Every finding on record at Harrodsburg Health & Rehabilitation Center

Based on observation, interview, review of the Serve Safe flyer, and review of the facility's policies, the facility failed to prepare and serve food under sanitary conditions. Observations during the lunch meal service on 02/24/2026 revealed staff pulled gloves out of his pocket, the cleaning cloth was not kept in the sanitizer bucket, and the soiled sheet pans and pots were stacked over the food production table. Additional observation on 02/25/2026 again revealed soiled sheet pans and pots were stacked over the food production table. These deficient practices had the potential to affect the current 87 residents who received food from the kitchen.The findings include: Review of the facility's policy titled, Food Preparation, dated 02/2025, revealed all staff would practice proper hand-washing techniques and glove use. Review of the facility's policy titled, Manual Ware Washing, 3-Compartment Sink, dated 01/2024, revealed all cookware, dishware, and service ware that was not processed through the dish machine would be manually washed and sanitized. The policy stated before processing any dishware, service and /or cookware, it was best practice to set up the three compartment sink. Review of the Serve Safe flyer Cleaning and Sanitizing Practices that will Prevent Cross Contamination, dated 09/2021, revealed pathogens could spread to food if equipment had not been cleaned and sanitized correctly. The flyer stated that it could happen by the use of equipment and utensils that were not washed, rinsed, or sanitized between uses; by wiping clean but not washing, rinsing, and sanitizing food-contact surfaces; by the use of wiping clothes that were not stored in a sanitizer solution between uses; and by the use of sanitizing solutions that were not at the required levels to sanitize objects. Observation on 02/24/2026 at 11:33 AM during the lunch tray line revealed soiled baking sheets and pots stacked on the left side of the three-compartment sink which hung over one opened number 10 can of vanilla pudding and one opened number 10 can of fruit cocktail with clean plastic dessert bowls on a tray by the soiled side of the pans. Further observation revealed there was no detergent in the first sink, water for rinse in the second sink, and no sanitizer in the third sink. Observation of [NAME] 1 on 02/24/2026 at 11:35 AM revealed the cook used a cloth from the pot and pan sink, rinsed off the cleaning cloth under the faucet, and wrung the cloth out to clean the food production table by the robe coupe. The food production table had crumbs which appeared to be mechanical soft meat. [NAME] 1, using the cleaning cloth, brushed off the crumbs onto the rack of scoop plates behind the machine. The cleaning cloth was not kept in the sanitizer bucket and was left in the empty sanitizer sink. Further observation revealed the sanitizer bucket was located underneath the stack of soiled pots and sheet pans on the left side of the pot and pan sink. Then, [NAME] 1 removed a pair of gloves from his pocket and put them on his hands. Observation on 02/25/2026 at 8:30 AM revealed the soiled pots and sheet pans were stacked on the left side of the pot and pan sink overhanging the food production table. In an interview with [NAME] 1 on 02/25/2026 at 3:09 PM, he stated he changed gloves when he changed tasks. He stated the gloves pulled from his pocket could have bacteria or other items from his pocket with a potential for cross contamination. He stated food on the production table near the soiled pots and pans hanging over from the pot and pan sink could cause cross contamination. He stated the cleaning cloth should have been in the sanitizer bucket instead of using water to rinse and wring it out. He stated using the unsanitized cleaning cloth to wipe the tables could cause cross contamination. In an interview with the Account Manager (Dietary Manager) on 02/25/2026 at 3:31 PM, she stated [NAME] 1 wearing gloves taken from his pocket could cause cross contamination. She stated using cleaning cloths that were not kept in the sanitizer bucket would cause the surfaces wiped to not be disinfected. She also stated the soiled pots and sheet pans hanging over the food production table could cause cross contamination. In an interview with the Director of Nursing on 02/26/2026 at 10:30 AM, she stated she expected gloves to be stored and used appropriately to prevent cross contamination. She also stated she expected staff to follow infection control practices in the kitchen. In an interview with the Administrator on 02/26/2026 at 10:45 AM, she stated she expected gloves not to be put into pockets, cleaning cloths to be put in the sanitizer bucket, and clean and soiled dishes separated to prevent the potential for cross contamination.

Based on interview, record review, and review of the facility's policy, the facility failed to notify the resident and the resident's representative of the resident's transfer or discharge and the reasons for the move in writing and in a language and manner they understood as soon as practicable. The facility failed to ensure the notice included the reason, date, and location for the transfer, as well as a statement of the residents' appeal rights and the contact information for the state Long-Term Care Ombudsman. The deficient practice was identified for 1 of 20 residents reviewed for transfer and/or discharge practices, Resident (R) 68. The findings include:Review of the facility's policy titled, Facility Bed-hold, revised 02/02/2025, revealed the facility would notify the resident and or resident's representative of the facility's bed hold policy at admission and anytime a resident was transferred to the hospital or went out on therapeutic leave. Per the policy, the facility would also notify the resident and or resident's representative in writing of the reason for the transfer or discharge to another legally responsible institution or non-institutional setting, and the resident's right to appeal the transfer or discharge. Review of the facility's provided Grievance Log, dated 12/2025, revealed the Minimum Data Set (MDS) Coordinator documented a grievance concern, Family was not notified resident was taken to the ER [Emergency Room]. Review of R68's Face Sheet revealed the facility admitted the resident on 08/06/2023 with diagnoses of type 2 diabetes mellitus with no proliferative diabetic retinopathy without muscular edema bilateral, cerebrovascular disease, and cerebral infarction (stroke). Further review of R68's medical record revealed on 11/03/2025, R68 was sent to the hospital emergency department for evaluation.Review of R68's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 01/23/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 6 of 15, indicating she was severely cognitively impaired.During an interview with R68's family member (FM) on 02/26/2026 at 10:48 AM, she stated she had come to the facility to visit R68, when she overheard a nurse say to R68, How have you been feeling since you got back? Per the interview, the FM stated to the nurse, I was not aware my mother had been sent out. During an interview with the MDS Coordinator on 02/26/2026 at 2:15 PM, she stated she was unaware the FM was not called or given a written bed hold notice when R68 was sent to the hospital on [DATE]. She stated it was not a good standard to send residents out of the facility with family representatives not notified. She stated R68 had a low BIMS score, and she was left alone at the hospital because of the failure to notify family representatives. During an interview with the Director of Nursing (DON) on 02/26/2026 at 2:42 PM, she stated she was unaware the facility sent R68 to the hospital and her FM was not called. She stated it was not how the facility normally operated and was unsure how it happened. She stated moving forward and to have a good standard of practice at the facility, the resident and family representatives should be notified immediately if their loved one was being sent out of the facility. During an interview with the Administrator on 02/26/2025 at 2:57 PM, she stated she was not aware the family was not called or mailed a bed hold for R68 on 11/03/2025. She stated when residents were sent out of the facility for a medical emergency or a facility outing, the facility staff members called to inform the family. She stated with R68 having a low BIMS score, it would be imperative that she have someone with her.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure residents received treatment and care in accordance with the physician's orders and the comprehensive person-centered care plan for 1 of 20 sampled residents, Resident (R) 87.Review of R87's Orders revealed orders for the dressing to the right foot to be changed daily and for the central line dressing to be changed every 72 hours.However, during an interview on 02/24/2026 with R87, she stated there were orders for daily dressing changes to her right foot, and the dressing was not changed by staff on 02/16/2026, 02/17/2026, and 02/18/2026. R87 also stated her central line dressing had not been changed since 02/15/2026, which observation on 02/24/2026 verified. The findings include:Review of the facility's policy titled, Non-Tunneled Central Catheter, dated 10/2024, revealed it did not address care of the catheter.Observation on 02/24/2026 at 10:38 AM of R87's central line dressing revealed it had a date written on it of 02/15/2026, written in pink ink. Further observation of R87's right heel dressing revealed it did not have a date written on it.Review of R87's Face Sheet revealed the facility admitted R87 on 02/06/2026 with diagnoses of chronic obstructive pulmonary disease (COPD), acute osteomyelitis of the right ankle and foot, and chronic kidney disease.Review of R87's admission Minimum Data Set [MDS], with an Assessment Reference Date of 02/10/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 out of 15, which indicated the resident was cognitively intact.Review of R87's Orders, revealed an order for the central line dressing change to be done every 72 hours, dated 02/06/2026. Further review revealed an order to apply betadine-soaked gauze to the right heel, cover with an abdominal (ABD) pad (a large, thick, highly absorbent pad with multiple layers used for heavily draining wounds), wrap with Kerlix (cotton gauze roll used to protect wounds), and then wrap with Coban (a self-adherent wrap used to protect the wound dressing) once a day. The order's start date was 02/11/2026, and the end date was 02/19/2026. On 02/19/2026, the same right heel wound dressing order was increased to every shift.Review of R87's Care Plan revealed, Resident has surgical wound to right heel related to wound requiring surgical intervention prior to admission to facility, dated 02/13/2026. The intervention for the right heel wound was treatment per order, dated 02/13/2026. Further review revealed a focus for central line to right chest, with the intervention of dressing changes as ordered.Review of R87's Medication Administration Record [MAR] revealed Licensed Practical Nurse (LPN) 2 documented treatment to the right heel was done on 02/16/2026 and 02/18/2026. Further review revealed LPN3 documented treatment was done on 02/17/2026. Continued review revealed the central line dressing was documented as done on 02/18/2026 by LPN2; and the central line dressing was documented on 02/21/2026 as not done by LPN4. Further review revealed the central line dressing was documented on 02/24/2026 as being completed by LPN5.During an interview on 02/24/2026 at 10:38 AM with R87, she stated her central line dressing was supposed to be changed every Sunday, but it had not been changed since the previous Sunday, 02/15/2026. She stated the dressing to her right foot was not done several days the previous week from Monday, 02/16/2026, to Thursday, 02/19/2026. She stated she usually had the right heel dressing changed on Tuesdays by her podiatrist. However, she stated last Tuesday, 02/17/2026, the facility did not arrange transport to her appointment, so it had to be cancelled.The State Survey Agency (SSA) attempted to interview LPN2, but she was out-of-state and unreachable.During an interview on 02/25/2026 at 3:07 PM with LPN1, she stated dayshift staff usually did the dressing changes, and she did not have an answer as to why dressing changes were not done as ordered for R87. She stated wound care staff made rounds on Tuesdays, and they did the dressing changes to R87's right heel. She stated LPNs were not allowed to change central line dressings, and the Assistant Director of Nursing (ADON) or (Infection Prevention) IP Nurse usually did them. However, she stated it was the nurses' responsibility to make them aware. She stated she thought central line dressings were to be changed once a week and was not aware R87's order was for every 72 hours.During an interview on 02/25/2026 at 3:10 PM with LPN3, she stated the Registered Nurse (RN) on duty would be the one changing central line dressings. She stated that it was important to prevent infections. She stated she did not remember if she changed R87's foot dressing, and she just signed it off on the [MAR] on 02/17/2026 because she thought it was being done by wound care staff during their rounds.During an interview on 02/25/2026 at 3:45 PM with the Director of Nursing (DON), she stated if an LPN was checked off to change central line dressings, then they were allowed to do so. However, she stated she was not sure which LPNs were competent and would need to check and get back to me. She stated staff should not document tasks being done if they did not complete them. She stated it was her expectation that staff followed care plans and orders to ensure proper care was given.During an interview on 02/26/2026 at 10:30 AM with the Administrator, she stated it was her expectation that all staff should be following the residents' orders to follow directions from the provider. She stated it was her expectation that staff followed the residents' care plans because they were put in place for each resident to ensure they were getting the correct care.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good oral hygiene for 1 of 24 sampled residents (Resident (R) 28). Observation of R28 on 11/05/2024 at 10:51 AM and again on 11/06/2024 at 3:11 PM revealed the resident had dry, cracked lips with peeling skin. The findings include: Review of the facility's policy titled, Resident Rights, revised 09/15/2023, revealed all residents would be treated in a manner and in an environment that promoted maintenance or enhancement of quality of life. Review of the facility's policy titled, Activities of Daily Living (ADLs), dated 09/15/2023, revealed direct healthcare staff would assist, support, and encourage residents to maintain adequate ADLs such as the following: bathing, grooming, eating, toileting, bed mobility, and transfers. Further review revealed for those residents who were unable to perform their own ADLs, the facility would provide the needed assistance for completion of cares. Review of R28's Face Sheet revealed the facility admitted the resident on 05/28/2021 with diagnoses including Rett's syndrome (a rare neurological genetic disorder that caused severe muscle movement disability), muscle contractures of both upper arms and both lower legs, and left-hand contracture. Review of R28's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/22/2024, revealed a Brief Interview for Mental Status (BIMS) assessment was not completed because of the resident's neurological status. Further review revealed R28 received enteral feeding via a gastrostomy tube and was completely dependent on staff for ADL care. Review of R28's Comprehensive Care Plan, dated 06/25/2024, revealed a focus of dental care with an intervention that included oral care every shift and as needed. Review of R28's current Physician's Orders revealed an order, dated 01/03/2024, that included oral care every shift. Review of R28's point of care (POC) documentation, dated 11/02/2024 to 11/08/2024, revealed the resident was totally dependent on staff for personal hygiene care. Further review revealed no documented personal hygiene care on 11/05/2024 or 11/07/2024. Observation of R28 on 11/05/2024 at 10:51 AM revealed the resident was in bed with contractures to arms, legs, and hands. In addition, R28 had dry, cracked lips with peeling skin. Observation of R28 on 11/06/2024 at 3:11 PM revealed the resident had dry, cracked lips with peeling skin. Observation on 11/07/2024 at 1:52 PM revealed State Registered Nurse Aide (SRNA) 2 provided oral care to R28. SRNA2 used a lemon-glycerin swabstick and cleaned the inside of R28's mouth. Additional observation revealed SRNA2 obtained a new swabstick and cleaned R28's lips. Observation after oral care revealed R28's lips were smooth and moist. During an interview on 11/07/2024 at 10:51 AM with SRNA1, she stated R28 was fragile, unable to move, and required two people for assistance with care. SRNA1 stated oral care was provided at least every day, but more often if needed. During an interview with SRNA3 on 11/08/2024 at 8:50 AM, she stated oral care for dependent residents like R28 was provided a couple of times a shift and more if needed. During an interview with the MDS Nurse on 11/08/2024 at 9:14 AM, she stated she previously worked as a floor nurse and provided care to R28 in the past. The MDS Nurse stated it was her expectation staff provided oral care when they provided other care. She further stated the facility policy for oral care was at least once a shift and as needed. During an interview with the Director of Nursing (DON) on 11/08/2024 at 2:19 PM, she stated it was her expectation residents' ADL needs were met daily and as needed. She further stated oral care was routine care and provided every shift and as needed as residents allowed. She stated it was her expectation staff assessed and provided oral care as necessary when they made their rounds. The DON stated oral care was important because it provided comfort for residents that were dependent on staff for ADL care. During an interview with the Administrator on 11/08/2024 at 3:39 PM, she stated it was her expectation all staff helped with residents' ADL care. She further stated she expected oral care was provided to residents as ordered and per the facility policy.

Based on observation, interview, record review, review of a Food and Drug Administration (FDA) website, review of the American Biotech Supply document Medication Refrigerator Temperature Guidelines: What You Should Know, and facility policy review, the facility failed to store all drugs and biologicals under proper temperature control for 1 of 2 medication refrigerators, the refrigerator in the South Medication Room. Observation revealed two vials of Tuberculin Purified Protein Derivative (PPD) were stored in the door of the South Medication Room refrigerator. The findings include: Review of the facility's policy titled, Medication Storage, dated 01/2023, revealed it was the policy of the facility to ensure medications and biologicals were stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. Further review revealed medication requiring refrigeration or a temperature between 36 degrees Fahrenheit (F) and 46 degrees (F) were kept in a refrigerator with a thermometer to allow temperature monitoring. Also, the temperature of any refrigerator that stored vaccines should be monitored and recorded twice daily. Review of website https://www.fda.gov/media/74866/download, under Storage for Tuberculin PPD stated PPD should be stored in a refrigerator at a temperature between 35 to 46 degrees F. Review of the American Biotech Supply document Medication Refrigerator Temperature Guidelines: What You Should Know, undated, revealed medications should be stored in the center of the refrigerator, away from the bottoms and sides. It stated to never store medications in door shelves or bins as these areas were prone to larger fluctuations in temperature. Observation on 11/06/2024 at 10:05 AM of the medication refrigerator in the Medication Room on the South Hallway revealed there were two vials of Tuberculin PPD stored in the door of the medication refrigerator. In an interview on 11/08/2024 at 8:05 AM with Licensed Practical Nurse (LPN) 8, she stated issues with storing medications in the door of the refrigerator could be that items could accidentally fall out when the door was opened/closed or the medications could lose efficacy if the door was left open too long or opened/closed frequently. In an interview on 11/08/2024 at 8:14 AM with the Director of Nursing (DON), she stated she could think of no issues with storing medications in the door of the refrigerator. When asked if heating/cooling of medications such as Tuberculin PPD could decrease their potency, she stated, Yes. In an interview with the Administrator on 11/08/2024 at 8:37 AM, she stated she would defer to the DON about proper medication storage and would work with her on any issues with medications stored improperly. She stated she was unaware of any medications stored in the door of any medication refrigerators but did not see that it would be an issue. She stated the medication refrigerator door should always be opened and immediately shut to keep any items in the door cool.

Based on observation, interview, record review, and review of the facility's policies, it was determined 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 and control the development and transmission of communicable diseases, including COVID-19, and to implement interventions per the Centers for Medicare and Medicaid Services (CMS), the Centers for Disease Control and Prevention (CDC), and the Kentucky Department for Public Health (Health Department) State guidelines for COVID-19. Observation, upon entry to the facility, revealed facility staff failed to screen the State Survey Agency (SSA) Surveyor for signs and symptoms of COVID-19. Observations revealed Residents #1, #5, and #6's nasal cannula tubing was not labeled with either the date of initial set-up or the date changed. Observations revealed inappropriate use of personal protective equipment (PPE). These observations included a resident, under droplet precautions, ambulating in the hall without wearing a mask. In addition, multiple residents were observed not wearing face masks or wearing them below the mouth and chin. Further, there were multiple staff members not wearing face shields/goggles, when there was a positive case of COVID-19 in the building, which indicated there was an outbreak. Observations revealed staff members failed to perform hand hygiene after touching masks or face shields/goggles, after doffing contaminated PPE, and after touching contaminated equipment. Observations revealed inappropriate handling of clean and contaminated linen and dirty equipment in the hallway. The findings include: Review of facility records revealed, on 08/16/2021, there were eight (8) residents diagnosed as COVID-19 positive. Ten (10) residents were in Transmission-Based Precautions (TBP) due to an exposure to COVID-19. Eight (8) staff members were COVID-19 positive and quarantined due to a work exposure. Review of the facility's policy titled, Cleaning and Disinfection of Environmental Services, last reviewed 08/2019, revealed environmental surfaces would be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities. Review of the CDC's, Guidelines for Disinfection and Sterilization in Healthcare Facilities, updated 05/2019, revealed that at a minimum, noncritical patient-care devices should be Disinfected when visibly soiled and on a regular basis (such as after use on each patient or once daily or once weekly), with an Environment Protection Agency (EPA) registered disinfectant product approved for health care facilities. Review of the CDC's Clean Hands Count for Healthcare Providers, last reviewed 01/08/2021, revealed alcohol-based hand rub (ABHR) and washing hands with soap and water were the two (2) methods for hand hygiene. Further review revealed the clinical indications for the use of hand hygiene included immediately before touching a patient, after touching a patient or the patient's immediate environment, after hands touched contaminated surfaces, and immediately after PPE removal. Additionally, the document stated healthcare facilities should require healthcare personnel to perform hand hygiene in accordance with CDC recommendations. Review of the facility's policy titled, Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures, revision date 07/2020, revealed the facility followed recommended standard and transmission based precautions, environmental cleaning, and social distancing practices to prevent the transmission of COVID-19 within the facility. Further review revealed, while in the facility, personnel were required to strictly adhere to established infection prevention and control (IPC) policies, including: hand hygiene; appropriate use of PPE; Transmission Based Precautions (TBP) where indicated; universal source control by staff wearing face masks at all times while in the facility except while eating or drinking in designated areas; and social distancing. Review of the facility's policy, Infection Control: Transmission Based Precautions (Airborne, Contact, Droplet), revised 10/2018, revealed Transmission Based Precautions (TBP) would be used when caring for residents who were documented or suspected to have communicable diseases or infections that could be transmitted to others. Additional review revealed if the use of common items were unavoidable, then the shared equipment would be cleaned and disinfected before use with another resident. Review of the facility's policy titled, Novel Coronavirus (COVID-19), revision date 06/02/2021, revealed, during a COVID-19 outbreak, staff would wear eye protection (face shield or goggles) until the facility went fourteen (14) days without a new resident or staff positive case. Per the policy, a staff member must always wash hands when removing any mask or after touching his/her mask or face. Furthermore, the facility was expected to adhere to the CDC's Core Principles, which included: screening all who entered the facility; proper hand hygiene; appropriate staff use of PPE; use of masks to cover the mouth and nose; and social distancing. Review of the facility's policy, Oxygen Administration - Nasal Cannula Clinical Practice Guideline, revised 10/23/2020, revealed nasal cannula tubing must be labeled with the date it was set-up and changed every seven (7) days. The SSA Surveyor, on 08/16/2021, requested a policy on handling and storage of clean linens, but one (1) was not provided. 1. Observation, upon entry to the facility, on 08/16/2021 at 11:50 AM, revealed facility staff failed to screen the SSA Surveyor for signs and symptoms of COVID-19. Interview with the Assistant Business Office Manager, on 08/16/2021 at 2:35 PM, revealed all staff and visitors were to be directed to the electronic COVID-19 screening system at the front entrance upon entry. The ABOM stated she did not know why staff failed to screen the SSA Surveyor. Interview with the Infection Preventionist (IP), on 08/16/2021 at 1:25 PM, revealed all staff and visitors were to be screened at the front entrance upon entry. She stated the facility used electronic screening equipment to screen staff and visitors. In addition, the IP stated the system scanned the user's temperature and provided an electronic COVID-19 questionnaire to be answered. Interview with the Administrator, on 08/16/2021 at 2:10 PM, revealed she expected that all staff and visitors were to be screened at the front entrance upon entry. 2. Observation of Resident #11, on 08/16/2021 at 11:52 AM and 1:23 PM, and on 08/17/2021 at 8:50 AM, revealed the resident, who was in droplet precautions, was ambulating, per self in a wheelchair, in patient care areas without wearing a mask. Further observation revealed staff did not redirect or educate the resident to remain in his/her room. On 08/17/2021 at 9:45 AM, Resident #11 was observed ambulating in the hall without a mask, and he/she stopped at the doorway of the Administrator's office. Per the observation, the Administrator and several other staff members were in the office. Then, several staff members walked past the resident and did not redirect or educate Resident #11 to place his/her mask over the chin and nose or to return to his/her room. Review of Resident #11's medical record revealed the resident was admitted to the facility on [DATE]. Resident #11's Brief Interview for Mental Status (BIMS) score was fifteen (15), indicating intact cognition. Resident #11's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed Resident #11 was placed in isolation per a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further observations, on 08/16/2021 and 08/17/2021, revealed multiple residents not wearing masks or wearing masks below the nose and chin. In addition, residents were observed to be seated within six (6) feet of each other. Per the observation, staff did not redirect these residents to wear masks or social distance. Interview with Licensed Practical Nurse (LPN) #1, Unit Manager, on 08/17/2021 at 11:05 AM; LPN #3, on 08/17/2021 at 2:02 PM; and Registered Nurse (RN) #1, on 08/20/2021 at 12:30 PM, revealed staff should redirect and educate residents who did not wear face masks. Per the interview, they stated residents in quarantine must stay in their rooms. All stated if residents came out of their rooms, they must wear a mask, and social distancing was encouraged. Further, all stated these requirements were important to prevent the spread of infectious diseases. Interview with the DON, on 08/17/2021 at 2:23 PM, revealed Resident #11 was on droplet precautions due to being exposed to his/her roommate who was COVID-19 positive. She stated a resident in quarantine must stay inside his/her room. She stated residents in quarantine were care planned as such and had care plan interventions, which staff should follow. Further, the DON stated, if the quarantined resident came out of his/her room, the resident must wear a mask. She stated staff should redirect the resident and educate on the importance of wearing a mask and remaining in his/her room. Furthermore, the DON stated staff should redirect all residents to wear masks appropriately and social distance because these requirement were important to prevent the spread of infection. Interview with the Administrator, on 08/17/2021 at 4:45 PM, revealed residents who did not wear masks were to be redirected and educated. Further interview revealed that Resident #11 was educated by the Administrator regarding COVID-19 isolation and the importance of staying inside his/her room while quarantined. Furthermore, the Administrator stated Resident #11 was educated when to wear his/her mask and how to wear the mask appropriately. The Administrator stated she updated Resident #11's care plan, on 08/17/2021, to include re-education as needed and to redirect the resident to stay in his/her room during periods of droplet isolation to prevent the spread of infection. 3. Observation, on 08/16/2021 at 11:55 AM, revealed several biohazard trash receptacles, located on the outside of Transmission-Based Precaution (TBP) rooms #202 and #112, overflowing with contaminated gowns hanging outside of the biohazard receptacle. Interview with State Registered Nurse Aide (SRNA) #3, on 08/17/2021 at 11:20 PM; SRNA #4, on 08/17/2021 at 1:25 PM; SRNA #5, on 08/17/2021 at 1:36 PM; LPN #2, on 08/17/2021 at 1:48 PM; and LPN #3, on 08/17/2021 at 2:02 PM, revealed staff emptied biohazard bags when full and took them to the contaminated utility room to be discarded by housekeeping. Interview with LPN #1, Unit Manager, on 08/16/2021 at 11:05 AM; and Registered Nurse (RN) #1, on 08/20/2021 at 12:30 PM, revealed biohazard receptacles were to be emptied when full. Per the interviews, nursing leadership monitored compliance of staff related to infection prevention and control (IPC) practices. Both stated if staff was non-compliant with IPC practices, supervisors would educate immediately. Interview with the Housekeeping Manager, on 08/16/2021 at 3:10 PM, revealed patient care staff should empty biohazard trash receptacles when full. Then, the red biohazard bags were placed in biohazard box containers located in a separate dirty utility room. The Manager stated boxes were taped up and disposed of by housekeeping. Interview with the Plant Manager (PM), on 08/16/2021 at 2:49 PM, revealed biohazard receptacles were to be emptied when full and taken to biohazard containers located in a separate dirty utility room. The PM stated when the containers were full, they were taped and awaited final disposal by an outside vendor. Interview with the DON, on 08/17/2021 at 2:23 PM, revealed when red biohazard bags were full they should be changed and taken into a separate dirty utility room where biohazard containers were located. Per the interview, nursing leadership monitored compliance of staff related to IPC practices. The DON stated if staff was non-compliant with IPC practices, supervisors should re-educate immediately. 4. Observation, on 08/16/2021 at 12:05 PM, revealed a Hoyer lift, stored in the hallway, was visibly dirty. Additional observation revealed a clean linen cart in the hall with visibly dirty middle and bottom shelves. Interview with SRNA #2, on 08/16/2021 at 12:05 PM, revealed the linen cart should not be stored in resident care hallways. Furthermore, she stated the middle and bottom shelves were visibly dirty, and she would clean them immediately. She stated staff should clean and disinfect equipment after each use and when visibly soiled. Interview with LPN #1, Unit Manager, on 08/16/2021 at 11:05 AM, revealed shared equipment was cleaned after use with bleach wipes. She stated Hoyer lifts and wheelchairs were cleaned by the night shift nursing staff. Interview with the Housekeeping Manager, on 08/16/2021 at 3:10 PM, revealed nursing staff was responsible for cleaning shared medical equipment, wheelchairs, and lifts. Per the interview, he stated he was not aware if there was a schedule to clean Hoyer lifts. Interview with the Infection Preventionist (IP), on 08/16/2021 at 1:25 PM, revealed Hoyer lifts and wheelchairs were cleaned on night shift. She stated she expected staff to clean and disinfect Hoyer lifts after each use. Interview with the DON, on 08/17/2021 at 2:23 PM, revealed it was her expectation staff should clean and disinfect Hoyer lifts after each use. The DON stated night shift nursing staff routinely cleaned large equipment such as wheelchairs, lifts, and ice chests. 5. Observation of the residents' shower room, on 08/16/2021 at 12:15 PM, revealed a large, uncovered shelf filled with clean linen inside the shower room, which was actively used for residents' showers, within three (3) feet of dirty linen and trash barrels. Interview with the Housekeeping Manager, on 08/16/2021 at 3:10 PM, revealed SRNA's emptied trash and dirty linen in barrels located in the shower room. He stated the housekeeping department and laundry were responsible for emptying the barrels when full. Interview with the DON, on 08/17/2021 at 2:23 PM, revealed the shower room that stored clean linen, was also used to store the barrels used for dirty linens and trash. The DON further stated the shower room was used to bathe residents. She stated there was nowhere else to store the clean linen or dirty trash and linen barrels. 6. Observation, on 08/16/2021 at 12:30 PM, revealed multiple staff not wearing face shields/goggles per facility policy during an outbreak of COVID-19. Additionally, on multiple occasions throughout the survey, the Administrator was observed unmasked or not wearing face shields or goggles while in her office, located on a resident care hall, directly across from a droplet isolation room and the front lobby offices. The Administrator was with other individuals on these occasions. Further observation, on 08/16/2021 at 2:25 PM, revealed the Administrator, Social Services Director, and the Plant Manager, in the Administrator's office, all without face shields or goggles and not practicing social distancing. Interview with SRNA #1, 08/16/2021 at 3:27 PM; and SRNA #3, on 08/17/2021 at 11:20 PM, revealed staff was to wear an N-95 mask with a face shield/goggles while in the facility to prevent the spread of COVID-19. Interview with RN #1, on 08/20/2021 at 12:30 PM, revealed N-95 masks with goggles/face shields were to be worn while providing resident care and while in resident care areas to prevent the spread of COVID-19. Interview with LPN #1, Unit Manager, on 08/16/2021 at 11:05 AM, revealed all staff was required to wear an N-95 mask with face shield/goggles while in the facility when there was an outbreak of COVID-19. Per the interview, nursing leadership monitored compliance of staff related to IPC practices, and if staff was non-compliant with IPC practices, supervisors would educate immediately. LPN #1 stated wearing appropriate face coverings during an outbreak of COVID-19 was important to prevent the spread of infection. Interview with the DON, on 08/17/2021 at 2:23 PM, revealed, during an outbreak of COVID-19, all staff was required to wear an N-95 mask with face shield/goggles while in the facility and in resident care areas. She stated staff should perform hand hygiene after touching their mask, but also stated many times they did not even realize they were touching the mask. Per the interview, nursing leadership monitored compliance of staff related to IPC practices. However, she did not provide documentation of audits. The DON stated if staff was non-compliant with IPC practices, supervisors should reeducate. 7. Observations, on 08/16/2021 at 1:00 PM and 08/17/2021 at 10:00 AM, revealed Residents #1, #5, and #6's nasal cannula tubing was not labeled with the date the cannula tubing was placed on the residents. Review of Resident #1's medical record revealed he/she was admitted to the facility, on 05/19/2019, with a Brief Interview for Mental Status (BIMS) score of ten (10), indicating moderate cognitive impairment. Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Resident #1, on 08/16/2021 at 1:00 PM, revealed Resident #1 stated he/she did not remember when staff changed the nasal cannula and tubing. Review of Resident #5's medical record revealed he/she was admitted to the facility, on 12/17/2011, with a BIMS score of fourteen (14) out of fifteen (15), indicating intact cognition. Resident #5's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Resident #5, on 08/17/2021 at 10:00 AM, revealed he/she used oxygen due to his/her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #5 stated he/she got short of breath because of [CONDITION(S)]. Resident #5 stated he/she did not remember when staff changed the nasal cannula and tubing. Review of Resident #6's medical record revealed he/she was admitted by the facility on 04/25/2017. Resident #6's BIMS score was zero (00), indicating severe cognitive impairment. Resident #6's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Resident #6, on 08/17/2021 at 10:10 PM, revealed Resident #6 was non-interviewable. Interview with the Director of Nursing (DON), on 08/17/2021 at 2:23 PM, revealed according to nursing procedure, oxygen tubing was changed one (1) time weekly. Additionally, she stated the nasal cannula tubing must be labeled with the date it was placed on the resident. Per the interview, the DON stated it was important to date and change oxygen tubing so you knew how long the resident had been using it and to prevent infections. 8. Observation, on 08/16/2021 at 1:20 PM, revealed LPN #4 in the hallway outside of room [ROOM NUMBER] and discarding a contaminated gown in a biohazard receptacle, located outside of the room. Additional observation revealed LPN #4 then took off his mask and replaced it with a mask from the PPE supply cubby. LPN #4 failed to perform hand hygiene after doffing contaminated PPE and donning a clean mask. Further observation, on 08/16/2021 at 2:25 PM, revealed LPN #4 touched the wheelchair of Resident #11, who was under droplet precautions, while the resident was out in the hall without his/her mask. LPN #4 did not perform hand hygiene after touching the wheelchair. Observation of the Administrator, on 08/16/2021 at 2:10 PM, revealed she adjusted her mask and face shield without performing hand hygiene. Additional observations throughout the survey revealed multiple staff failed to perform hand hygiene after readjusting the facemask or touching face shields/goggles. Continued interview with the Administrator, on 08/17/2021 at 4:45 PM, revealed she took off her face shield because she stated she was hot. Furthermore, she stated she was not aware she had touched her mask and face shield. Interview with SRNA #2, on 08/17/2021 at 11:00 AM; SRNA #3, on 08/17/2021 at 11:20 PM; SRNA #4, on 08/17/2021 at 1:25 PM; SRNA #5, on 08/17/2021 at 1:36 PM; LPN #2, on 08/17/2021 at 1:48 PM; LPN #3, on 08/17/2021 at 2:02 PM; LPN #1, Unit Manager, on 08/16/2021 at 11:05 AM; and RN #1, on 08/20/2021 at 12:30 PM, revealed all received annual training on hand hygiene, donning and doffing of PPE, IPC practices, and COVID-19 IPC measures through the facility's Learn 365 training modules and in-service training. All stated staff should perform hand hygiene before touching a patient, after touching a patient or the patient's immediate environment, when hands touched contaminated surfaces, and immediately after PPE removal. Interview with the DON, on 08/17/2021 at 2:23 PM, revealed all staff received training upon hire and continuing education annually. She stated staff completed modules on hand hygiene, donning and doffing of PPE, IPC practices, and COVID-19 IPC measures through the facility's Learn 365 online learning platform. Furthermore, she stated staff got continual education related to COVID-19 updates through in-service trainings. Per the interview, the DON stated staff was expected to perform hand hygiene before touching a patient, after touching a patient or the patient's immediate environment, when hands touched contaminated surfaces, and immediately after PPE removal. Continued interview with LPN #1, Unit Manager, on 08/16/2021 at 11:05 AM; and RN #1, on 08/20/2021 at 12:30 PM revealed nursing leadership monitored compliance of staff related to IPC practices; however, she was not aware of formal audits. She stated if staff was non-compliant with IPC practices, supervisors would educate on the spot. Continued interview with the DON, on 08/17/2021 at 2:23 PM, revealed it was her expectation that all nursing staff follow IPC policies and CDC guidelines for the safety of residents and staff. Per the interview, the DON stated following IPC procedures and facility policies was important to prevent the spread of infection. Additional interview with the Administrator, on 08/20/2021 at 12:55 PM, revealed it was her expectation that IPC guidelines were to be maintained at all times in the facility. The Administrator stated she expected staff to wear the appropriate PPE for the situation and to don and doff PPE correctly. Additionally, she reported it was her expectation that hand hygiene was performed per facility policy and CDC guidelines. She stated following the facility's policies was important to decrease the potential spread of infection and COVID-19.

Based on observation, interview and review of facility Policy, it was determined the facility failed to ensure drugs and biologicals were stored properly, and labeled in accordance with accepted professional principles and include the expiration date. Observation on [DATE] of the South Medication refrigerator, revealed an opened and undated vial of single dose pneumonia vaccine. In addition, observation on [DATE] of the North Medication refrigerator, revealed a plastic container with a creamy white substance which was unlabeled and undated. The findings include: Review of the facility Policy, titled Medication Storage, Section 4.1, dated ,[DATE], revealed the provider pharmacy dispenses medications in containers that meet state and federal labeling requirements. Outdated medications are to be immediately removed from stock and disposed of and reordered from pharmacy. Further review revealed each prescription label should include resident's name, directions for use, medication name, strength of medication, prescriber's name, date medication is dispensed, quantity dispensed, expiration or end-of-use date, name, address and telephone number of the dispensing pharmacy, prescription number, accessory/precautionary labels, and dispensing pharmacists's initials. Observation on [DATE] at 1:46 PM, of the South Medication refrigerator, revealed an opened and undated vial of single dose pneumonia vaccine. Interview with Licensed Practical Nurse (LPN) #2, on [DATE] at 1:46 PM, revealed per professional standards of nursing practice, nurses were to date vials of medication when opened in order to know when the medication was expired for the safety of the residents. Per interview, the vaccine could be less effective if not given within the recommended time frame after it was opened. LPN #2 stated since the pneumonia vaccine was a single dose medication, it should have been used when opened, and then the vial discarded. Further, any multidose vials of medications should be dated when opened in order for staff to know the expiration date. Observation on [DATE] at 2:16 PM, of the North Medication refrigerator, revealed a plastic container with a creamy white substance and the container was unlabeled and undated. Interview with LPN #1, on [DATE] at 2:16 PM, revealed only medications should be stored in the medication refrigerator for the safety of the residents. LPN #1 denied knowledge of what was in the plastic container in the North medication room refrigerator; however, did state it should be discarded. Interview with the Assistant Director of Nursing (ADON) #1, on [DATE] at 3:00 PM, revealed she was the Unit Manager and the Assistant Director of Nursing for the North Unit. Per interview, only medications should be in the medication refrigerator and she had no knowledge of what the white substance was in the plastic container or why it was locked up in the medication room refrigerator. Further interview revealed if a single dose medication vial was opened, it should be used at the time it was opened and then discarded. Further, any mutidose vials should be dated when opened. Interview with ADON #2, on [DATE] at 3:10 PM, revealed it was her expectation for nursing staff to follow the policy related to medication storage. Per interview, if a single dose vial was opened, it should be used right then or wasted. Further interview revealed only medications should be stored in the medication refrigerator as per facility policy. Interview with the Staff Development Coordinator, on [DATE] at 3:30 PM, revealed per facility policy, only medications should be stored in the medication refrigerators. Per interview, if medication vials were opened, they should be dated with the open date and discarded when expired. Further, if a single dose medication vial was opened, the medication should be administered when opened, or discarded if not administered. Continued interview revealed there should not be opened single use vials of medications in the medication refrigerator accessible for use, as staff would not know if part of the dose had been used or if the vial was contaminated. Per interview, the nursing staff received education related to proper storage of drugs and biologicals, and also received competency tests. Interview with the Director of Nursing (DON), on [DATE] at 3:45 PM, revealed it was her expectation for all staff to follow the policy for medication storage. Per interview, staff should use a single dose vial of medication when uncapped to ensure the integrity of the medication. Continued interview revealed it would be against facility policy to have a plastic container with a white substance in the medication refrigerator. The DON stated the facility did offer education regarding medication storage in the form of inservices, meetings and tests for the licensed nursing staff. Interview with the Administrator, on [DATE] at 4:00 PM, revealed it was her expectation for staff to follow facility policy regarding storage and labeling of medications. Continued interview revealed only medications should be in the medication refrigerator.

Based on observation, and interview, it was determined the facility failed to ensure services necessary to maintain a sanitary, orderly, and comfortable interior. Observation during survey on 07/17/18, 07/18/18, and 07/19/18, revealed shared resident bathrooms on the 200, and 300 units had bed pans, fracture pans, and urinals which were not stored in a sanitary manner and were not labeled for resident identification. In addition, observation on 07/19/18, revealed the 400 unit had a plunger which was not stored in a sanitary manner as it was partially bagged on the floor of a resident bathroom. The findings include: Interview on 07/19/18 at 6:29 PM, with the Administrator, revealed the facility did not have a specific written policy related to storage of bed pans, urinals and plungers. 1. Observation on 07/17/18 at 12:40 PM, 2:31 PM, and 3:35 PM, of the shared bathroom for Resident room [ROOM NUMBER], revealed an uncovered bedpan which was not labeled for resident identification stored on the floor, behind the toilet. There was also two (2) male urinals hanging on the wall above the toilet in clear plastic bags with no resident identification located on either urinal. Additionally, the urinal observed furthest from the bathroom sink, contained approximately sixty (60) millimeters of clear yellow liquid. Additional observation on 07/18/18 at 8:41 AM, 9:45 AM and 11:05 AM, of the shared bathroom for Resident room [ROOM NUMBER], revealed a bedpan stored on the floor without a storage bag and without a label for resident identification. Further observation revealed two (2) male urinals, hanging on the wall above the toilet, unlabeled for resident identification and stored in clear plastic bags. Additional observation revealed the urinal furthest from the bathroom sink contained approximately thirty (30) millimeters of clear yellow liquid. Continued observation on 07/19/18 at 9:16 AM, of the shared bathroom for Resident room [ROOM NUMBER], revealed two (2) male urinals hanging on the wall above the shared toilet in clear plastic bags which were not labeled with identification. 2. Observation on 07/18/18 at 9:08 AM and 07/19/18 at 7:10 AM and 4:20 PM, revealed the shared bathroom for resident room [ROOM NUMBER], had two (2) fracture pans in a plastic bag in the tub which were not labeled with resident identification. Continued observation on 07/19/18 at 7:10 PM, of the shared bathroom for room [ROOM NUMBER], revealed two (2) bagged and fracture pans which were not labeled with resident identification leaning against the wall and resting on the bathroom floor. 3. Observation of the private bathroom for resident room [ROOM NUMBER] on 07/19/18 at 3:45 PM, revealed a plunger partially bagged and sitting on the floor. Interview on 07/19/18 at 4:05 PM, with State Registered Nurse Assistant (SRNA) #9 who was working on the 200 unit, revealed bed pans, and urinals should be labeled with resident identification, bagged, and hung on the hooks in the bathroom. She further revealed if she found any unlabeled bed pans or urinals she would throw them away and get new bed pans and urinals to prevent cross contamination. Interview on 07/19/18 at 4:07 PM, with SRNA #10, who was working on the 300 unit, revealed bed pans and urinals should be bagged, labeled with resident identification, and hung up. Per interview, if the bed pans, and urinals were not bagged and labeled she would get new bed pans and urinals to prevent cross contamination. Additional interview revealed plungers should be bagged or removed from resident bathrooms because leaving a plunger in a resident bathroom without covering it with a plastic bag was an infection control concern. Interview on 07/19/18 at 4:30 PM, with Licensed Practical Nurse (LPN) #2 who worked the 300-400 unit, revealed bed pans should be bagged, labeled with resident identification and kept in the bottom drawer in the bathroom. Per interview, bed pans should be stored properly to prevent cross contamination. Interview on 07/19/18 at 4:20 PM, with the Assistant Director of Nursing (ADON) #2, revealed all bed pans and urinals should be labeled with resident identification and bagged to prevent cross contamination. Per interview, if staff find bed pans and urinals which were not labeled or bagged, they should be thrown away. Additional interview revealed Housekeeping was responsible for removing the plungers after use. Interview on 07/19/18 at 4:35 PM with ADON #1, revealed bed pans and urinals should be bagged and identified with the resident's name and room number and hung on the hook in the bathroom to prevent infection control concerns. Interview on 07/19/18 at 6:05 PM, with the Director of Nursing (DON), revealed residents should have a clean home like environment. Per interview, the bed pans, fracture pans, and urinals should be cleaned after use, bagged and labeled with resident identification and hung on hooks in the bathroom to prevent cross contamination. Additional interview revealed the plunger should be bagged or removed from the bathroom. Interview on 07/19/18 at 6:29 PM, with the Administrator, revealed bed pans, and urinals should be cleaned after each use and stored in a bag in the bathroom on the railing with the resident's name and/or room number. Per interview, plungers should also be properly stored.

Based on observation, interview, and review of facility Policy, it was determined the facility failed to label drugs and biologicals in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. Observation on 07/18/18, of the medical storage room cabinet on the North Middle Unit, which included Heavenly Avenue, Reminisce Lane, and Majestic Valley, revealed one (1) box of thirty-four (34) [MEDICATION NAME] Chloride Towelettes (antiseptic wipes) with an expiration date of 04/2016. In addition, observation on 07/19/18, of the Glory Road South-2 medication cart, revealed three (3) opened insulin Flex Pens which were not marked with the open date. Also, observation of the North Hall Heavenly Ave Medication Cart, on 07/19/18, revealed one (1) bottle of [MEDICATION NAME] Propionate Nasal spray and one (1) bottle of Bromonidine 0.2% eye drops which were open, but not marked with the open date. The findings include: Review of the facility Medication Administration General Guidelines Policy, dated 12/2012, revealed staff were to Check expiration date on package/container. No expired medication will be administered to a resident. Continued review revealed, The nurse shall place a date opened sticker on the medication if one is not provided by the dispensing pharmacy and enter the date opened. Certain products or package types such as multi-dose vials and ophthalmic drops have specified shortened end-of-life dating, once opened, to ensure medication purity and potency. 1. Observation on 07/18/18 at 4:18 PM, of the medical storage room cabinet on the North Middle Unit, which included Heavenly Avenue, Reminisce Lane, and Majestic Valley Units, revealed one (1) box of thirty-four (34) [MEDICATION NAME] Chloride Towelettes (antiseptic wipes) with an expiration date of 04/2016. Interview with Licensed Practical Nurse (LPN) #7, on 07/18/18 at 4:42 PM, revealed staff two (2) staff members were responsible for checking supplies and expiration dates of supplies throughout the building weekly. Further interview revealed if supplies were outdated they may not work as good. Additional interview revealed if an outdated antiseptic was used on a resident it could potentially cause an infection to set up or not treat the infection as well. Interview on 07/18/18 at 5:11 PM, with the Central Supply staff member responsible for ordering supplies for the facility, revealed she usually checked supplies for the facility on Tuesdays and Fridays. She stated another staff member assisted her when needed or when she was on vacation. She further stated she usually checked expiration dates of the supplies while restocking. However, per interview, the facility recently changed supply companies and ninety (90) percent of the supplies were from the new supply company and had recently been ordered; therefore the supplies had not had time to expire and she did not check the expiration dates when she last stocked on 07/17/18. In addition, she stated staff used the supplies pretty quickly so they usually did not expire. Additional interview revealed the facility had no sign off sheet to indicate when expiration dates were checked or supplies checked and restocked. 2. Review of the facility Pharmacy Medication Expiration Dates document, dated 11/2017, revealed Humalog insulin pens and [MEDICATION NAME]pens expired thirty (30) days after being opened. Continued review revealed [MEDICATION NAME] 70-30 insulin pens expired fourteen (14) days after being opened. Observation on 07/19/18 at 10:53 AM, of the Glory Road South-2 medication cart with Registered Nurse (RN) #1, who was also one of the Assistant Directors of Nursing (ADON), revealed one (1) [MEDICATION NAME] Insulin Flex pen three (3) milliliters (ml) which was open, but not marked with the open date. Continued observation revealed the medication label contained a pharmacy fill date of 07/12/18; however, the manufacturer's expiration date was unknown as the RN #1/ADON discarded the medication prior to this surveyor looking at the date. Interview with RN #1/ ADON at the time of observation, revealed the medication had been discontinued on 07/18/18 and a new insulin order received. Further observation revealed one (1) [MEDICATION NAME] Mix 70-30 Insulin Flex Pen which was open, but not but not marked with the open date. Continued observation revealed the medication had a pharmacy fill date of 07/12/18 and a manufacturer's expiration date of 06/2019. RN #1/ADON was observed by this surveyor writing the date of 07/18/18 on the label of the insulin pen after this surveyor noted there was no date marked on the pen to indicate the date in which the pen had been opened. Interview with RN #1/ADON at the time of observation, revealed that was when it was opened. When questioned by the surveyor regarding the fill date of 07/12/18, on the medication label, the ADON stated Oh. No it was opened on that date and was observed rewriting a new opened date of 07/12/18 on the medication label. Continued observation revealed one (1) Humalog 100 units Insulin Flex Pen opened; however, not marked with the open date. The medication label had a pharmacy fill date of 07/18/18 and a manufacturer's expiration date of 12/2020. RN #1/ADON was observed by this surveyor writing a date of 07/18/18 on the medication label and she stated the insulin came from the pharmacy yesterday (07/18/18) and was opened the night of 07/18/18. Interview with RN #1/ADON, on 07/19/18 at 11:00 AM, revealed it was the nurse's responsibility to check for opened dates and expiration dates on medications before administering the medications. Further interview revealed insulin was to be kept in the refrigerator until opened and once opened, the Insulin vial or pen was to be labeled with the date it was opened. She stated insulin was good for thirty (30) days after it was opened. Additional interview revealed she checked the medication carts when she worked on the carts; and due to finding Insulins which had been opened without being marked with the open date, she would be checking the medication carts during her daily rounds. She further stated it was important to date insulin when it was opened to ensure the medication was at its best to ensure efficacy. Per interview, I'm sure there are possible negative outcomes if outdated insulin was given to the residents, but I'm unsure what they are. She further stated if insulin was expired it may not be effective, and could possibly affect residents' blood sugars by causing the blood sugars to remain high. Interview with Licensed Practical Nurse (LPN) #8, on 07/19/18 at 12:14 PM, revealed she had been working at the facility for just a few weeks. Continued interview revealed she thought RN #1/ADON checked expiration dates of medications on the medication carts; however, nurses should ensure the medications were dated when opened. Further interview revealed it was important to date medications, including insulin when opened, so staff would know when the medication expired. Additional interview revealed there could possibly be negative outcomes from giving Insulin which was not dated when opened, because staff would be unsure of the expiration date. 3. Observation on 07/19/18 at 11:59 AM, of the North Hall Heavenly Ave medication cart, revealed one (1) sixteen (16) gram bottle of [MEDICATION NAME] Propionate Nasal spray that was opened, but not dated with the open date. Continued observation revealed the medication label contained a pharmacy fill date of 05/16/18 and an expiration date of 12/2020. Further observation revealed one (1) ten (10) milliliter (ml) bottle of Bromonidine 0.2% eye drops that was open, but not dated with the open date. Additional observation revealed the medication had a pharmacy fill date of 05/10/18 and an expiration date of 06/2019 on the medication label. Interview with LPN #7, on 07/19/18 at 12:08 PM, revealed nurses were responsible for checking the medications on the medication carts for expiration dates. Continued interview revealed if a medication was not dated when opened or was expired, she would remove the refill sticker from the medication container, place the medication in the pharmacy bin, and call the pharmacy to reorder the medication. Further interview revealed it was important to date medications when opened because some medications were only good for a certain amount of time after they were opened. Per interview, eye drops were good for sixty (60) days after being opened. She stated she was unsure how long nasal sprays could be used after being opened. Additional interview revealed residents should not be given a medication that was outdated due to the medication would not work as well. Interview with the Director of Nursing (DON), on 07/19/18 at 7:10 PM, revealed it was her expectation when a nurse opened a medication, such as eye drops, nasal spray or insulin, the nurse would date the medication with the date in which the medication was opened. Continued interview revealed it was her expectation the nurses check the expiration dates of the medications before administering the medication, and also checked expiration dates of supplies before use. Interview with the Administrator, on 07/19/18 at 7:20 PM, revealed it was her expectation nursing staff follow the facility policies related to opening medications.

Based on observation, interview, and review of the facility's Policy, it was determined the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Observation on 07/17/18 at 11:32 AM, 2:48 PM, 5:11 PM, and 07/18/18 at 9:25 AM, revealed a raised toilet seat in the shared bathroom for rooms [ROOM NUMBERS] was soiled with a dried brown substance resembling dried liquid stool. This bathroom was shared by four (4) residents. In addition, observation on 07/18/18 at 4:00 PM, of the shared bathroom between rooms [ROOM NUMBERS], revealed three (3) soiled areas on the wall above the toilet tissue holder, which resembled stool. Each area was approximately (5) five to (6) six centimeter (cm) long and each approximately (2) two centimeters wide and were brown in color. The findings include: Review of the facility's Standard Precautions Policy, dated 08/2007, revealed staff should ensure that reusable equipment is not used for the care of another resident until it has been appropriately cleaned and reprocessed . Continued review revealed the policy stated ensure that environmental surfaces, beds, bedrails, bedside equipment and other frequently touched surfaces are appropriately cleaned. Observation on 07/17/18 at 11:32 AM, revealed a raised toilet seat in the shared bathroom for rooms [ROOM NUMBERS] was soiled with a dried brown substance resembling dried liquid stool. There were four (4) residents who shared this bathroom. Further observation on 07/17/18 at 2:48 PM, 07/17/18 at 5:11 PM, and 07/18/18 at 9:25 AM, revealed the raised toilet seat was still soiled with the dried brown substance. Observation on 07/18/18 at 9:50 AM, revealed a Housekeeping cart was parked in the hall outside of room (212). Continued observation revealed the Housekeeper and the Housekeeping Manager were in the shared bathroom for rooms [ROOM NUMBERS] and were cleaning the soiled toilet seat. Observation on 07/18/18 at 10:22 AM and on 07/19/18 at 9:52 AM, revealed the shared bathroom for rooms [ROOM NUMBERS] was neat and clean, with no dried brown substance on the raised toilet seat. Interview with State Registered Nurse Aide (SRNA) #11, on 07/18/18 at 9:34 AM, who was working the hall where rooms [ROOM NUMBERS] were located, revealed the SRNAs would clean what they could when a bathroom was soiled and then they would call housekeeping to sanitize further. She stated Housekeeping checked the bathrooms during their rounds; however, she was unsure how often Housekeeping performed rounds. Additional interview revealed if the toilet seat was soiled staff would clean the toilet seat before allowing a resident to sit on the seat when assisting the residents with toileting. However, per interview, the residents who took themselves to the bathroom were probably sitting on the soiled seat. Interview with Licensed Practical Nurse (LPN) #6, on 07/18/18 at 9:51 AM, revealed the SRNAs would clean the bulk of anything soiled including toilet seats and bathrooms, and then would call Housekeeping to sanitize. Continued interview revealed SRNAs usually assisted the residents to the bathroom; however, some residents would go to the bathroom without asking for assistance. She stated it was important to keep bathrooms and toilet seats clean for safety and infection control. Interview on 07/19/18 at 12:23 PM, with a Housekeeper, revealed the housekeepers were assigned to different halls, and he did not work the hall with rooms [ROOM NUMBERS]. He stated he cleaned the residents' bathrooms on his assigned hall daily and as needed after that. He further stated the middle hall which was the shared bathroom for rooms [ROOM NUMBERS] gets the shaft. and explained this meant that this hall was not cleaned as well as the other halls. Per interview, it was the dirtiest hall. Additional interview revealed it was important to keep bathrooms clean due to cross contamination and for the comfort of the residents. 2. Observation on 07/18/18 at 4:00 PM, of the shared bathroom between rooms [ROOM NUMBERS], revealed three (3) soiled areas on the wall above the toilet tissue holder, which resembled stool. Each of the areas was approximately (5) five to (6) six centimeter (cm) long and approximately (2) two centimeters wide and were brown in color. Interview with LPN #2, on 07/18/18 at 5:05 PM, revealed the SRNAs were expected to make sure resident rooms and bathrooms were cleaned. Per interview, if a SRNA found soiled areas, they were to call housekeeping. LPN #2 stated the SRNAs were to clean any area which appeared as stool and then have housekeeping disinfect. Further interview revealed this was important to prevent cross contamination and illnesses such as Escherichia coli (E-coli). (E-coli is a bacteria which normally lives in the colon and can be spread from person to person. Symptoms of an E-coli infection can range from diarrhea to severe abdominal cramps, bloody diarrhea, and vomiting) Interview with SRNA #1, on 07/18/18 at 5:12 PM, revealed after providing care to residents, the bathroom and toilet areas were to be checked to ensure there was no soiling of areas which may need to be cleaned. Per interview, it was the SRNA's responsibility to clean soiled areas when they found them and Housekeeping would be called as needed. Further interview revealed maintaining a clean environment prevented the spread of disease in the facility keeping the residents safe. Interview with the Staff Development Coordinator (SDC), on 07/19/18 at 6:18 PM, revealed she was not aware of the brown soiled area (resembling stool) on the resident's bathroom wall in the shared bathroom for rooms [ROOM NUMBERS]. Further interview with the SDC, revealed there could be negative consequences of soiled or dirty walls as there could be the potential for infectious organism transmission to residents, especially those who shared a bathroom. Additional, interview revealed it was a housekeeping/facility rule to give more attention to bathrooms with independent residents who may soil the bathroom without staff present. Interview with the Housekeeping Manager, on 07/18/18 at 10:00 AM, and 5:15 PM, revealed the SRNAs cleaned the bulk of the stool found on toilets in the bathrooms and then called Housekeeping to sanitize. Continued interview revealed Housekeeping performed rounds four (4) times daily, and while cleaning the bathroom the housekeeping staff wiped down the toilets and cleaned around the toilets and walls if dirt/soiling was noted. Further interview revealed Housekeeping signed off to indicate they had performed the four (4) rounds daily. Additional interview revealed Quality Assurance (QA) rounds were performed by him daily and if he found an area that had not been cleaned, he had Housekeeping clean the area. He stated during the QA rounds, he checked one (1) common area, one (1) random bathroom, and one (1) deep cleaned room daily. He further stated it was important to keep bathrooms clean due to safety and infection prevention. Interview with the Director of Nursing (DON), on 07/19/18 at 7:10 PM, revealed, it was a joint effort between nursing staff and housekeeping to ensure bathrooms and resident rooms were clean and a homelike environment was maintained. Further interview revealed soiled or contaminated areas posed a risk for cross contamination of infection. Interview with the Administrator, on 07/29/18 at 7:20 PM, revealed all staff was to maintain resident rooms and bathrooms in a homelike manner. Per interview, when a SRNA entered a resident bathroom and noted it was soiled, they should clean the bathroom if it was manageable, and otherwise they were to call housekeeping to ensure cleanliness. Further interview revealed if the bathrooms were not clean, there was the risk of cross contamination and this would be an infection control issue for the residents.

Based on observation and interview, it was determined the facility failed to ensure sound levels did not interfere with resident privacy and comfort. The laundry room located in the back hallway had two doors and there was also an exit door to the outside patio. Despite signs posted on each door to not let the door slam, staff was observed disregarding the posted signs and the doors slammed causing a loud noise. Interviews with residents revealed they had problems with the lound noise levels. The findings include: Review of Resident Council Meeting Minutes revealed noise levels at night had been brought up as concerns in March 2017 as well as in May 2017. Observation on 05/30/17 at 11:31 AM during initial tour of the back hallway revealed both doors to the laundry room and a door to the outside patio had two signs taped to them. The first sign stated We have had numerous complaints about noise levels on the back hall during the night. Please remember that this is our resident's home. The second sign stated Please do not let this door slam, It disturbs the residents. Thanks. Observation, on 05/30/17 at 11:51 AM, revealed State Registered Nursing Assistant (SRNA) #2 entering the laundry room carrying several items and letting the door slam behind her. Observation, on 5/31/17 at 1:22 PM, revealed SRNA #7 entered the laundry room and the door slammed shut, causing a loud slamming noise. Observation, on 05/31/17 at 1:52 PM, revealed the Housekeeping Director exited the laundry room and let the door slam behind him, making a very loud slamming noise. 1. Review of the medical record revealed the facility admitted Resident #17 on 07/03/09 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of thirteen (13) out of fifteen (15), indicating the resident was cognitively intact. Interview with Resident #17, on 05/31/17 at 1:12 PM, regarding the noise level revealed, it was noisy all day long, usually with the staff slamming the doors going into the laundry room and going outside to the patio. Resident #17 reported he/she had have never complained but the door was loud and it bother him/her at times. Resident #17 stated, I wish they would do something about it. It can drive you crazy. 2. Review of the medical record revealed the facility admitted Unsampled Resident A on 07/28/15 with a [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of six (6) out of fifteen (15), indicating Moderate cognitive impairment. Interview with Unsampled Resident A, on 06/01/17 at 2:55 PM, revealed his/her roommate always had the television up extremely loud all day long and even during the night. Unsampled Resident A further revealed his/her roommate was hard of hearing and the staff have been unable to get the roommate to agree to use headphones. Unsampled Resident A further revealed the laundry room doors and exit door on the back hall slam loudly throughout the day and at night. 3. Review of Resident #4's medical record revealed Resient #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 03/21/17 Quarterly MDS revealed the facility assessed Resident #4 as a 15/15 BIMS, indicating no cognitive impairment. Interview with Resident #4 on 05/31/17 at 9:00 AM revealed, when questioned during a resident interview regarding the noise level, that it was noisy at night about 80% of the time, usually with staff cutting up. He/She revealed he/she was once a nurse aide, and understood the need to cut up sometimes to keep awake. She went on to reveal it had been brought up in resident council, and the residents had been told it would be taken care of, but it hadn't been. 4. Review of the medical record revealed the facility admitted Resident #15 on 04/28/17 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of fifteen (15) out of fifteen (15), indicating no cognitive impairment. Interview, on 06/01/17 at 10:55 AM, with Resident #15 revealed a resident who lived in the next room always has his/her television up loud during the night. Resident #15 further revealed he/she knew staff tried to get the resident to turn down his/her television with no success. Resident #15 also stated the slamming of doors was an issue as well. Interview with Plant Operations Director, on 06/01/17 at 3:02 PM, revealed signs were posted on the laundry room doors to reduce the noise levels because the doors were loud. The Plant Operations Director revealed he thought the signs had fixed the issue. Interview with the Director of Nursing (DON), on 06/01/17 at 4:05 PM, revealed wind caused the outside door to slam. The DON revealed the laundry room doors also slammed and the staff have been reminded to close the doors slowly. The DON revealed it was her expectation the staff not disturb the residents and the loud noises needed to be address and fixed.

Based on observation, interview, and review of the facility policy, it was determined the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted principles. Observation on 05/30/17 of the North Heavenly Avenue and South Glory Road Hall Medication Refrigerators, revealed one (1) open multidose vial of Aplisol (Tuberculin purified protein derivative) without an open date in each refrigerator. The findings include: Review of the facility's Medication Administration General Guidelines policy, dated 12/12, revealed medications were administered as prescribed in accordance with manufacturers' specifications. Further review revealed procedures included checking the expiration date on the package/container, and the nurse shall enter an 'open date' on the medication. Continued review revealed multi-dose vials had specified shortened end-of-use dates once opened, and in order to ensure medication potency and purity vials in use more than thirty (30) days should be discarded. Review of the Aplisol Manufacturer's Usage Instructions indicated on the vial of medication, revealed Vials in use more than thirty (30) days should be discarded due to possible oxidation and degradation, which may affect potency. Observation of the North Heavenly Avenue Medication Refrigerator, on 05/30/17 at 3:30 PM, revealed one (1) open vial of Aplisol (Tuberculin purified protein derivative) without an open date indicated on the vial. Additionally, observation of the South Glory Road Medication Refrigerator, on 05/30/17 at 3:35 PM, revealed one (1) open vial of Aplisol (Tuberculin purified protein derivative) without an open date indicated on the vial. Interview with Licensed Practical Nurse (LPN) #2, on 05/30/17 at 3:30 PM, revealed it was her understanding the medication was not expired. Further interview revealed she acknowledged it did indicate on the vial to discard the medication after thirty (30) days of opening, and the vial should have been dated when opened. Interview with LPN #3, on 05/30/17 at 3:35 PM, revealed the vials were supposed to be dated when opened. Continued interview revealed she acknowledged the vial without an 'open date', and the medication was only good for thirty (30) days after opening. LPN #3 also stated expired medications may not be as effective, therefore should not be used. Interview with Registered Nurse (RN) #2/Infection Control Nurse, on 06/01/17 at 2:30 PM, revealed expired medications would not be as effective, and the vials should be dated when opened. Continued interview revealed the medications were only good for thirty (30) days after opening, and that was why it was important to write the date on the vials. Interview with LPN #1, on 06/01/17 at 2:40 PM, revealed medications that were opened should have a 'date open' written on the medication. Continued interview revealed the medication was only good for thirty (30) days. Further interview revealed the nurses should not use the vials if they did not have a date on them. LPN #1 stated administering expired medication could cause side effects or an adverse reaction or may not be as potent. Interview with RN #1, on 06/01/17 at 2:54 PM, revealed vials should be dated when opened. Continued interview revealed they should be dated for infection control purposes and for effectiveness. RN #1 stated the staff would call the pharmacy if there were any questions regarding the medications. In addition, the nurses should check to see if a date is written on the vials, and if there was not a date indicated, the medications would not be given and the vials were supposed to be discarded. Interview with the Director of Nursing (DON), on 06/01/17 at 3:55 PM, revealed it was her expectation the vials were dated when opened in order for staff to be aware of when the medication was expired. Continued interview revealed when the nurses acknowledged the vials were not dated, they were expected to discard the vials and retrieve a new one to use. The medication was only good for thirty (30) days after opening. Interview with the Administrator, on 06/01/17 at 4:30 PM, revealed it was her expectation the vials were dated when opened. Further interview revealed if the medications were not dated, they could be expired, which were not supposed to be administered to the residents.

Based on observation, interview, and review of facility policy it was determined the facility failed to promote the rights of the resident for three (3) of twenty (20) sampled residents. Observation during the course of the survey revealed toileting schedules posted for Residents #9, #10, and #11. Then findings include: Review of the facility's Notice of Privacy Practices, revised 11/13, revealed resident health information could be shared with other professionals providing treatment; however, on the following page, under the heading Our Responsibilities, the policy goes on to state We are required by law to maintain the privacy and security of your protected health information. 1. Review of Resident #11's medical record revealed the facility admitted Resident #11 on 11/24/14 with [DIAGNOSES REDACTED]. The facility assessed Resident #11, on a Quarterly Minimum Data Set ((MDS) dated [DATE], as 11/15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. Observation on 05/30/17 at 4:03 PM revealed documentation posted on the outside of Resident #9's bathroom door, visible to anyone entering the room. The documentation included Resident #9's name at the bottom, with Incontinence Management Program Baseline Elimination Data Collection Form on the top. The body of the form contained instruction to indicate the resident's bowel and bladder status by hour and shift, documenting whether resident was continent or incontinent of bowel or bladder, assisted to toilet with or without results, or refused to cooperate. Resident #9's documentation began on 03/26/17 at 10:00 AM, and was last documented on 04/17/17 at 6:00 AM. Interview with Resident #11 on 05/31/17 at 9:59 AM revealed the posted toileting schedule didn't bother him, and he stated it was there for staff. Interview with State Registered Nurse Aide (SRNA) #3, who worked on the same unit as Resident #11, on 06/01/17 at at 11:14 AM revealed she had observed toileting schedules in the past, but was unaware of any residents on her unit having any posted at the time of the interview. She went on to reveal she was unaware of any residents complaining about toileting schedules being posted. When further questioned, she stated toileting schedules did have resident names on them, and probably shouldn't be posted on bathroom doors as it was not other people's business. She went on to reveal she posted resident toileting information in the kiosk. Interview with Licensed Practical Nurse (LPN) #1, on 06/01/17 at 2:40 PM, revealed no residents had complained to her about privacy. She stated she believed therapy was responsible for the toileting schedules for staff to document on, with the goal of determining a pattern and assisting in developing a toileting schedule. She went on to reveal it could be a privacy issue. Interview with Occupational Therapist #1, on 06/01/17 at 3:40 PM, revealed the toileting program was done through the therapy department, and staff was educated about taking residents to the restroom every two hours. She revealed the goal was to determine the approach for toileting residents, and that the number of incontinent episodes was measured with fewer indicating improved quality of life. She revealed they discussed the toileting program with residents before posting the documentation, and agreed it could be a privacy issue, and the schedule could possibly be posted somewhere staff could get to it but not so public. 2. Review of Resident #10's medical record revealed the facility admitted Resident #10 on 02/03/14 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of thirteen (13), which was an indication Resident #10 was cognitively intact. Observation, on 05/30/17 at 11:40 AM, revealed documentation posted on the outside of Resident #10's bathroom door, which was visible to anyone entering the room. The documentation included Resident #10's name at the bottom, with Incontinence Management Program Baseline Elimination Data Collection Form on the top. The body of the form contained instruction to indicate the resident's bowel and bladder status by hour and shift, documenting whether the resident was continent or incontinent of bowel or bladder, assisted to toilet with or without results, or refused to cooperate. Resident #10's documentation began on 04/13/17 at 8:00 PM, and was last documented on 04/29/17 at 6:00 PM. Interview with LPN #2, on 06/01/17 at 10:40 AM, revealed the program for Resident #10 was started as an intervention for fall prevention. Further interview revealed she acknowledged the posting of the form to be a privacy concern. LPN #2 also stated other people could potentially see the form and it should be covered. Interview with Resident #10, on 05/31//17 at 3:25 PM, revealed Resident #10 hadn't really thought about it before but looking at it now, he/she really didn't like her personal information posted where visitors and family could see it. 3. Review of Resident #9's medical record revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #9 to have a Brief Interview for Mental Status (BIMS) score of thirteen (13), which was an indication Resident #9 was cognitively intact. Observation of Resident #9 on 05/30/17 at 3:50 PM, revealed documentation posted on the wall of Resident #9's bathroom, visible to anyone entering resident's room. Documentation posted on Resident #9's bathroom wall consisted of two (2) forms. Documentation observed on the first form titled, Toileting Schedule listed specific times for toileting Resident #9 and the second form, titled with Resident #9's full first and last name, gave instructions for transferring Resident #9 on and off of the toilet. Interview with Resident #9, on 05/31/17 at 2:20 PM, revealed it was nobody else's business about his/her toileting. Interview with SRNA #4, on 06/01/17 at 11:39 AM, revealed she worked with Resident #9, and Resident #9 had stated, regarding the posted toileting schedule, that it was nobody's business when he/she went to the bathroom and that not everyone needed to see that. SRNA #4 stated she felt it was a privacy issue, and that if she were a resident she wouldn't want her toileting information posted for family and friends to see. Interview on 05/31/17 at 5:20 PM, with LPN #3, revealed, Hanging resident toileting schedules and transfer instructions was a dignity issue. Anyone could see this information and this is a privacy concern; they're not supposed to have access to this information unless they are caring for the resident. Interview with the Social Services Director on 06/01/17 at 3:27 PM revealed she was previously unaware of the posted toileting schedules, and first became aware of them yesterday. She revealed no one had complained to her about them being posted, although she acknowledged it could be a dignity/privacy issue, and could probably be posted somewhere else. Interview with the Director of Nursing (DON) on 06/01/17 at 3:54 PM revealed she believed resident toileting schedules needed to be in a less public place for resident privacy. Interview with the Administrator on 06/01/17 at 4:30 PM revealed no one had complained to her about the toileting schedules being posted, and she stated if a resident said posting it was okay, she wouldn't see any privacy concerns with it.

Based on observation and interview, it was determined the facility failed to ensure residents received services with reasonable accommodation of needs and preferences except when to do so when endanger the health or safety of the resident(s). Observation throughout the course of the survey revealed call lights were not within reach for two (2) of thirteen (13) sampled residents; Resident #3 and Resident #9. 1. Review of Resident #9's medical record revealed the facility admitted Resident #9 on 04/12/12 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 04/18/17, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated the resident was cognitively intact. Observation of Resident #9's room on 05/30/17 at 3:55 PM, revealed Resident #9 seated in a wheelchair beside the bed near the entrance to the Resident #9's room. Resident #9's call light was located attached to the top quarter rail of the resident's bed, hanging on the underside of the head of the bed, near the floor. Resident #9's call light remote was positioned behind the resident's wheelchair and not within the resident's reach or sight. Observation of Resident #9's call light position on 05/31/17 at 2:55 PM, revealed the call light was attached to the top quarter rail of the resident's bed, hanging on the underside of the bed, near the floor, not within resident's reach. Resident #9 was seated in the wheelchair beside the bed, located towards the entrance of his/her room. Observation of Resident #9's call light position on 05/31/17 at 5:47 PM, revealed the call light was attached to the top quarter rail of the resident's bed, hanging on the underside of the bed, near the floor, out of resident's reach. Resident #9 was seated in the wheelchair beside the bed, located towards the entrance of his/her room. Observation of Resident #9's call light position on 06/01/17 at 10:55 AM, 2:00 PM, 5:00 PM and again at 6:00 PM, revealed the call light remained attached to the top quarter rail of the resident's bed, hanging on the underside of the bed, near the floor. Resident #9 was seated at the side of the bed, near the room's entrance with the bedside table in front of him/her with eyes closed. 2. Review of Resident #3's medical record revealed the facility admitted Resident #3 on 01/28/14 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #3 as having a Brief Interview for Mental Status (BIMS) score of eight (8) which indicated the resident was cognitively impaired. Observation of Resident #3's room on 05/30/17 at 4:10 PM, revealed the call light located on the floor, under the bed, toward the head of the resident's bed. Continued observations on 05/30/17 at 5:00 PM and 6:00 PM revealed the call light remained under the resident's bed, on the floor, out of the resident's reach. Observation of Resident #3's call light on 05/31/17 at 9:13 AM revealed call light on floor, under the resident's bed. Continued observations on 05/31/17 at 2:49 PM, 5 PM and 6 PM, revealed the call light in the same position as previous observations. Observations of Resident #3's call light on 06/01/17 at 11:40 AM, 11:58 AM, 12:04 PM, 2:00 PM, 2:40 PM, and 3:00 PM, revealed the call light located on floor, under the resident's bed. Interview with State Registered Nursing Assistant (SRNA) #11 on 05/31/17 at 3:50 PM, revealed call lights were to be placed within the resident's reach prior to exiting the resident's rooms. Interview with SRNA #12 on 05/31/17 at 4:13 PM revealed call lights were to be placed where residents could reach them before leaving a resident's room. All staff are responsible for making sure this is done. Interview with Licensed Practical Nurse (LPN) #4 on 05/31/17 at 5:20 PM revealed call lights were to be placed within the resident's reach before exiting the resident's room to ensure the resident's needs are being met in a timely manner. Interview with Registered Nurse (RN) #2 on 06/01/17 at 10:20 AM, revealed all staff are to ensure call lights are placed within resident's reach prior to leaving the residents' rooms. RN #2 advised it is her expectatation that all staff check resident call lights to be sure resident's are able to reach them to prevent accidents and injuries in case of emergencies. Interview with the Director of Nursing (DON) on 06/01/17 at 3:58 PM revealed it was her expectation that all staff ensure resident call lights are within reach and functioning prior to leaving a resident's room to ensure the resident's needs are being met. Interview with the Administrator on 06/01/17 at 4:40 PM, revealed it was her expectation that all staff follow policy and procedure related to the placement of call lights prior to exiting a resident's room. Further interview revealed the Administrator expected all facility staff to place each resident's call light within the resident's reach to allow them the ability to call for assistance from staff when needed.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Observation on initial tour, on 05/30/17, revealed the bathroom for rooms 312 and 313, shared by four (4) residents, had a bedpan and a plunger on the floor next to the commode, which were not bagged; the bathroom for rooms 310 and 311, shared by three (3) residents, had a bedpan on the floor stored behind the commode, which was not bagged; the private bathroom for room 400 had two (2) plungers on the floor next to the commode, which were not bagged; and one (1) pair of heel protector boots (foam boots used to elevate and cushion the heels) stored on the floor in room 314. The findings include: Review of the facility's policy titled, Standard Precautions, revised 08/07, revealed standard precautions presumed that all blood, body fluids, secretions, and excretions, non-intact skin and mucous membranes may contain transmissible infectious agents. Resident care equipment was to be handled in a manner that prevented skin and mucous membrane exposures, contamination of clothing, and transfer of other microorganisms to other residents and environments. Further review revealed staff was to ensure that reusable equipment was not used for the care of another resident until it had been appropriately cleaned and reprocessed and single use items were properly discarded. Observation on initial tour, on 05/30/17 from 11:35 AM to 11:58 AM, revealed the bathroom for rooms 312 and 313, shared by four (4) residents, had a bedpan and a plunger on the floor next to the commode, which were not bagged; the bathroom for rooms 310 and 311, shared by three (3) residents, had a bedpan on the floor stored behind the commode, which was not bagged; the private bathroom for room 400 had two (2) plungers on the floor next to the commode, which were not bagged; and one (1) pair of heel protector boots (foam boots used to elevate and cushion the heels) stored on the floor in room 314. Interview with State Registered Nursing Assistant (SRNA) #6, on 05/30/17 at 12:20 PM, revealed bedpans were supposed to be stored in plastic bags and not left on the floor when not in use. Further interview revealed it was unsanitary for the items to not be placed in bags and left on the floor. SRNA #6 also stated residents could trip over the items and fall if they were left on the floor. Interview with SRNA #1, on 05/31/17 at 2:45 PM, revealed bedpans were to be stored in plastic bags and labeled for proper sanitation. Continued interview revealed resident care devices, such as heel boots, were also supposed to be stored up off the floor when the residents were not using them. When not in use, the devices should be kept in the resident's closet for infection control. Interview with Licensed Practical Nurse (LPN) #2, on 06/01/17 at 10:40 AM, revealed bed pans and plungers were to be covered with plastic bags. LPN #2 stated the bedpans should not be left on the floor, as well. Further interview revealed heel boots were not supposed to be left on the floor. All items needed to be properly stored for infection control purposes. Interview with Registered Nurse (RN) #2, on 06/01/17 at 2:30 PM, revealed all bedpans and plungers were to be covered with plastic bags. Bedpans should not be left on the floor. Continued interview revealed heel boots and resident care devices should not stored on the floor when not in use. RN #2 stated proper storage of all the items related to infection control. In addition, staff had received education and training on standard precautions. Interview with RN #1, on 06/01/17 at 2:54 PM, revealed bedpans should be stored in plastic bags in order to maintain cleanliness. Continued interview revealed a toilet plunger should not be left in a resident's bathroom. RN #1 stated she would not expect to see a plunger in any bathroom. Further interview with RN #1 revealed if a resident was not using or wearing a device, those items were supposed to be stored in a closet or kept in a plastic bag and not directly on the floor for proper infection control. Interview with the Director of Nursing (DON), on 06/01/17 at 3:55 PM, revealed it was her expectation items would be labeled, covered, and stored appropriately when not in use for infection control purposes. Continued interview revealed plungers were supposed to be stored in bags, but did not expect plungers to be left in the bathrooms. The DON stated improper storage of the items was an infection control issue. Interview with Administrator, on 06/01/17 at 4:30 PM, revealed it was her expectation the residents' items would be bagged and stored appropriately. Continued interview revealed it was important for infection control purposes.

Based on observation, interview, record review and review of facility policy it was determined the facility failed to ensure the comprehensive care plan was followed for one (1) of twenty (20) sampled residents, (Resident #6). Observations on 05/30/17 during initial tour with continued observations on 05/30/17, revealed Resident #6 wearing hard sole shoes. The findings include: Review of the facility policy titled Care Plans-Comprehensive not dated, the nurse or interdisciplinary team develops and maintains a comprehensive care plan, and identifies the highest level of functioning the resident may be expected to attain. Care plan interventions are implemented to address the underlying source(s) of the problem area(s). Review of the medical record revealed the facility admitted Resident #6 on 11/15/13 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the facility assessed the resident as having a Brief interview for Mental Status (BIMS) of four (4) out of fifteen (15) with severe cognitive impairment. Review of Comprehensive Care Plan with initial date of 04/05/17 revealed problem of abrasions on my left ankle and left lateral foot. The goal for Resident #6 was to be free from new skin areas through next review date of 08/05/17. Intervention included to treat as ordered with heel boots while in bed and updated on 05/10/17 for Resident 6 not to wear hard shoes and only wear slippers when out of bed. Review of the Physician orders for Resident #6, dated 04/12/17, revealed to continue with skin prep to left foot/ankle areas. No shoes. Wear non-skid socks, soft house shoes, or heel boots at all times. Review of the Physician orders dated 05/10/17, revealed to discontinue current treatment to left foot and ankle. Paint with [MEDICATION NAME] every day, (QD). Leave open to air. No hard shoes! Slippers only! Review of the VOHRA Wound Physicians consult form titled Wound Care Specialist Evaluation dated 05/23/17 revealed the resident had an un-stageable deep tissue injury (DTI) to the left, lateral foot with absence of pain and was healing. Review of facility form titled Nurse Aide Assignment Sheets dated 05/30/17 revealed instructions for Resident #6 no hard shoes, slippers only. Observation on 05/30/17 at 12:00 PM during initial tour and at 3:30 PM, 4:40 PM, 5:05 PM revealed Resident #6 sitting in his/her room in the wheel chair was wearing hard shoes. Interview on 05/30/17 at 5:05 PM with the Assistant Director of Nursing (ADON)/Unit 2 Manager revealed Resident #6 was to wear slippers and not hard shoes. The ADON addressed Resident #6 in his/her room concerning the reason to wear slippers instead of shoes. Interview, on 05/31/17 at 3:00 PM, with State Registered Nursing Assistant (SRNA) #1 revealed they followed the Aide Care Plans and received updates and changes daily in report. She was aware that Resident #6 could not wear shoes and was only to wear slippers. Further interview revealed Resident #6 had reported pain when he/she tried to put his/her own hard shoes on without assistance. SRNA #1 revealed she explained to Resident #6 why he/she needed to wear the slippers and assisted with taking the hard shoes off and placed the slippers on the residents' feet. Interview, on 05/31/17 at 3:45 PM, with the ADON/Unit 2 Manager revealed Resident #6 had not reported any pain on 05/30/17. The ADON stated the Comprehensive Care Plan was not followed because the SRNA's should have seen the resident was wearing hard shoes, educated the resident and changed the hard shoes for the slippers. She further stated the same intervention concerning Resident #6 wearing slippers instead of hard shoes, was also on the Aide care plan. Interview, on 06/01/17 at 1:53 PM, with the Director of Nursing (DON) revealed staff should have followed the Comprehensive Care Plan. Interview, on 06/01/17 at 2:00 PM, with Administrator revealed her expectations was for staff to follow the Comprehensive Care Plan.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to establish and maintain an infection control program designed to provide a safe and sanitary environment to help prevent the development and transmission of disease for two (2) of twenty (20) sampled residents (Resident #3 and Resident #9). Observation of a skin assessment for Resident #9 revealed staff failed to use proper hand hygiene and glove usage during the assessment. In addition, observation of perineal care for Resident #3, revealed staff failed to perform proper hand washing. The findings include: Review of the facility's policy titled Standard Precautions, revised 08/2017, revealed standard precautions were used in the care of all residents regardless of diagnosis, or suspected or confirmed infection status. Standard Precautions presumed that all blood, body fluids, secretions, and excretions, non-intact skin and mucous membranes may contain transmissible infectious agents. Continued review revealed gloves were to be worn when direct contact with blood, body fluids, mucous membranes, non-intact skin, and other potentially infected materials was anticipated. Gloves were to be changed, as necessary, during the care of a resident to prevent cross-contamination from one body site to another (when moving from a dirty site to a clean one). In addition, gloves were removed promptly after use and hands were to be washed immediately. 1. Review of Resident #9's medical record revealed the facility admitted the resident on 04/12/12 with diagnoses, which included Contractures (shortening and hardening of muscles, tendons, or other tissue often leading to deformity and joint rigidity), Dysphagia (difficulty swallowing), Osteoporosis (weak and brittle bones), Hypertension (high force of blood against the arterial walls), and Ulcerative Colitis (inflammatory bowel disease). Observation of a skin assessment performed for Resident #9, on 05/31/17 at 11:20 AM, by Licensed Practical Nurse (LPN) #4 and with assistance from State Registered Nursing Assistant (SRNA) #5, revealed LPN #4 began assessing the resident's skin starting with Resident #9's head and proceeded in a downward manner towards the resident's perineal and buttocks area. Following the removal of Resident #9's incontinence brief, LPN #4 and SRNA #5 removed their dirty gloves and donned new gloves; however, neither staff member washed their hands after they removed their dirty gloves. LPN #4, with the assistance from SRNA #5, placed a clean brief on Resident #9, and continued with the skin assessment. LPN #4 completed the skin assessment, and both LPN #4 and SRNA #5 removed their gloves and performed hand hygiene. Interview with SRNA #5, on 05/31/17 at 11:40 AM, revealed she did not wash her hands after assisting the nurse with removal of Resident #9's brief and prior to donning clean gloves. Further interview revealed hand hygiene was supposed to be performed with glove changes for infection control. Interview with LPN #4, on 05/31/17 at 11:45 AM, revealed she did not wash her hands when she removed her dirty gloves after coming in contact with Resident #9's perineal and buttocks area and after removal of the resident's brief. LPN #4 stated she should have washed her hands after she removed her dirty gloves and prior to donning clean gloves for infection control purposes. Interview with Registered Nurse (RN) #2/Infection Control, on 06/01/17 at 2:30 PM, revealed staff was to perform hand hygiene and wash their hands with glove changes. Continued interview revealed hand washing should especially be completed after staff changed incontinence briefs. She further stated she observed staff perform perineal care and hand hygiene practices as part of the facility's tracking system for infection control. In addition, staff had received education on proper infection control and hand washing. Interview with LPN #1/Charge Nurse, on 06/01/17 at 2:40 PM, revealed hand washing should be performed prior to donning clean gloves and with each glove change. Further interview revealed she would not want anyone touching her with dirty hands or gloves. Continued interview revealed hand washing was done for infection control. 2. Review of Resident #3's medical record revealed the facility admitted the resident on 01/28/14 with [DIAGNOSES REDACTED]. Observation of perineal care provided for Resident #3 on 06/01/17 at 11:40 AM by SRNA #9 and SRNA #10, revealed staff failed to use proper hand hygiene and glove usage. Following the removal of Resident #3's soiled bed linens, with the assistance of SRNA #10 aiding in the positioning of resident, SRNA #9 cleansed Resident #3's perineal area with a soapy wash cloth in a downward motion towards the resident's buttocks. SRNA #9 failed to rinse or dry Resident #3's perineal area. Both SRNA #9 and SRNA #10 failed to washed hands and don clean gloves following the removal of soiled bed linens and providing perineal care to Resident #3. Interview with SRNA #9, on 06/01/17 at 11:58 AM, revealed she was aware of proper hand hygiene and how to provide perineal care. She stated she should have washed her hands and put on clean gloves as soon as she removed Resident #3's dirty linens. Interview with the Director of Nursing (DON), on 06/01/17 at 3:55 PM, revealed she expected staff to wash their hands prior to donning gloves, as well as after removal of dirty gloves. Further interview revealed it was important to wash hands when going from dirty to clean for infection control and to prevent contamination. Interview with the Administrator, on 06/01/17 at 4:30 PM, revealed it was her expectation that the facility's infection control policy and practices were followed by staff.

Based on observation, interview, record review and review of the facility's policies, it was determined the facility failed to have an effective system in place to ensure services were provided in accordance with each resident's written Plan of Care. There was no documented evidence the resident's care plans were implemented to ensure resident's achieved acceptable level of pain control as evidenced by the facility's failure to complete pain assessments, and assess and document effectiveness of pain medications for four (4) of twenty-one (21) sampled residents (Residents #1, #5, #12 and #16). The findings include: Review of the facility's policy, Care Plans-Comprehensive, dated 06/01/15, revealed an individualized comprehensive care plan includes measurable objectives to meet the resident's medical, nursing, mental and psychological needs. Further review revealed it was the policy of the facility a resident care plan shall reflect standards of practice for problem areas and conditions. Per Policy, care pan interventions were implemented after consideration of the resident's problem areas and their causes. Review of the facility's policy, titled Pain Management, undated, revealed Each resident identified with pain will have ongoing assessments, a monitoring system and a specific plan of care to address these issues. A pain scale was to be used to describe a resident's pain, as well as the amount of pain relief. Further review of the Policy revealed pain medication administration shall occur in EZMAR (Electronic Medication Administration Record) and documentation of indication and effectiveness shall be documented. A pain assessment was to be completed on each shift for all residents, and the findings were to be documented on the EZMAR. The effectiveness of routine pain medication will be monitored through use of every shift pain assessment. 1. Review of Resident #5's clinical record revealed the facility admitted the resident on 05/27/14 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Sets ((MDS) dated [DATE], revealed the facility assessed Resident #5 to have a Brief Interview for Mental Status (BIMS) score of nine (9), indicating the resident had moderate cognitive impairment. Continued review revealed the facility assessed the resident as having occasional pain in the last five (5) days limiting day to day activities, at a pain intensity of a six (6) on a scale of one (1) to ten (10) with ten (10) being the worst pain. Review of Resident #5's Comprehensive Care Plan, dated 07/08/15, revealed the resident had a problem of chronic, acute and breakthrough pain. The goal revealed the resident would demonstrate relief or reduction of discomfort within one (1) hour, and would not experience a decline in overall function related to pain. The interventions included the following: assessing for worsening pain, medication as ordered, and observe for effectiveness of medication. However, there was no documented evidence the resident's Care Plan was followed. Further review of the resident's clinical record revealed Resident #5 had an Implanted [MEDICATION NAME] Pump (a small pump surgically implanted under the skin that continuously delivers pain medication directly to the spinal cord), which contained [MEDICATION NAME] (narcotic used to treat moderate to severe pain) ten (10) milligrams (mg)/milliliter (ml) and [MEDICATION NAME] (local anesthetic) ten (10) mg/ml. Review of Resident #5's Physician order [REDACTED]. Review of Resident #5's Electronic Medication Administration Record [REDACTED]. Interview with Licensed Practical Nurse (LPN) #2 on 05/04/16 at 9:25 AM, revealed nurses were to check Resident #5's pain level every four (4) hours. Interview with the Assistant Director of Nursing (ADON) on 05/05/16 at 2:40 PM, revealed nursing staff should have documented pain assessments for Resident #5 every four (4) hours on the MAR. 2. Review of Resident #16's clinical record revealed the facility admitted the resident on 04/06/11, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #16 to have a BIMS score of fifteen (15), which was an indication Resident #16 was cognitively intact. Continued review of the MDS, revealed the facility assessed the resident as not needing a pain assessment interview. Review of Resident #16's Comprehensive Care Plan, dated 11/04/14 revealed a problem of the resident being at risk for pain related to Gout, generalized pain and [MEDICAL CONDITION]. The goal revealed the resident would be free of pain daily. The interventions included: assess pain on a scale of one (1) to ten (10) with complaints of pain, and observe for worsening pain. However, there was no documented evidence the resident's Care Plan was followed. Review of Resident #16's physician's orders [REDACTED]. Review of Resident #16's EZMAR, dated April 2016 and May 2016, revealed no documented evidence of a pain assessment with the administration of scheduled pain medications. Interview with LPN #1 on 05/05/16 at 3:50 PM, revealed nurses did not assess Resident #16's pain level when giving the resident the scheduled pain medications. 3. Review of Resident #12's clinical record revealed the resident was admitted by the facility on 07/31/15 with [DIAGNOSES REDACTED]. Review of the resident's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of ten (10), which indicated the resident was moderately cognitively impaired. Further review of the resident's Quarterly MDS, revealed the facility assessed the resident as having a pain intensity score of two (2), which indicated the resident's pain was moderate. Review of Resident #12's last pain evaluation, dated 02/01/16, revealed the resident had chronic leg pain. Review of Resident #12's Comprehensive Care Plan, dated 08/12/15, revealed the resident had a problem of chronic pain and pain in the legs. The goal revealed the resident would verbalize an acceptable level of comfort. The interventions included: observe for signs and symptoms of pain; report changes in pain location and type of pain; and encourage the resident to report discomfort. However, there was no documented evidence the Care Plan was followed. Review of Resident #12's physician's orders [REDACTED]. Continued review of the resident's physician's orders [REDACTED]. Review of Resident #12's EZMAR, dated April 2016, and May 2016, revealed the resident received [MEDICATION NAME] (narcotic pain medication -used to treat moderate to severe pain) HCL ten (10) MG tablet by mouth four (4) times a day with no documented evidence the pain level was assessed before the medication was administered. Also, there was no documented evidence of a pain assessment after the medication was administered to assessed the effectiveness of the medication. Review of Resident #12's Progress Notes for the period of April 2016 and May 2016, revealed the resident was assessed for pain on 04/23/16, 04/24/16, and 04/26/16, and the resident did not voice complaints of pain at those times. Interview with Resident #12, on 05/04/16 at 8:44 AM, revealed he/she should have another physician to address his/her pain, adding he/she had pain in his/her leg and the physician would not provide additional pain medication. Interview with State Registered Nurse Aide (SRNA)#2, on 05/05/16 at 4:38 PM, revealed she worked with Resident #12 and he/she would at times complain of leg pain, but not on a consistent bases, adding it had been awhile since she had heard the resident complain. Continued interview with SRNA #2, revealed she would report to the nurse if the resident complained of pain and the nurse often administered Tylenol ([MEDICATION NAME] for mild pain) medication. Interview with Licensed Practical Nurse (LPN) #3, on 05/05/16 at 2:51 PM, revealed a pain assessment should be performed and documented prior to pain medication being administered, adding the pain scale would show up on their computer screen before administering the medication to the residents. Further interview with LPN #3, revealed staff was to follow up with the resident in an hour to determine the effectiveness of the medication and also document this on the EZMAR. Continued interview with LPN #3, revealed Resident #12 received scheduled [MEDICATION NAME] for pain and would ask for a Tylenol for a headache, but not often. LPN #3 stated the resident would report his/her pain level was at a five (5) or six (6), when asked. Per interview, the pain assessments prior to the pain medication administration were not documented, but should have been. Also, she revealed the resident should have been assessed to see if the pain medication was effective after administration and this should have been documented as well. 4. Review of Resident #1's clinical record, revealed the facility admitted the resident on 05/30/13 with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 04/28/16, revealed the facility assessed Resident #1 as having long term and short term memory loss. Continued review of the MDS revealed the facility assessed the resident to be unable to answer pertaining to pain assessment. Review of the Comprehensive Care Plan, initiated on 12/02/14, revealed Resident #1 was at risk for potential Acute and Chronic Pain related to [DIAGNOSES REDACTED]. The care plan goal revealed the resident would verbalize adequate relief of pain or ability to cope with incompletely relieved pain and would exhibit relaxed facial expression and or body language. The interventions included: observing and reporting complaints of pain or request for pain treatment to the nurse; observing for the effectiveness of pain interventions, compliance, alleviating of symptoms, resident satisfactions with results, impact on functional ability and impact on cognition; and observing pain characteristics as needed for quality of pain and severity of pain on a scale of one (1) to ten. However, there was no documented evidence the Care Plan was followed. Review of Resident #1's Physician order [REDACTED]. Review of Resident #1's EZMAR, dated April 2016 and May 2016, revealed the resident received the [MEDICATION NAME] on the 3rd, 6th, 9th, 12th, 15th, 18th, 21st, 24th, 27th, and 30th, of April 2016 and on 05/03/16. However, continued review of the EZMAR revealed no documented evidence the resident received a pain assessment before or after the administration of the patch. Interview and record review, on 05/05/16 at 3:30 PM and 4:40 PM, with Licensed Practical Nurse (LPN) #3 revealed she did always assess Resident #1 for pain before administering pain medication. Per interview there was no documented evidence on the EZMAR Resident #1's pain was assessed before administering the patch. LPN #4 revealed the resident's pain level should have been assessed prior to application of the [MEDICATION NAME] Patch and this should have been documented on the EZMAR because the resident's pain may be worse than usual and if the assessment was not done, staff would not be aware of the worsening pain. Interview with the Director of Nursing (DON), on 05/05/15 at 5:45 PM, revealed the Care Plans directed staff on how to provide care to the residents. She further revealed if staff were not performing and documenting pain assessments, the Care Plan was not followed. Interview with the Administrator on 05/05/16 at 6:05 PM revealed it was her expectation that Care Plans would be followed.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being for four (4) of twenty-one (21) sampled residents (Residents #1, #5, #12 and #16). The facility failed to implement their Pain Management Policy. The findings include: Review of the facility's policy, titled Pain Management, undated, revealed Each resident identified with pain will have ongoing assessments, a monitoring system and a specific plan of care to address these issues. A pain scale was to be used to describe a resident's pain, as well as the amount of pain relief. Further review of the Policy revealed pain medication administration shall occur in EZMAR (Electronic Medication Administration Record) and documentation of indication and effectiveness shall be documented. A pain assessment was to be completed on each shift for all residents, and the findings were to be documented on the EZMAR. The effectiveness of routine pain medication will be monitored through use of every shift pain assessment. 1. Review of Resident #5's medical record revealed the facility admitted the resident on 05/27/14 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Sets ((MDS) dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of nine (9), indicating the resident had moderate cognitive impairment. Further review revealed the facility assessed the resident as having occasional pain in the last five (5) days limiting day to day activities, at a pain intensity of a six (6) on a scale of one (1) to ten (10) with ten (10) being the worst pain. Review of Resident #5's Comprehensive Care Plan, dated 07/08/15, revealed the resident had chronic, acute and breakthrough pain. The goal stated the resident would demonstrate relief or reduction of discomfort within one (1) hour, and would not experience a decline in overall function related to pain. The interventions included assessing for worsening pain, medication as ordered, and observe for effectiveness of medication. Further review of the resident's medical record revealed [REDACTED]. Review of Resident #5's current active Physician order [REDACTED]. Review of Resident #5's Electronic Medication Administration Record [REDACTED]. Interview with Licensed Practical Nurse (LPN) #2 on 05/04/16 at 9:25 AM, revealed nurses were supposed to check Resident #5's pain level every four (4) hours. Interview with the Assistant Director of Nursing (ADON) on 05/05/16 at 2:40 PM, revealed nursing staff should have documented pain assessments for Resident #5 every four (4) hours on the MAR indicated [REDACTED] 2. Review of Resident #16's medical record revealed the facility admitted the resident on 04/06/11, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of fifteen (15), which was an indication Resident #16 was cognitively intact. Further review of the MDS, revealed the facility assessed the resident as not needing a pain assessment interview. Review of Resident #16's Comprehensive Care Plan, dated 11/04/14 revealed the resident was at risk for pain related to Gout, generalized pain and [MEDICAL CONDITION]. The goal stated the resident would be free of pain daily. The interventions included assessing pain on a scale of one (1) to ten (10) with complaints of pain, and observe for worsening pain. Review of Resident #16's physician's orders [REDACTED]. Review of Resident #16's EZMAR, dated April 2016 and May 2016 revealed no documented evidence of a pain assessment with the administration of the scheduled pain medications. Interview with LPN #1 on 05/05/16 at 3:50 PM, revealed the nurses did not assess Resident #16's pain level when giving the resident the scheduled pain medications. 3. Review of Resident #12's medical record revealed the resident was admitted by the facility on 07/31/15 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of ten (10), which indicated the resident was moderately cognitively impaired. Continued review of the resident's Quarterly MDS, revealed the facility assessed the resident as having a pain intensity score of two (2), which indicated the resident's pain was moderate. Review of the resident's last pain evaluation, dated 02/01/16, revealed the resident had chronic leg pain. Review of Resident #12's Comprehensive Care Plan, dated 08/12/15, revealed the resident had a history of [REDACTED]. The goal stated the resident would verbalize an acceptable level of comfort. The interventions included observe for signs and symptoms of pain; report changes in pain location and type of pain; and remind and encourage the resident to report discomfort. Review of Resident #12's physician's orders [REDACTED]. Continued review of the resident's physician's orders [REDACTED]. Review of Resident #12's EZMAR, dated April 2016, and May 2016, revealed the resident was administered [MEDICATION NAME] (narcotic pain medication -used to treat moderate to severe pain) HCL ten (10) MG tablet by mouth four (4) times a day with no documented evidence the pain level was assessed before the medication was administered. In addition, there was no documented evidence of a pain assessment after the medication was administered to assessed the effectiveness of the medication. Review of Resident #12's Progress Notes for the period of April 2016 and May 2016, revealed the resident was assessed for pain on 04/23/16, 04/24/16, and 04/26/16, and the resident did not voice any complaints of pain at those times. Interview with Resident #12, on 05/04/16 at 8:44 AM, revealed he/she should have another physician to address his/her pain, adding he/she had pain in his/her leg and the physician would not provide him/her with additional pain medication. Interview with State Registered Nurse Aide (SRNA)#2, on 05/05/16 at 4:38 PM, revealed she worked with the resident and he/she would at times complain of leg pain, but not on a consistent bases, adding it had been awhile since she had heard the resident complain. Further interview with SRNA #2, revealed she would report to the nurse if the resident complained of pain and the nurse often administered Tylenol ([MEDICATION NAME] for mild pain) medication. Interview with Licensed Practical Nurse (LPN) #3, on 05/05/16 at 2:51 PM, revealed a pain assessment should be performed and documented prior to pain medication administered, adding the pain scale would show up on their computer screen before administering the medication to the residents. Continued interview with LPN #3, revealed staff was to follow up with the resident in an hour to determine the effectiveness of the medication and also document this on the EZMAR. Further interview with LPN #3, revealed Resident #12 received scheduled [MEDICATION NAME] for pain and would ask for a Tylenol for a headache, but not often. LPN #3 stated the resident would report his/her pain level was at a five (5) or six (6), when asked. Continued interview revealed the pain assessments prior to the pain medication administration was not documented, but should have been. Additionally, she revealed the resident should have been assessed to see if the pain medication was effective after administration and this should have been documented as well. 4. Review of Resident #1's medical record, revealed the facility admitted the resident on 05/30/13 with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 04/28/16, revealed the facility assessed Resident #1 to have both long and short term memory loss. Continued review of the MDS revealed the facility assessed the resident to be unable to answer pertaining to pain assessment. Review of the Comprehensive Care Plan, initiated on 12/02/14, revealed Resident #1 was at risk for potential Acute and Chronic Pain related to [DIAGNOSES REDACTED]. The care plan goal revealed the resident would verbalize adequate relief of pain or ability to cope with incompletely relieved pain and would exhibit relaxed facial expression and or body language. The interventions included observing and reporting complaints of pain or request for pain treatment to the nurse; observing for the effectiveness of pain interventions, compliance, alleviating of symptoms, resident satisfactions with results, impact on functional ability and impact on cognition; and observe pain characteristics as needed for quality of pain and severity of pain on a scale of one (1) to ten. Review of Resident #1's Physician order [REDACTED]. Review of Resident #1's EZMAR, dated April 2016 and May 2016, revealed the resident was administered the [MEDICATION NAME] on the 3rd, 6th, 9th, 12th, 15th, 18th, 21st, 24th, 27th, and 30th, of April 2016 and on 05/03/16. However, continued review of the EZMAR revealed no documented evidence the resident was assessed for pain before or after the administration of the patch. Interview and record review, on 05/05/16 at 3:30 PM and 4:40 PM, with Licensed Practical Nurse (LPN) #3 revealed she did always assess Resident #1 for pain before administering pain medication. Additional interview revealed there was no documented evidence on the EZMAR Resident #1's pain was assessed before administering the patch. LPN #4 stated the resident's pain level should have been assessed prior to application of the [MEDICATION NAME] Patch and this should have been documented on the EZMAR because the resident's pain may be worse than usual and if the assessment was not done, staff would not be aware of the worsening pain. Interview with the Director of Nursing on 05/05/16 at 5:45 PM, revealed nursing staff should assess the resident's pain prior to pain medications being administered, whether scheduled or PRN, and pain assessments were to be documented on the EZMAR. Further interview revealed follow up pain assessments were to be done after administration of pain medications to assess for effectiveness of the medication and this should also be documented on the EZMAR. Continued interview revealed nurses should utilize the pain scale to determine the residents' pain or observe for signs and symptoms of pain for residents who could not be interviewed. Interview with the Administrator on 05/05/16 at 6:05 PM revealed it was her expectation that staff would follow the facility's Pain Management policy.

Based on observation, interview and review of facility's Policies and Procedures, it was determined the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection for two (2) of twenty-one (21) sampled residents (Resident #1 and Resident #7) Observation of a dressing change on 05/04/16 for Resident #1, revealed the Assistant Director of Nursing (ADON) failed to clean the bedside table and failed to establish a barrier for the dressing supplies prior to the dressing change. In addition, the ADON failed to perform hand hygiene in order to prevent cross contamination during the dressing change. Additionally, observation on 05/03/15, revealed housekeeping staff entered the room of Resident # 7, who was on contact precautions for Clostridium-difficile Colitis (inflammation of the large intestine resulting from infection with Clostridium difficile, a spore forming bacterium that causes an infectious diarrhea) , without donning Personal Protective Equipment (PPE) while touching Resident # 7's furniture, and surfaces in the room. Also, the housekeeper was observed to sweep dust, dirty Kleenexes and one (1) wet washrag out into the hallway. The findings include: 1. Review of the facility Infection Control Policy and Manual for Clostridium difficile revised August 2013, revealed preventive measures would be taken to prevent the occurrence of Clostridium difficile infections among residents and precautions would be taken while caring for residents with Clostridium difficile to prevent the transmission of Clostridium difficile to other residents. In addition to Standard Precautions, implement Contact Precautions for residents with known or suspected to be infected with Difficile microorganism which could be transmitted by direct contact with the resident or indirect contact with environmental surfaces of resident-care items in the resident's environment. Further review of the Infection Control Policy and Manual, revealed residents with diarrhea associated with Clostridium difficile would be placed on Contact Precautions. Healthcare workers and visitors would wear gloves and gown when entering the room of a resident with Clostridium difficile infection. Glove use when caring for residents with Clostridium difficile infection, washing hands with soup and water upon exiting the room of a resident with Clostridium difficile infection and strict adherence to hand hygiene in general was considered best practice. Due to the persistence of Clostridium difficile spores for prolonged periods of time, the environment shall be disinfected with a disinfecting agent recommended for Clostridium difficile (household bleach and water solution or an Environmental Protection Agency (EPA) registered germicidal agent effective against Clostridium difficile spores). Review of Resident #1's medical record revealed Resident #7 was admitted by the facility on 07/15/14 with [DIAGNOSES REDACTED]. Review of the Hospital Discharge Summary, dated 04/20/16, revealed Resident #7 was admitted to the hospital for Mental Status Changes, Peripheral Vascular Disease with History of [DIAGNOSES REDACTED] and Decubitus, and developed Clostridium difficile Colitis. Per the Summary, the resident was started on [MEDICATION NAME] (antibiotic medication) ,[MEDICATION NAME] (antibiotic medication), and [MEDICATION NAME] (antibiotic medication). Continued review of the Summary revealed the resident was being discharged back to the nursing home with continued treatment for [REDACTED]. Review of the Interim Admission Care Plan dated 04/20/16, revealed Resident #7 was readmitted to the facility on contact precautions. Observation on 05/03/16 at 2:20 PM, revealed Housekeeper #11 entered Resident # 7's room, and without applying gloves, and gown (Personal Protective Equipment), began to sweep the floor, and was touching the bedside table, curtains, and the trash can. Housekeeper #1 then swept the dust, four (4) dirty Kleenex and one (1) wet washrag out into the hallway. Interview with Housekeeper #11, on 05/03/16 at 2:30 PM, revealed he was aware of how to clean a room in contact isolation for Clostridium difficile, but had forgotten to look at the sign on the door and did not notice the PPE equipment on the door. Housekeeper # 11 revealed he would be more attentive and observe the isolation signs on the resident's doors before entering the rooms. Interview with Housekeeping/Laundry employee # 7 on 05/05/16 at 4:10 PM, revealed we always wear a gown and gloves and a mask if we need it. I always go to the nurses at the desk to make sure I am wearing the right thing. They teach us and remind us about it at least once a month. Interview on 05/05/16 at 2:30 PM, with the Housekeeping Director, revealed all housekeepers were instructed to contact the nurse of the resident when they observed a contact precaution sign on the door of a resident's room before entering the room, to know what type of PPE they should wear and how to dispose of the trash properly. Further interview revealed the Housekeepers obtained this education when they were first hired during orientation and during trainings and in-services throughout the year. The Housekeeping Director stated, the infection control information was important to protect the employee and the resident from spreading any infection in the facility. Interview on 05/05/16 at 2:30 PM, with the Staff Development Coordinator, revealed all new employees were educated on hire related to infection control, handwashing and PPE, before they were allowed to go on the floor to work. Interview with the Director of Nursing (DON) on 05/05/16 at 6:05 PM, revealed all employees were to follow the infection control policies and wear the appropriate PPE when necessary to prevent the spread of infection in the facility. Interview with the Administrator, on 05/05/15 at 4:35 PM, revealed all employees were to follow the policy related to contact isolation and were to gown and glove whenever they entered a resident's room in contact precautions. 2. Review of the facility's policy titled Dressing, Dry/Clean revised August 2014, revealed the purpose of the procedure was to provide guidelines for the application of dry, clean dressings. The procedure included: use a clean bedside stand, establish a clean field, place the clean equipment on the clean field; arrange the supplies so they could be easily reached; tape biohazard or plastic bag on the bedside stand or use a waste basket below clean field; wash and dry your hands thoroughly; using clean technique open other products (i.e. dressing; dry clean gauze); wash and dry your hands thoroughly and put on clean gloves. Review of the facility's policy titled Handwashing/Hand Hygiene revised August 2014, revealed the facility considered hand hygiene the primary means to prevent the spread of infections. Review of Resident #1's medical record revealed the facility admitted the resident on 05/30/13 with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 04/28/16, revealed the facility assessed Resident # 1 as having both long and short term memory problems. Continued review of the MDS revealed the facility assessed the resident as having an unhealed Stage III or IV Pressure Ulcer with length of one (1) cubic centimeter (cm), width of two (2) cm, and depth of one (1) cm. Observation on 05/04/16 at 11:28 AM, of Resident #1's wound care, revealed the Assistant Director of Nursing (ADON) gathered supplies to provide wound care; however, did not clean the resident's bedside table and did not use a barrier prior to placing clean items including bandages, a bottle containing Doform packing (packing strips for wound), and pink tape on the bare bedside table. The ADON washed her hands and donned gloves, removed the soiled dressing, and placed the soiled dressing in the trash can beside the resident's door. She then washed her hands and donned new gloves. Further observation revealed the ADON picked up the bottle of DoForm, removed the top and placed it on the unclean table. Continued observation revealed she pulled the Doform gauze from the bottle, took a pair of scissors (lying on uncleaned bedside table) and cut the gauze. The ADON opened the packet containing the dry dressing and with materials in her hand, proceeded to the opposite side of the bed to complete the dressing change. Additional observation revealed the ADON went back to the bedside table, picked the empty packet that held the dressing bandage and placed it on Resident's #1's bed. She placed the clean bandage half on the empty packet and half on the resident's bed. The ADON, without washing her hands and donning new gloves after handling the scissors and the bottle of Doform, proceeded to complete the dressing change. Interview on 05/04/16 at 11:34 AM, with the ADON, revealed she tried not to touch anything once she had the gauze in her hands; however should have washed her hands and changed gloves after touching the bottle and scissors and prior to completing the dressing change. Continued interview revealed she should have cleaned the bedside table before the dressing change, and used a barrier for the bedside table for the supplies in order to keep the supplies clean. The ADON revealed this was an infection control issue. Interview with the Staff Development/Infection Control Nurse (SD/IC) Registered Nurse (RN) on 05/05/16 at 4:30 PM, revealed although the facility used clean technique for dressing changes of pressure ulcers, the bedside stand should have been cleaned with a disinfectant prior to the dressing change and a clean field for the supplies should have been established. The SD/IC RN further stated the bed was not an acceptable surface for the clean dressing and poor infection control with completing dressing changes could potentially delay wound healing. Interview with the Director of Nursing (DON), 05/05/16 at 5:48 PM, revealed she expected staff to use clean technique and to follow the facility policy regarding wound care for Pressure Ulcers. The DON revealed she expected the staff to wash their hands when appropriate during a dressing change to prevent cross contamination.