 p.m., Resident # 8 said there were no activities offered on weekends, except church. He said he did not attend church. 2. Physicians orders dated 12/27/2016 indicated Resident #9, admitted [DATE] [DIAGNOSES REDACTED]. The activity quarterly assessment dated [DATE] indicated Resident #9 participated in activities independently. The assessment indicated Resident #9 .prefers to be with people, makes friends easily, and prefers to be out of room . During interview on 01/04/2017 at 2:10 p.m., Resident # 9 said there were no activities offered on weekends. She said said she did not enjoy watching television or movies. She said she would like sewing projects with a group. 3. Physicians orders dated 12/27/2016 indicated Resident #10, admitted [DATE], with [DIAGNOSES REDACTED]. The activity quarterly assessment dated [DATE] indicated Resident #10 attended activities regularly and participated independently. The Resident prefered to be out of his room. During interview on 01/04/2017 at 2:10 p.m., Resident # 10 said there were no activities offered on weekends. He said he liked to play dominoes with other residents, but dominoes were not available on the weekends. 4. Physicians orders dated 12/27/2016 indicated Resident #20, admitted [DATE], with [DIAGNOSES REDACTED]. The activity quarterly sssessment dated 11/22/2016 indicated Resident #20 .attends activities regularly and participates independently . During interview on 01/04/2017 at 2:10 p.m., Resident #20 said there were no activities offered on weekends. She said she liked to play bingo and reading. 5. Physicians orders dated 12/27/2016 indicated Resident #21, admitted [DATE], with [DIAGNOSES REDACTED]. The activity quarterly assessment dated [DATE] indicated Resident #21 .attends activities regularly and participates independently . During interview on 01/04/2017 at 2:10 p.m., Resident #21 said there were no activities offered on weekends. He said he missed activities on the weekend, because it's too quiet . 6. Physicians orders dated 12/27/2016 indicated Resident #30, admitted [DATE], with [DIAGNOSES REDACTED]. The activity quarterly assessment dated [DATE] indicated Resident #30 .attends activities regularly and participates independently. The resident prefers to be out of room . During interview on 01/05/2017 at 2:05 p.m., Resident #30 said no activities were offered on weekends. He said the nurses were too busy taking care of the residents. He said he would like to play bingo or cards, something besides a movie. 7. Physicians orders dated 12/27/2016 indicated Resident #21, admitted [DATE], with [DIAGNOSES REDACTED]. The activity quarterly assessment dated [DATE] indicated Resident #21 .attends activities regularly and participates independently. The Resident prefers to be out of room . During interview on 01/05/2017 at 10:00 a.m., Resident #32 said no activities were offered on the weekends. She said since her husband passed she liked to stay busy, but Its too quiet on the weekends. 8. Physicians orders dated 12/27/2016 indicated Resident #35, admitted [DATE], with[DIAGNOSES REDACTED]. The activity quarterly assessment dated [DATE] indicated Resident #32 .attends activities regularly and requires assistance to attend. The Resident prefers to be out of room . During interview on 01/03/2017 at 2:10 p.m., Resident #35 said no activities were offered on weekends. She said she enjoyed the activities during the week but wanted to have activities on the weekends too. 9. Physicians orders dated indicated Resident #37 had the following [DIAGNOSES REDACTED]. The activity quarterly assessment dated [DATE] indicated Resident #37 . participated in independent activities of choice and all psychosocial needs were checked including group interaction, and competition . During interview on 01/04/2017 at 2:10 p.m., Resident #37 said no activities were offered on weekends. During an interview on 01/04/2017 at 3:10 p.m., the activity director said she did not know if weekend activities were being done or not. She said there was no system in place for the residents to have planned activities on the weekends. During interview on 01/05/2017 at 2:00 p.m., the administrator said there was no staff to provide weekend activities. A list provided by the activity director on 01/05/2017 at 2:30 p.m., indicated 14 residents attended group activities.

Based on interview and record review, the facility failed to ensure 2 of 44 employees (CNAs D and F) were trained on their responsibilities in emergency procedures. CNA D did not know the actions to take in the event of a fire. CNA F did not know where the disaster plan was located. This failure could place the census of 38 residents at risk of injury in the event of a fire or disaster. Findings Included: During an interview on 1/12/16 at 1:45 p.m., CNA D said if the fire alarm was activated, her response would be to avoid the fire and seek the nearest exit. During an observation and interview on 1/12/16 at 11:45 a.m., the disaster plan was in a red notebook labeled Disaster Plan on a shelf at the nurses' station. CNA F said the disaster plan was located at the nurses' station. CNA F pointed to the facility floor plan posted on the wall and said that was the disaster plan. She said a detailed plan, such as a Disaster Plan notebook, was not there. During an interview on 1/12/16 at 2:00 p.m., the administrator said the facility conducted training on emergency preparedness and had fire drills monthly. She said the staff should know how to respond to a fire and where the disaster manual was located. The CMS 672 dated 1/11/16 indicated a census of 38 residents.

Based on observation, interview, and record review, the facility failed to ensure 3 of 3 CNAs (CNA B, CNA C and CNA D) observed for incontinent care demonstrated competency in techniques for 2 of 2 residents reviewed for incontinent care. (Resident #s 5 and 25) 1. CNA D provided incontinent care for Resident #5. She did not change gloves between cleaning Resident #5's perineal area and rectum and used gloves from her uniform pocket. 2. CNAs B and C provided incontinent care for Resident #25. CNA B did not change gloves between cleaning the resident's perineal area and rectum. CNAs B and C used gloves from their uniform pocket. This failure could place 30 incontinent residents at risk for cross-contamination and infections. Findings included: 1. During an observation on 01/13/16 at 11:00 a.m., CNA D and CNA E provided incontinent care for Resident #5. CNA D donned gloves from her pocket and cleaned Resident #5's perineal area. With the soiled gloves, CNA D cleaned Resident #5's rectum and buttocks. She removed her gloves, washed her hands, and donned gloves from her pocket. CNA D placed a clean brief under Resident #5, dried the resident's buttocks, and applied a barrier cream. She removed her gloves and donned a new pair from her uniform pocket without washing her hands. 2. During an observation on 01/13/16 at 2:10 p.m., CNA B and CNA C provided incontinent care for Resident #25. CNA C obtained several gloves from the box of gloves and placed them in her uniform pocket. CNA C donned gloves from her pocket and CNA B donned gloves from her uniform pocket. CNA C assisted in turning Resident #25 and CNA B cleaned Resident #25's perineal area. With the soiled gloves, CNA B cleaned Resident #25's rectum and buttocks. She removed her gloves, washed her hands, and donned gloves from her pocket. CNA B placed a clean brief under Resident #25 and applied a barrier cream to Resident #25's buttocks. Both CNAs donned a new pair of gloves from their pocket and positioned the resident. During an interview on 01/13/16 at 2:35 p.m., CNA B said she always kept gloves in her pocket and acknowledged that she did not change gloves when she moved from cleaning Resident #25's front to the back. During an interview on 01/13/16 at 1:58 p.m., the DON said CNAs should not put on gloves from their pockets and they were to change gloves when they moved from cleaning the front (perineal area) to the back (rectum and buttocks). A Perineal Care Female Policy revised 02/14/07 noted, .Wash hands and put on clean gloves for perineal care .Continue to wash the rest of the perineal are, wiping from front to back, alternating from side cloth with each wipe .Change gloves .Assist resident to turn on side .Gently wash the rectal area and buttock .Change gloves .Apply moisture barrier .Remove gloves . The CMS 672 dated 01/11/16 indicated 30 residents were incontinent.

Based on observation, interview, and record review, the facility failed to maintain an effective infection control program to help prevent the development and transmission of disease for 2 of 2 residents reviewed for incontinent care (Resident #s 5 and 25). 1. CNA D provided incontinent care for Resident #5. She did not change gloves between cleaning Resident #5's perineal area and rectum and used gloves from her uniform pocket. 2. CNAs B and C provided incontinent care for Resident #25. CNA B did not change gloves between cleaning the resident's perineal area and rectum. CNAs B and C used gloves from their uniform pocket. This failure could place 30 incontinent residents at risk for cross-contamination and infections. Findings included: 1. During an observation on 01/13/16 at 11:00 a.m., CNA D and CNA E provided incontinent care for Resident #5. CNA D donned gloves from her pocket and cleaned Resident #5's perineal area. With the soiled gloves, CNA D cleaned Resident #5's rectum and buttocks. She removed her gloves, washed her hands, and donned gloves from her pocket. CNA D placed a clean brief under Resident #5, dried the resident's buttocks, and applied a barrier cream. She removed her gloves and donned a new pair from her uniform pocket without washing her hands. 2. During an observation on 01/13/16 at 2:10 p.m., CNA B and CNA C provided incontinent care for Resident #25. CNA C obtained several gloves from the box of gloves and placed them in her uniform pocket. CNA C donned gloves from her pocket and CNA B donned gloves from her uniform pocket. CNA C assisted in turning Resident #25 and CNA B cleaned Resident #25's perineal area. With the soiled gloves, CNA B cleaned Resident #25's rectum and buttocks. She removed her gloves, washed her hands, and donned gloves from her pocket. CNA B placed a clean brief under Resident #25 and applied a barrier cream to Resident #25's buttocks. Both CNAs donned a new pair of gloves from their pocket and positioned the resident. During an interview on 01/13/16 at 2:35 p.m., CNA B said she always kept gloves in her pocket and acknowledged that she did not change gloves when she moved from cleaning Resident #25's front to the back. During an interview on 01/13/16 at 1:58 p.m., the DON said CNAs should not put on gloves from their pockets and they were to change gloves when they moved from cleaning the front (perineal area) to the back (rectum and buttocks). A Perineal Care Female Policy revised 02/14/07 noted, .Wash hands and put on clean gloves for perineal care .Continue to wash the rest of the perineal are, wiping from front to back, alternating from side cloth with each wipe .Change gloves .Assist resident to turn on side .Gently wash the rectal area and buttock .Change gloves .Apply moisture barrier .Remove gloves . According to the website, <http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm>, accessed 1/21/16, the CDC indicated: Recommendations .Decontaminate hands after removing gloves .Change gloves during patient care if moving from a contaminated body site to a clean body site . The CMS 672 dated 01/11/16 indicated 30 residents were incontinent.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to assure the accurate administration of medication for 1 of 5 residents reviewed for medication administration. (Resident #26) MA E administered a Stress Formula vitamin with zinc instead of a Stress Formula vitamin with iron as ordered for Resident #26. This failure could place 33 residents who received oral medications from MA E on the 6:00 a.m. to 2:00 p.m. shift at risk for not receiving the intended therapeutic benefit of their medication. Findings included: Physician orders [REDACTED].#26 was to receive Stress Formula with iron one tablet daily. During an observation on 12/16/14 at 9:20 a.m., MA E administered a Stress Formula with zinc to Resident #26. During an interview on 12/16/14 at 11:50 a.m., MA E verified the Medication Administration Record [REDACTED]. During an interview on 12/17/14 at 3:40 p.m., the DON stated, "Okay" when told about the medication error for Resident #26. The DON made no further comment. An oral medication administration policy dated 2003 did not indicate to verify the correct medication before administering. During an interview on 12/16/14 at 8:45 a.m., MA E said he gave medications to all residents who took oral medications on the 6:00 a.m. to 2:00 p.m. shift. The CMS 672 dated 12/15/14 indicated a census of 35 and 2 residents had gastric tubes.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the kitchen. *A bin of potatoes was stored on the floor in the kitchen. *A heavy accumulation of carbon build-up and grease was on 4 of 4 stove burners. This failure could place 33 residents who ate food from the kitchen at risk of foodborne illness. Findings included: During observations of the kitchen on 12/15/14, the following was noted: *at 10:30 a.m. there was a heavy accumulation of carbon build-up and grease on 4 of 4 stove burners. *at 10:40 a.m. there was a bin of potatoes stored on the floor in the kitchen. During an interview on 12/15/14 at 11:00 a.m., the FSS said she was in the process of cleaning the stove and that she knew food should not be stored on the floor in the kitchen. The CMS 672 dated 12/15/14 indicated there were 33 residents who ate food prepared in the kitchen.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent accidents for 1 of 4 residents reviewed for falls. (Resident #11) The facility failed to develop and implement interventions to prevent injuries from falls after Resident #11 fell on [DATE]. On 08/14/14, Resident #11 fell and sustained a fractured hip and required surgical correction. This failure could place 4 residents who had falls at risk for injury and neglect. Findings included: Physician orders [REDACTED].#11 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #11's cognition was severely impaired. She required supervision of one person with bed mobility and transfers, but had no history of falls. A fall risk assessment dated [DATE] for Resident #11 indicated she had intermittent confusion, no falls in the past three months, and normal gait/balance. An incident report dated 06/22/14 indicated Resident #11 fell and sustained a laceration to her left hand. A fall risk care plan initiated on 07/11/14 for Resident #11 noted she was unaware of safety needs, had periods of confusion, and a history of wandering. The interventions included: "...The resident needs activities to minimize the potential for falls while providing diversion and distraction; Ensure that the resident is wearing appropriate footwear when ambulating; Follow facility fall protocol; Anticipate and meet the resident's needs; The resident needs a safe environment with: floors free from spills and clutter; adequate, glare-free light, a working and reachable call light, personal items within reach..." An incident reported dated 08/03/14 indicated Resident #11 sat on the floor and grazed her arm on the chair when falling. No other injuries were noted. A fall risk assessment dated [DATE] for Resident #11 indicated she was a high risk for falls. The assessment indicated she was disoriented, had 1-2 falls in the past three months, jerked/unstable when turning, and showed a change in gait pattern when walking through the doorway. The fall risk care plan initiated on 07/11/14 for Resident #11 indicated it was revised 08/11/14, but no new interventions were implemented after her fall on 08/03/14. An incident report dated 08/14/14 indicated Resident #11 had an unwitnessed fall with pain to her left leg, hip, back, and tailbone. An x-ray report dated 08/14/14 for Resident #11 indicated, "...mildly displaced fracture of the left femoral neck (hip)..." During an observation/interview on 08/21/14 at 2:00 p.m., Resident #11 was lying in bed, eyes closed, with staff present. CNA D said staff had been sitting with Resident #11 since 08/18/14. CNA D said Resident #11 broke her hip and had hip surgery. During an interview on 08/21/14 at 4:08 p.m., the DON indicated no new interventions were implemented to address Resident #11's falls between 07/11/14 and 08/14/14. During an interview on 08/21/14 at 5:24 p.m., MDS Coordinator said all care plans for Resident #11 were provided. A Preventive Strategies to Reduce Fall Risk policy revised 05/20/11 indicated, "...2. Residents that score in the high risk category will be placed on fall precautions and care planned for fall prevention...4. After risk is assessed, individualized nursing care plans will be implemented to prevent falls...6. Residents who fail to respond or improve with medical treatment and continue to remain fall risks may respond to a number of rehabilitative strategies. Rehabilitative strategies will be evaluated for all high risk residents. Rehabilitation Strategies: a) low intensity leg strengthening and weight bearing exercises, b) gait, balance, and transferring training, c) exercise programs..." The CMS 802 form received 8/21/14 indicated 4 residents had falls.

Based on observation, interview, and record review, the facility failed to revise or implement a care plan to prevent falls for 1 of 4 residents reviewed for falls. (Resident #11) The facility failed to develop and implement interventions to prevent injuries from falls after Resident #11 fell on [DATE]. On 08/14/14, Resident #11 fell and sustained a [MEDICAL CONDITION] and required surgical correction. This failure could place 4 residents who had falls at risk for injury and neglect. Findings included: Physician orders [REDACTED].#11 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #11's cognition was severely impaired. She required supervision of one person with bed mobility and transfers, but had no history of falls. A fall risk assessment dated [DATE] for Resident #11 indicated she had intermittent confusion, no falls in the past three months, and normal gait/balance. An incident report dated 06/22/14 indicated Resident #11 fell and sustained a laceration to her left hand. A fall risk care plan initiated on 07/11/14 for Resident #11 noted she was unaware of safety needs, had periods of confusion, and a history of wandering. The interventions included: "...The resident needs activities to minimize the potential for falls while providing diversion and distraction; Ensure that the resident is wearing appropriate footwear when ambulating; Follow facility fall protocol; Anticipate and meet the resident's needs; The resident needs a safe environment with: floors free from spills and clutter; adequate, glare-free light, a working and reachable call light, personal items within reach..." An incident reported dated 08/03/14 indicated Resident #11 sat on the floor and grazed her arm on the chair when falling. No other injuries were noted. A fall risk assessment dated [DATE] for Resident #11 indicated she was a high risk for falls. The assessment indicated she was disoriented, had 1-2 falls in the past three months, jerked/unstable when turning, and showed a change in gait pattern when walking through the doorway. The fall risk care plan initiated on 07/11/14 for Resident #11 indicated it was revised 08/11/14, but no new interventions were implemented after her fall on 08/03/14. An incident report dated 08/14/14 indicated Resident #11 had an unwitnessed fall with pain to her left leg, hip, back, and tailbone. An x-ray report dated 08/14/14 for Resident #11 indicated, "...mildly displaced [MEDICAL CONDITION] femoral neck (hip)..." During an observation/interview on 08/21/14 at 2:00 p.m., Resident #11 was lying in bed, eyes closed, with staff present. CNA D said staff had been sitting with Resident #11 since 08/18/14. CNA D said Resident #11 broke her hip and had hip surgery. During an interview on 08/21/14 at 4:08 p.m., the DON indicated no new interventions were implemented to address Resident #11's falls between 07/11/14 and 08/14/14. During an interview on 08/21/14 at 5:24 p.m., MDS Coordinator said all care plans for Resident #11 were provided. A Preventive Strategies to Reduce Fall Risk policy revised 05/20/11 indicated, "...2. Residents that score in the high risk category will be placed on fall precautions and care planned for fall prevention...4. After risk is assessed, individualized nursing care plans will be implemented to prevent falls...6. Residents who fail to respond or improve with medical treatment and continue to remain fall risks may respond to a number of rehabilitative strategies. Rehabilitative strategies will be evaluated for all high risk residents. Rehabilitation Strategies: a) low intensity leg strengthening and weight bearing exercises, b) gait, balance, and transferring training, c) exercise programs..." The CMS 802 form received 8/21/14 indicated 4 residents had falls.