Every finding on record at Henry County Health and Rehabilitation

Based on policy review, record review, and interview the facility failed to revise a care plan for 1 of 20 (Resident #90) sampled residents reviewed. The findings include: 1. Review of the facility's undated policy titled, Providing End of Life Care, revealed The facility is committed to providing the needed care and services to those residents at or approaching end of life in accordance with the resident's preferences, goals, and professional standards in order to promote their highest practicable physical, mental, and psychosocial well-being.The facility and resident/family will coordinate a plan of care, and will implement interventions in accordance with the comprehensive assessment, and the resident's needs, goals, and preferences.The plan of care will identify the care and services that each discipline will provide.Factors influencing the choice of treatments may include.The resident's preferences expressed either directly or in an advance directive.The care plan of care will be revised to reflect and/or address changes. 2. Review of the medical record revealed Resident #90 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Dementia, Chronic Kidney Disease, and Hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated Resident #90 was severely cognitively impaired. Resident #90 received hospice care. Review of the care plan dated [DATE], revealed .Full code .initiate cpr [cardiopulmonary resuscitation] .limited measures, hospice care .Notify hospice if no heart rate and no respirations. Do not activate EMS [Emergency Medical Services] services if no heart rate and no respirations .notify next of kin .RESIDENT IS FULL CODE .K [Kardex- a patient summary worksheet that provides key information for direct care]. The care plan was not revised to reflect Resident #90's change in code status. Review of the Tennessee Physician Orders for Scope of Treatment, form dated [DATE], revealed .Do Not Attempt Resuscitation .Comfort Measures . Review of the progress notes dated [DATE], revealed .Care conference held with resident's wife and IDT [Interdisciplinary Team]. Reviewed medications and code status. Code status updated to DNR [Do Not Resuscitate] comfort measures . Review of the Physician's Orders dated [DATE], revealed .DNR comfort measures. Review of the Kardex dated [DATE], revealed .RESIDENT IS FULL CODE. During an interview on [DATE] at 2:03 PM, the MDS Coordinator was asked when a care plan should be revised if a resident changes their code status. The MDS Coordinator responded as soon as possible.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure a safe, sanitary, and comfortable environment for Resident #65 for 1 of as evidenced by a dirty bedpan was observed on the bathroom counter next to open toiletries. Findings include: 1. Review of the facility's undated policy titled, Cleaning and Disinfection of Resident-Care Equipment revealed .Reusable resident-care equipment will be cleaned and disinfected in accordance with the current Centers for Disease Control and Prevention (CDC) Recommendations .Reusable single resident items .include bedpans .Staff shall follow established infection control principles for cleaning and disinfecting reusable . equipment .General guidelines include .each user is responsible for routine cleaning and disinfection of multi-resident items after each use .Direct care staff are responsible for cleaning single-resident equipment when visibly soiled . 2. Review of the medical record revealed Resident #65 was admitted to the facility on [DATE], with diagnoses of Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Hypertension, Respiratory Failure, and Palliative Care. Observation in Resident #65's bathroom on 7/23/2024 at 7:58 AM, revealed a bedpan with visible brown smears sitting on top of a gray wash basin, next to an open denture cup containing water but no dentures on Resident #65's bathroom counter. During an interview on 7/23/24 at 10:37 AM, Certified Nursing Assistant (CNA) M was asked if a dirty bedpan should be left on the counter with Resident #65's toiletries. CNA M state No, we normally put them in a bag and store them in this cabinet .I will do that right now . During an interview on 7/25/2024 at 2:36 PM, the Director of Nursing (DON) confirmed that all bedpans should be cleaned after each use, bagged, and stored out of sight.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure proper infection control practices were followed during medication administration when 2 of 4 Licensed Practical Nurses (LPN A, and B) failed to perform proper hand hygiene and failed to allow proper drying time for the use of the blood glucose (machine used to measure sugar in the blood) meter after use, and when 1 of 2 (LPN D) failed to clean the enteral feeding syringe (plastic syringe used to give medications or feeding supplements to residents through a plastic tube connected to the stomach) after use, and when Certified Nurse Assistant (CNA P) failed to wear Protective Protection Equipment (PPE) while providing care to a resident on contact isolation. The findings include: 1. Review of the facility's undated policy titled, Glucometer Disinfection, revealed, The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use .Glucometers should be cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use . Review of the undated manufacturer's guidelines titled, Super Sani-Cloth GERMICIDAL DISPOSAL WIPE, revealed, .SPECIAL INSTRUCTIONS FOR CLEANING AND DECONTAMINATION AGAINST HIV-1, HEPATITIS B VIRUS [HBV] AND HEPATITIS C VIRUS [HCV] ON SURFACES/OBJECTS SOILED WITH BLOOD/BODY FLUIDS .When using this product, wear disposable protective gloves .Contact time .Allow surface to remain wet two [2] minutes, let air dry . Review of the facility's undated policy titled, Hand Hygiene, revealed, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility .Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or to the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR) .The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning (putting on) gloves, and immediately after removing gloves .Conditions .Before applying and after and removing personal protective equipment (PPE), including gloves .After handling items potentially contaminated with blood, body fluids, secretions, or excretions .Either Soap Water or Alcohol Based Hand Rub . Review of the Centers for Disease Control and Prevention (CDC) Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings dated September 2018, revealed .when Contact Precautions are used .donning of both gown and gloves upon room entry is indicated to address unintentional contact with contaminated .surfaces . 2. Review of the medical record revealed Resident #60 was admitted on [DATE], with diagnoses including Hemiplegia and Hemiparesis, Diabetes, Atherosclerotic Heart Disease, and Depression. Review of Physician's Order dated 6/1/2024 to 6/30/2024, revealed AC & HS [before meals and at bedtime] .NOVOLOG .(Insulin Aspart) [medication used to lower the sugar in the blood] per sliding scale Subcutaneous . before meals .81-220 .4 units . Observation during medication administration on the [NAME] Wing at the medication cart on 7/23/24 at 11:10 AM, revealed LPN A, donned a clean pair of gloves removed the blood glucometer machine and supplies from the top drawer, locked the cart, knocked and entered Resident #60's bathroom. LPN A then returned to the resident's bedside with a paper towel, placed the paper towel on the bedside table, and placed the supplies on top of the barrier. LPN A obtained Resident #60's blood glucose level with an error message on the machine. LPN A placed all supplies in the biohazard container, removed her gloves, cleaned the machine with a super sani cloth from a clear plastic bag. LPN A immediately exited the resident's room, walked down the hall to the nurses' desk with the blood glucometer machine in her bare hand to the medication cart, and placed the blood glucometer machine in the black storage bag. LPN A donned a clean glove to her right hand, removed a test strip with her left hand and placed the supplies into the gloved right hand, knocked on Resident #60's door with her left hand and entered the resident's room bathroom. LPN A obtained a paper towel from the resident's bathroom, returned to the resident's bedside, and placed supplies on the barrier on the bedside table. LPN A donned a clean glove to her left hand, rechecked Resident #60's blood glucose level (results of 213) and placed the dirty supplies in the biohazard container. LPN A then removed the glove from her right hand, cleaned the machine with a Super Sani cloth with her gloved left hand while holding the blood glucometer machine in her right hand, removed the glove to the left hand. LPN A then immediately returned to the medication cart and placed the blood glucometer machine back into the black storage bag on top of the medication cart. LPA failed to wash and/or sanitize hands upon removal of gloves and failed to allow the blood glucometer machine to air dry for 2 minutes before returning to the black storage bag. Observation during medication administration on the [NAME] Wing, at the medication cart on 7/23/24 at 11:20 AM, revealed LPN A donned a clean pair of gloves, removed and drew up 4 units of Insulin Aspart into an insulin syringe, removed her right glove, failed to wash and/or sanitize her right hand after the removal of her glove. LPN A locked the medication cart, knocked and entered Resident #60's room, donned a clean glove to her right hand, administered the 4 units of insulin into Resident #60's right upper arm and exited the room and returned to the medication cart. 3. Review of the medical record revealed Resident #4 was admitted on [DATE] with diagnoses including Hemiplegia and Hemiparesis, Dysphagia, Aphasia, and Diabetes. Review of an Order Review History Report dated 6/25/2024 to 7/25/2024 revealed, NovoLOG Injection .inject as sliding scale .61-150 = [symbol for equal] 0 No Treatment .subcutaneously before meals and at bedtime or Diabetes . Observation during medication administration on South Hall on 7/23/24 at 11:43 AM, revealed LPN B removed supplies from the medication cart to check Resident #4's blood glucose and placed inside of a black storage bag and removed a plastic container of Super Sani clothes from the medication cart. LPN B knocked and entered Resident #4's bathroom, removed a paper towel and placed the supplies and the plastic container of Super Sani cloths on the barrier on top of the over the bed table. LPN B donned a clean pair of gloves, checked Resident #4's blood glucose level, cleaned the blood glucose machine with a Super Sani cloth and immediately placed the blood glucose machine back into the black storage case and zipped it up, placed the trash in the biohazard container, removed her gloves and exited the resident's room and returned to the medication cart. LPN B failed to wash and/or sanitize her hands after removing her gloves and after obtaining Resident #4's blood glucose level. 4. Review of the medical record revealed Resident #22 was admitted on [DATE], with diagnoses including Cerebrovascular Disease, Alzheimer's Disease, Hemiplegia, Dysphagia, Aphasia, Convulsions, and Epilepsy. Review of the Physician Orders dated 6/1/2024 to 6/30/2024 revealed, 1 can pulmocare (meal supplement for residents with enteral feeding tubes) via [by way of] PEG [percutaneous endoscopic gastrostomy tube] (tube inserted into the stomach to administer meal supplements and medications) .IF PT [patient] EATS < [symbol for less than] 25% [symbol for percent] of MEAL, MAY GIVE 1 CAN PULMOCARE .AFTER MEALS .Valproic Acid (medication used for seizures) 250 MG [milligrams] / 5 ML [milliliters] SYRUP .7.5 ml .Three Times Daily .06:00, 14:00, 18:00 for seizures . Observation during medication administration on the South hall medication cart on 7/23/24 at 1:27 PM, revealed LPN D, removed Valproic Acid 7.5 ml solution for Resident # 22. LPN D donned personal protective equipment (PPE), entered the resident's room and bathroom for water, returned to the bedside, donned clean gloves and checked placement and residual with 60 ml of milky stomach content returned back to the resident's stomach. LPN D stated, This is the feeding I just gave him . LPN D removed the plunger from the syringe and flushed with water, administered the Valproic Acid 7.5 ml per gravity, removed the glove from her right hand, returned the syringe and plunger to the plastic bag. LPN D failed to rinse and dry the syringe and plunger before returning to the plastic bag that contained white milky droplets inside the plastic bag. 5. Review of the medical record revealed Resident #54 was admitted on [DATE], with diagnoses that include Benign Prostatic Hyperplasia, Diabetes, Transient ischemic Attack, Hypertension, and Osteoarthritis. Review of Doctor's Order and Progress Note dated 6/24/2024, revealed Patient must use Artificial Tears 3-4 times a day . Observation during medication administration on Cart #2 of the East Hall on 7/23/24 at 2:13 PM, revealed LPN C removed a bottle of Artificial Tears Ophthalmic Solution (medication to lubricate eyes) for Resident # 54. LPN C entered the resident's room, went to the resident's bathroom and washed her hands, donned a clean pair of gloves and returned to the resident's bedside. LPN C removed the cap from the Artificial Tears bottle and placed it on the over the bed table without a barrier. LPN C administered the eye drops, replaced the cap back onto the eye drops, removed her gloves, sanitized her hands and exited the room and returned the eye drops to the medication cart. During an interview on 7/23/24 at 2:54 PM, LPN C confirmed she should have placed the cap of the eye drops on a barrier and that she should have discarded the eye drops and not returned to the medication drawer. During an interview on 7/24/24 at 5:03 PM, the Director of Nursing (DON) was asked when should nursing staff wash their hands. The DON confirmed nursing staff should wash or sanitize their hands when they take off gloves and change their gloves. The DON was asked how the enteral syringe should be stored after use. The DON confirmed the enteral syringe should be rinsed and dried of any residue and they should be stored separated in the plastic bag. The DON was asked how the glucose monitor should be cleaned after use. The DON confirmed that nursing staff should don clean gloves, clean the machine with the approved Super Sani Cloth and placed on a barrier to dry for at least 2 minutes, remove their gloves and wash their hands. The DON was asked what the nursing staff should do with the cap of the eye drops when administering the eye drops. The DON confirmed the cap should be placed on a barrier and replaced once the eye drops have been administered. The DON was confirmed the cap to the eye drops should not be placed on the table without a barrier. 6. Review of the medical record revealed Resident #65 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Hypertension, Respiratory Failure, and Palliative Care. Review of the Physician Orders dated 5/31/2024 revealed .CONTACT ISOLATION FOR VRE (Vancomycin-Resistant Enterococcus) (a type of bacteria that is resistant to the antibiotic Vancomycin) IN URINE . During an observation on 7/23/2024 at 1:51 PM, CNA P was observed giving Resident #65 a bed bath without donning PPE. Resident #65 was in contact isolation for VRE in the urine. During an interview on 7/25/24 at 2:36 PM, the Director of Nursing was asked if all staff including contract staff was required to observe contact isolation recommendations. The DON stated, Of course .anyone who provides care is required to dress out.

Based on review of the Certified Nursing Assistant (CNA) staff in-services, and interview the facility failed to ensure the mandatory annual 12 hours of CNA in-services were provided for 15 of 19 staff members (CNAs A, B, C, D, E, F, G, H, I, J, K, L, M, N, and O reviewed for CNA in-servicing training. The findings include: 1. Review of the facility's policy titled, Required Training, Certification and Continuing Education of Nurses Aides, dated 11/2017, revealed It is the policy of this facility to comply with State and Federal regulations and requirements as they pertain to the training, certification, and continuing education of its nurse aides .The facility will provide at least 12 hours of in-service training annually . 2. Review of a list of the CNA staff provided by the facility revealed the following: CNA A was hired on 7/12/2021. CNA B was hired on 10/3/2022. CNA C was hired on 8/21/2001. CNA D was hired on 4/17/2023. CNA E was hired on 2/1/2016. CNA F was hired on 5/7/2000. CNA G was hired on 2/4/2003. CNA H was hired on 6/18/2012. CNA I was hired on 9/18/2022. CNA J was hired on 11/5/2018. CNA K was hired on 4/4/2016. CNA L was hired on 6/6/2022. CNA M was hired 11/11/2019. CNA N was hired 8/8/2011. CNA O was hired 7/2/2007. The facility was unable to provide documentation of 12 hours of required in-service training for CNA's A, B, C, D, E, F, G, H, I, J, K, L, M, N, and O for the past 12 months. During an interview on 7/25/2024 at 8:15 AM, the Administrator was asked about the required CNA in-services for CNAs employed over one year. The Administrator confirmed the CNAs did not receive their annual training and should have had at least 12 hours in the last year.

Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured when 1 of 4 staff members (Licensed Practical Nurse (LPN) #1) left the medication cart unlocked, unattended, and out of sight, and when in 7 of 18 medication storage areas (South Wing Medication Room, South Wing Medication Cart #2, West Wing #1 Medication Room, East Wing Clean Utility Room, West Wing #1 Treatment Cart, West Wing #2 Storage Room and South Wing Treatment Cart) had expired medications, open and undated medications, and externals and internals stored together in the medication storage areas, and when a medication left at the bedside in a resident's room. The findings include: Review of the facility's policy titled, ORAL MEDICATION ADMINISTRATION, reviewed 10/2022, revealed .Be sure to stay with patient until medication is swallowed . Review of the facility's policy titled, MEDICATION STORAGE IN THE FACILITY, reviewed 10/2022, .Medication room and carts should be under lock and key and accessed by personnel who have authority to access .All oral medications should be kept separated from topical medication on the cart and in the medication room . Observation in Resident #10's room on 4/3/2023 at 11:03 AM, and at 11:17 AM, revealed on the over bed table a plastic cup containing yellow liquid with white sediments in the bottom of the plastic cup. During an interview on 4/3/2023 at 11:17 AM, LPN #2 was asked to identify the yellow liquid substance with the white sediments in the plastic cup and the white powdery substance in the medication cup. LPN #2 confirmed the plastic cup contained the medication Cholestyramine (treatment for high cholesterol) for oral suspension. Observation in the South Wing Medication Room on 4/3/2023 at 11:21 AM, revealed 13 cartons of Pulmocare Supplement (high-calorie, low carbohydrate formula designed to help reduce carbon dioxide production) with an expiration date of 4/1/2023, one carton of Boost Supplement (nutritional shake) with an expiration date of 1/1/2023, and 5 packets of Glycerin swab sticks with an expiration date of 4/2022. Observation on the South Wing on 4/3/2023 at 11:36 AM, revealed Medication Cart #2 with the following: a. Glargine insulin (to control high blood sugar) flex pen with an expiration date of 3/22/2023. b. Novolog flex insulin (to control high blood sugar) pen with an opened date of 2/22/2023 and an expiration date of 3/22/2023. c. One Heparin (blood thinner) syringe was in the same drawer with a tube of petroleum jelly skin protectant, one tube of triple antibiotic ointment, multiple batteries, scissors, keys, a flash light, pill crusher, and a pair of goggles. During an interview on 4/3/2023 at 11:36 AM, LPN #2 confirmed there should not be internals and externals in the same drawer on the medication cart. Observation on the West Wing #1 on 4/4/2023 at 11:44 AM, in the Medication room with LPN #3, revealed one bottle of Vitamin B-12 (water-soluble vitamin) with an expiration date of 1/2023, and 36 Heparin syringes with an expiration date of 3/2023. Observation on the West Wing #1 on 4/4/2023 at 4:44 PM, revealed in the Clean Utility room [ROOM NUMBER] cartons of Plumocare Supplement with an expiration date of 4/1/2023. Observation on the East Wing on 4/4/2023 at 4:52 PM, revealed in the Clean Utility Room refrigerator one vial of Tuberculin Purified Protein (a test used to detect if you have a tuberculosis infection) opened and undated. Observation on the West Wing #1 on 4/4/2023 at 5:30 PM, revealed the following on the West Wing #1 Treatment Cart: a. One bottle of Hydrogen Peroxide with an expiration date of 7/2021. b. 2 tubes of Mupirocin Ointment (used to treat certain skin infections) with an expiration date of 12/2022. c. 26 sticks of Sliver Nitrate applicators (cauterizing (reduce bleeding) small wounds) with an expiration date of 9/2021. d. 1 pack of Iodine Solution with an expiration date of 1/2023. e. 2 tubes of Moisture Barrier Antifungal Cream with an expiration date of 2/2023. Observation on the East Wing Hallway on 4/5/2023 at 8:02 AM, revealed the East Wing Medication Cart #1 unattended, unlocked, and out of sight of LPN #1. During an interview on 4/5/2023 at 8:05 AM, LPN #1 confirmed the medication cart should not be unattended and unlocked and out of sight. Observation on West Wing #2 on 4/5/2023 at 10:23 AM, revealed in the Storage room [ROOM NUMBER] tubes of Moisture Barrier Antifungal Cream with an expiration date of 2/2023. Observation on the South Wing on 4/5/2023 at 10:28 AM, revealed on the Treatment Cart one bottle of Hydrogen Peroxide with an expiration date of 1/2023. During an interview on 4/5/2023 at 8:36 AM, the Director of Nursing (DON) confirmed there should not be any expired medications, open and undated medications, externals, and internals together in the medication storage areas. The DON confirmed the medication carts should not be left unlocked and unattended in the hallway.

Based on policy review, medical record review, observation, and interview the facility failed to follow physician's order for 1 of 1 (Resident #364) sample residents reviewed for falls. The findings include: Review of the facility's policy titled Fall Prevention and Fall Risk Interventions, reviewed 10/22 revealed, .If a fall occurs, nursing will initiate immediate interventions to prevent further fall . Review of the facilities undated Fall Risk Guidelines, revealed .apply a personal alarm .body alarm . Review of the medical record, revealed Resident #364 was admitted to the facility on [DATE] with diagnoses of Osteoarthritis, Fracture of Right Patella, Fracture of Left Arm, Difficulty Walking, and Unsteadiness on Feet. Review of the admission Minimum Data Set, dated dated dated [DATE], revealed Resident #364 had a Brief Interview for Mental Status score of 10, indicating the resident was moderately impaired and required extensive assist for activities of daily living. Review of the Care Plan dated 4/3/2023, revealed .Potential for Falls .r/t (related to) impaired balance, hx (history of) falls .Ensure placement/functioning of body alarm . Review of the Incident Report dated 3/17/2023, revealed, .Incident Date . 3/17/23 Incident Time 01:00 AM .Resident observed on floor by nurse .Body Alarm to patient to prevent injury . Review of a Physician's Order dated 3/17/2023, revealed .Body Alarm clipped to resident when in bed . Review of a Physician's Order dated 3/21/2023, revealed .Body Alarm to patient. Monitor for placement & [and] functioning every shift . The facility was unable to provide documentation to show placment and functioning of the body alarm every shift. Observation in Resident #364's room on 4/4/2023 at 9:02 AM, revealed the resident in bed with no body alarm on. During an observation and interview in Resident #364's room on 4/5/2023 at 3:42 pm, revealed the resident in bed with no body alarm on. The Director of Nurses (DON) confirmed Resident #364 should have a body alarm on while in bed. During an interview on 4/5/2023 at 5:57 PM, the DON and Registered Nurse #1 confirmed no order was put in the computer for the use of a body alarm and to monitor the body alarm for functioning and placement until 4/5/2023.

Based on medical record review and interview, the facility failed to ensure 4 of 16 sampled residents (Resident #21, #25, #34 and #35) or their families were invited to participate in planning their care. The findings include: Review of the medical record, revealed Resident #21 was admitted to the facility on [DATE], with diagnoses of Atrial Fibrillation, Diabetes, Alcohol Abuse, Pressure Ulcers, and Chronic Obstructive Pulmonary Disease. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #21 had a Brief Interview for Mental Status (BIMS) of 14, which indicated cognitively intact. The facility was unable to provide documentation that a care plan meeting was held with Resident #21 or his family. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses of Staphylococcus Aureus Infection, Diabetes, Parkinson's Disease, and Anxiety. Review of the admission MDS dated [DATE], revealed Resident #25 had a BIMS of 13, which indicated cognitively intact. The facility was unable to provide documentation that a care plan meeting was held with Resident #25 or his family. Review of the medical record revealed Resident #34 was admitted on [DATE] with diagnoses of Diabetes, Chronic Obstructive Pulmonary Disease, Cardiomegaly, and Rheumatoid Arthritis. Review of the significant change MDS dated [DATE] revealed Resident #34 had a BIMS of 14 which indicated cognitively intact. The facility was unable to provide documentation that a care plan meeting was held with Resident #34 or her family. Review of the medical record, revealed Resident #35 was admitted to the facility was admitted to the facility on [DATE] with a diagnosis of Senile Degeneration of Brain, Hypertension, Insomnia, and Depression. Review of the quarterly MDS assessment dated [DATE], revealed Resident #35 had severe cognitive impairment. During a family interview on 4/3/2023 at 10:45 AM, Resident #35's husband confirmed he had not been invited to Care Plan meetings for Resident #35. The facility was unable to provide documentation that a care plan meeting was held with Resident #35's family on 2/7/2023. During an interview on 4/4/2023 at 5:06 PM, the MDS Coordinator confirmed there was no documentation of a Care Plan meeting for Resident #35's family and there should have had one quarterly. During an interview on 4/5/2023 at 2:21 PM, the Director of Nursing confirmed there should be a documentation for the resident or responsible party's notification to attend Care Plan meetings.

Based on policy review, medical record review, and interview, the facility failed to provide information regarding a resident's right to formulate an advance directive for 1 of 16 sampled residents (Resident #15) reviewed for advance directives. The findings include: Review of the facility's undated policy titled Advanced Directives revealed .wishes of that patient will be respected and followed out in accordance with that advanced directive .On admission, each resident will be asked to provide a copy of any current advanced directive .Those not having advanced directives will be offered the opportunity and will be provided with information in writing regarding advanced directives and their content .on admission, families will be provided with information educating them as to how to legally acquire a power of attorney for patients that are not cognitively intact . Review of the medical record revealed Resident #15 was admitted to the facility on [DATE], with diagnoses of Dementia, Aphasia, Chronic Obstructive Pulmonary Disease, Gastrostomy Status, Anxiety, and Seizures. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #15 had severe cognitive impairment. Resident #15 required total dependence for ADLs. During an interview on 4/5/2023 at 9:33 AM, the Director of Social Services was unable to provide education about an advance directive had been provided to the resident or family.

Based on policy review, observation, and interview, the facility failed to maintain or enhance resident dignity and respect when 2 of 12 (Certified Nursing Assistant) (CNA) #1, and Licensed Practical Nurse (LPN) #1, staff members observed during dining failed to use courtesy titles to address residents. The findings include: 1. Review of the facility's policy titled, Addressing a Resident, revised 12/30/2010, revealed, .Resident will be addressed with courtesy and respect at all times . 2. Review of the facility's undated policy titled, Dignity, revealed, The facility will promote care for residents in a manner and in a environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. 3. Observation during dining in the East Wing on 4/3/2023 beginning at 12:07 PM, revealed the following: a. CNA #1 entered Resident #29's room and stated, .He's a feeder . b. CNA #1 entered Resident #18's room, CNA #1 stated, Hello darling .and placed the meal tray on the over-the-bed table. CNA #1 failed to use a courtesy title when addressing the resident. c. CNA #1 entered Resident #13's room, and placed the meal tray on the over-the-bed table, set her meal tray up and stated, .There ya (you) go darling. CNA #1 failed to use a courtesy title when addressing the resident. 4. Observation during dining in the East Wing on 4/4/2023 beginning at 5:35 PM, revealed the following: a. CNA #1 entered Resident #58's room, CNA #1 stated, Hey darling . CNA #1 failed to use a courtesy title when addressing the resident. b. LPN #1 was assisting with Resident #40's meal tray and stated, .Ok dear ., LPN #1 failed to use a courtesy title when addressing the resident. c. CNA #1 entered Resident #47's room, CNA #1 stated, Hey darling . CNA #1 failed to use a courtesy title when addressing the resident. During an interview on 4/5/2023 at 2:22 PM, the Director of Nurses confirmed staff should always use courtesy titles when addressing all residents.

Based on observation and interview, the facility failed to ensure food was served under sanitary conditions when 3 of 13 staff members (Nursing Assistant (NA) #1, Certified Nursing Assistant (CNA) #1, and Licensed Practical Nurse (LPN) #2) served meal trays with food uncovered for 7 of 66 Residents (Resident #4, #16, #34, #44, #54, #60, and #215) observed during dining. The findings include: Observation of the South Hall on 11/15/2021 at 12:21 PM, revealed Meal Cart #2 arrived on the South hall and remained across from the Nurses' Station during dining. Observation of the South Hall on 11/15/2021 at 12:28 PM, revealed NA #1 removed a meal tray from the meal cart, walked down the hall, with the salad and dessert uncovered, entered Resident #215's room, set the tray up, exited the room, and walked back down the hall to the Nurses' Station to the meal cart. Observation of the South Hall on 11/15/2021 at 12:29 PM, revealed NA #1 removed a meal tray from the meal cart, walked down the hall, with the dessert uncovered, entered Resident #4's room, set the tray up, exited the room, and walked back down the hall to the Nurses' Station to the meal cart. Observation of the South Hall on 11/15/2021 at 12:30 PM, revealed NA #1 removed a meal tray from the meal cart, walked down the hall with the salad and dessert uncovered, entered Resident #60's room, set up the tray, exited the room, and walked back down the hall to the Nurses' Station to the meal cart. Observation of the South Hall on 11/15/2021 at 12:30 PM, revealed CNA #1 removed a meal tray from the meal cart, walked down the hall with the salad and dessert uncovered, entered Resident #16's room, set up the tray, exited the room, and walked back down the hall to the Nurses' Station to the meal cart. Observation of the South Hall on 11/15/2021 at 12:32, revealed CNA #1 removed a meal tray from the meal cart, walked down the hall with the dessert uncovered, entered Resident #44's room, set up the tray, exited the room, walked back down the hall to the Nurses' Station to the meal cart. Observation of the South Hall on 11/15/2021 at 12:33 PM, revealed LPN #2 removed a meal tray from the meal cart, walked down the hall with the salad and dessert uncovered, entered Resident #54's room, set up the tray, exited the room, walked back down the hall to the Nurses' Station to the meal cart. Observation of the South Hall on 11/15/2021 at 12:35 PM, revealed NA #1 removed a meal tray from the meal cart, walked down the hall with the dessert uncovered, entered Resident #34's room, set up the tray and exited the room. During an interview on 11/17/2021 at 3:40 PM, the Registered Dietician confirmed that staff should move the meal cart down the hall with them to each room when they deliver the meal trays, and the food should be covered while transporting a meal down the hall.

Based on the Geriatric Medication Handbook, policy review, medical record review, observation, and interview, the facility failed to ensure residents were free from a significant medication error when 1 of 5 nurses (Licensed Practical Nurse (LPN) #1) failed to provide a substantial snack or meal within 15 minutes of insulin administration for 1 of 5 sampled residents (Resident #165) observed during medication pass. The failure to provide a substantial snack or meal within 15 minutes of insulin administration resulted in a significant medication error. The findings include: Review of the GERIATRIC MEDICATION HANDBOOK, 13TH edition, provided by the American Society of Consultant Pharmacists, page 41 and 43, revealed .DIABETES: INJECTABLE MEDICATIONS .Novolog .Insulin [MEDICATION(S)] .Rapid-Acting Insulin Analog .Onset .15 min [minutes] .ADMINISTRATION/COMMENTS .15 minutes prior to meals .NovoLog .Insulin [MEDICATION(S)] .Rapid-Acting Insulin .ONSET .15 min .ADMINISTRATION/COMMENTS .5-10 minutes before meals . Review of the facility's policy titled, Blood Glucose Fingerstick Monitoring, revised 9/2020, revealed .Anytime a resident's meal may be delayed, a snack should be given to the resident, especially when Sliding Scale Insulin has been administered . Review of the medical record, revealed Resident #165 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .per sliding scale subcutaneous .181-220 = 4 units . Observation in the resident's room on 11/16/2021 at 11:12 AM, revealed LPN #1 administered Novolog (insulin) 4 units subcutaneous per sliding scale to Resident #165 for a blood glucose of 197. At 12:30 PM, Resident #165 had not received a meal tray or a substantial snack. During an interview on 11/16/2021 at 11:45 AM, LPN #1 was asked what time she expected the meal trays to be delivered to the hall. LPN stated, 12:05 PM. During an interview on 11/17/2021 at 1:42 PM, the Director of Nursing (DON) was asked when residents should receive a meal or substantial snack after receiving Novolog Insulin. The DON stated, .within a short period of time .10-15 minutes .

Based on medical record review, observation, and interview, the facility failed to provide care and services for timely reassessment following the administration of pain medication for 1 of 2 (Resident #66) sampled residents reviewed for pain. The findings include: 1. The facility's .Pain Management policy reviewed 5/14 documented, .it is every resident's right to have his or her pain appropriately and aggressively managed. Any report of pain by a resident is considered sufficient evidence to establish pain as a problem/need/nursing diagnosis .Individual Patient's Narcotic Record .The scale of pain 1-10, the type of pain, location, treatment and follow-up for effectiveness .to indicate the level and type of pain when pain medication is administered and when follow up for effectiveness is documented . 2. Medical record review revealed Resident #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Nursing History and assessment dated [DATE] documented .Pain Assessment .Is the resident complaining or showing signs of pain .Yes .On a scale of 1 to 10 , with 10 being the most pain ever felt, how does the resident rate the pain .7 .location of pain .Left hip .with movement . The Physician order [REDACTED].[MEDICATION NAME]-[MEDICATION NAME] 325 MG (milligrams)-5 MG TAB (tablet) ([MEDICATION NAME]/[MEDICATION NAME]) 1 TAB Oral Every Four Hours As Needed for Pain . The (MONTH) 2019 Medication Administration Record (MAR) documented that [MEDICATION NAME]/[MEDICATION NAME] 325 MG-5 MG was administered to Resident #66 and review of the PRN (as needed) Results and Documentation report revealed the reassessments following the administration of the [MEDICATION NAME]/[MEDICATION NAME] were not performed timely on the following dates: a. administered on 10/9/19 at 7:35 PM, reassessed on 10/10/19 at 1:41 AM b. administered on 10/11/19 at 9:20 AM, reassessed on 10/11/19 at 11:49 AM c. administered on 10/12/19 at 7:41 PM, reassessed on 10/12/19 at 11:24 PM d. administered on 10/13/19 at 2:55 PM, reassessed on 10/13/19 at 4:56 PM e. administered on 10/14/19 at 5:42 AM, reassessed on 10/14/19 at 2:47 PM f. administered on 10/14/19 at 10:58 AM, reassessed on 10/14/19 at 2:47 PM g. administered on 10/14/19 at 2:46 PM, reassessed on 10/14/19 at 5:07 PM h. administered on 10/14/19 at 9:57 PM, reassessed on 10/14/19 at 11:49 PM i. administered on 10/15/19 at 9:26 AM, reassessed on 10/15/19 at 2:15 PM j. administered on 10/15/19 at 2:16 PM, reassessed on 10/15/19 at 4:05 PM k. administered on 10/15/19 at 8:37 PM, reassessed on 10/15/19 at 11:27 PM l. administered on 10/16/19 at 6:22 PM, reassessed on 10/16/19 at 11:27 PM m. administered on 10/17/19 at 4:06 AM, reassessed on 10/17/19 at 6:12 AM n. administered on 10/17/19 at 6:39 PM, reassessed on 10/17/19 at 11:03 PM o. administered n 10/18/19 at 8:20 PM, reassessed on 10/19/19 at 2:46 AM p. administered on 10/19/19 at 12:36 AM, reassessed on 10/19/19 at 2:57 AM q. administered on 10/20/19 at 1:40 AM, reassessed on 10/20/19 at 6:49 AM r. administered on 10/20/19 at 6:49 AM, reassessed on 10/20/19 at 11:28 AM s. administered on 10/20/19 at 3:37 PM, reassessed on 10/20/19 at 6:25 PM t. administered on 10/20/19 at 7:47 PM, reassessed on 10/21/19 at 1:39 AM u. administered on 10/21/19 at 7:06 AM, reassessed on 10/21/19 at 9:40 AM v. administered on 10/21/19 at 6:24 PM, reassessed on 10/22/19 at 12:31 AM w. administered on 10/21/19 at 9:41 PM, reassessed on 10/22/19 at 12:31 AM x. administered on 10/22/19 at 1:45 PM, reassessed on 10/22/19 at 4:12 PM y. administered on 10/22/19 at 5:55 PM, reassessed on 10/23/19 at 11:34 AM z. administered on 10/23/19 at 5:57 AM, reassessed on 10/23/19 at 11:34 AM aa. administered on 10/23/19 at 8:59 PM, reassessed on 10/24/19 at 1:48 AM bb. administered on 10/24/19 at 4:24 AM, reassessed on 10/24/19 at 6:40 AM cc. administered on 10/24/19 at 8:39 PM, reassessed on 10/25/19 at 2:01 AM dd. administered on 10/25/19 at 1:31 PM, reassessed on 10/25/19 at 3:47 PM ee. administered on 10/25/19 at 5:20 PM, reassessed on 10/26/19 at 3:36 AM ff. administered on 10/25/19 at 9:35 PM, reassessed on 10/26/19 at 3:36 AM gg. administered on 10/26/19 at 5:56 AM, reassessed on 10/26/19 at 9:55 AM hh. administered on 10/26/19 at 5:42 PM, reassessed on 10/26/19 at 9:41 PM ii. administered on 10/26/19 at 5:57 AM, reassessed on 10/26/19 at 9:51 AM jj. administered on 10/27/19 at 7:25 PM, reassessed on 10/27/19 at 9:27 PM kk. administered on 10/28/19 at 3:22 AM, reassessed on 10/28/19 at 6:12 AM ll. administered on 10/29/19 at 8:41 PM, reassessed on 10/30/19 at 1:20 AM mm. administered on 10/30/19 at 3:44 AM, reassessed on 10/30/19 at 6:04 AM nn. administered on 10/30/19 at 1:36 PM, reassessed on 10/30/19 at 3:22 PM oo. administered on 10/30/19 at 9:24 PM, reassessed on 10/30/19 at 11:31 PM pp. administered on 10/31/19 at 8:01 AM, reassessed on 10/31/19 at 9:51 AM qq. administered on 10/31/19 at 9:04 PM, reassessed on 10/31/19 at 11:15 PM The (MONTH) 2019 MAR documented that [MEDICATION NAME]/[MEDICATION NAME] 325 MG-5 MG was administered to Resident #66 and review of the PRN (as needed) Results and Documentation report revealed the reassessments following the administration of the [MEDICATION NAME]/[MEDICATION NAME] were not performed timely on the following dates: a. administered on 11/1/19 at 10:05 AM, reassessed on 11/1/19 at 1:23 PM b. administered on 11/1/19 at 3:08 PM, reassessed on 11/1/19 at 6:16 PM c. administered on 11/1/19 at 7:24 PM, reassessed on 11/2/19 at 2:23 AM d. administered on 11/1/19 at 11:34 PM, reassessed on 11/2/19 at 2:23 AM e. administered on 11/2/19 at 9:05 AM, reassessed on 11/2/19 at 6:04 PM f. administered on 11/2/19 at 2:38 PM, reassessed on 11/2/19 at 6:04 AM g. administered on 11/2/19 at 7:12 PM, reassessed on 11/3/19 at 3:39 AM h. administered on 11/3/19 at 9:35 AM, reassessed on 11/3/19 at 11:57 AM i. administered on 11/3/19 at 2:37 PM, reassessed on 11/3/19 at 5:55 PM j. administered on 11/3/19 at 8:16 PM, reassessed on 11/4/19 at 1:30 AM k. administered 11/4/19 at 7:58 AM, reassessed on 11/4/19 at 9:42 AM l. administered on 11/4/19 at 4:30 PM, reassessed on 11/4/19 at 6:21 PM m. administered on 11/4/19 at 9:11 PM, reassessed on 11/5/19 at 12:03 AM n. administered on 11/5/19 at 1:42 AM, reassessed on 11/5/19 at 5:21 AM o. administered on 11/5/19 at 6:51 AM, reassessed on 11/5/19 at 10:09 AM p. administered on 11/5/19 at 6:28 PM, reassessed on 11/5/19 at 9:55 PM q. administered on 11/5/19 at 11:06 PM, reassessed on 11/6/19 at 7:04 AM r. administered on 11/6/19 at 11:56 AM, reassessed on 11/6/19 at 2:04 PM s. administered on 11/6/19 at 9:41 PM, reassessed on 11/7/19 at 3:02 AM t. administered on 11/7/19 at 10:53 PM, reassessed on 11/8/19 at 5:47 AM u. administered on 11/9/19 at 8:58 PM, reassessed on 11/9/19 at 11:24 PM v. administered on 11/10/19 at 8:50 PM, reassessed on 11/10/19 at 11:31 PM w. administered on 11/11/19 at 1:52 PM, reassessed on 11/11/19 at 10:22 PM x. administered on 11/11/19 at 10:22 PM, reassessed on 11/12/19 at 1:13 AM y. administered on 11/12/19 at 9:19 AM, reassessed on 11/12/19 at 12:10 PM Observations in Resident #66's room on 11/13/19 at 8:54 AM, revealed the resident eating breakfast and stated, .I have a lot of pain in my back besides my hip . Interview with the Director of Nursing (DON) on 11/14/19 at 1:21 PM, in the Conference Room, the DON was asked how long after pain medication administration should the pain be reassessed. The DON stated, Within an hour. The DON was shown Resident #66's MAR and confirmed the pain reassessment had not been performed in a timely manner.

Based on policy review, observation, and interview, the facility failed to maintain or enhance resident dignity and respect when 2 of 5 (Licensed Practical Nurse (LPN) #1 and #2) nurses failed to knock before entering a resident's room during medication administration. The findings include: 1. The facility's Resident Privacy policy reviewed 6/18 documented, .All residents will be provided personal privacy .All staff will knock on doors before entering or verbally announce presence . 2. Observations in Resident #14's room on 11/13/19 at 4:28 PM, revealed LPN #1 entered Resident #14's room to administer medications without knocking on the door or verbally announcing her presence. LPN #1 performed hand hygiene and then stated, I left my stethoscope. LPN #1 exited the room. At 4: 30 PM, LPN #1 re-entered Resident #14's room without knocking on the door or verbally announcing her presence. 3. Observations in Resident #74's room on 11/14/19 at 9:57 AM, revealed LPN #2 entered Resident #74's room to administer medications without knocking or verbally announcing her presence. Interview with the Assistant Administrator on 11/14/19 at 9:22 AM, in the Dining Room, the Assistant Administrator was asked if staff should knock before entering a resident's room. The Assistant Administrator stated, Staff should knock before entering a resident's room.

Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were followed when appropriate isolation precautions were not followed for 1 of 2 (Resident #3 ) sampled residents observed in isolation and when 2 of 5 (Licensed Practical Nurse (LPN) #1 and 2) nurses failed to perform hand hygiene between glove use and failed to follow appropriate infection control practices with a Percutaneous Endoscopic Gastrostomy (PEG) tube during medication administration observations. The findings include: 1. The facility's INFECTION CONTROL POLICIES ISOLATION AND INFECTION PRECAUTIONS undated policy documented, .1 .g. Place food tray in a clear bag to alert the dietary department that the tray came from an isolation room .i. Place the bag on the food service cart . Observations outside Resident #3's room on 1/13/19 at 1:30 PM revealed Certified Nursing Aide (CNA) #5 removed the meal tray from the isolation room, and placed the tray on the food cart. The tray was not placed in a bag. Interview with CNA #5 on 1/13/18 at 1:30 PM, outside Resident #3's room, CNA #5 was asked how the meal tray should be removed from the isolation room. CNA #5 stated, We pick up the isolation trays last and then the cart goes to the kitchen .we don't use bags for isolation trays . Interview with the Director of Nursing (DON) on 1/15/19 at 11:15 AM, in the Administrator Office, the DON was asked if staff should remove a meal tray from the isolation room without a bag and place it on the meal cart in the hall. The DON stated, No. 2. The facility's Handwashing/Hand Hygiene policy dated 2/18 documented, .Policy Interpretation and Implementation .1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .5. Use an alcohol-based hand rub containing at least 62% (percent) alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations .l. After removing gloves .9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections .Applying and Removing Gloves .1. Perform hand hygiene before applying non-sterile gloves . Observations in Resident #48's room on 1/14/19 at 11:45 AM, revealed LPN #1 was preparing to administer a medication through a PEG tube to the resident. LPN #1 disconnected the enteral feeding tube from the PEG, removed a glove from her right hand turning it inside out, and placed the tip of the enteral feeding tube into the used glove. LPN #1 applied a new glove, without performing hand hygiene, and continued to administer the medication through the PEG tube to the resident. Observations in Resident #23's room on 1/15/19 at 9:25 AM, revealed LPN #2 administered medications by mouth to Resident #23, applied gloves, and administered eye drops to the resident without performing hand hygiene. LPN #2 removed her gloves, washed her hands, applied new gloves, and administered insulin to the resident. LPN #2 placed the used needle into the sharps container. She did not remove her gloves or perform hand hygiene. LPN #2 removed a medication patch from Resident #23's left arm, cleaned the skin on Resident #23's right upper arm with an alcohol prep, and applied a medication patch to the right upper arm. Interview with the DON on 1/15/19 at 10:20 AM, in the Conference Room, the DON was asked what should be done when changing gloves. The DON stated, Wash hands. The DON was asked if the tip of an enteral feeding tube should be placed in a used glove. The DON stated, No. The DON was asked what should be done between procedures, such as administering medications, eye drops, insulin, and patches. The DON confirmed gloves should have been changed and hand hygiene performed.

Based on policy review, observation, and interview, 4 of 20 (Certified Nursing Assistant (CNA) #1, 2, 3, and 4) staff members failed to serve food under sanitary conditions during dining. The findings include: The facility's HAND HYGIENE DURING MEALTIME policy dated 6/05 documented, .All facility staff will maintain infection control procedures during resident mealtimes .5. Passing trays in hallways: If contact is made with the residents saliva, body fluids, resident possessions, physical contact with self or other staff, you must use soap and water before leaving the room, assisting the resident and prior to going on to pass other trays . Dining observations in the West 1 Hall on 1/13/19 beginning at 12:19 PM, revealed CNA #1 delivered a meal tray to Resident #137. She assisted the resident up in bed and adjusted the bed without performing hand hygiene. CNA #1 continued to set up the tray, poured drinks into cups and touched the inner lid of the cup. CNA #1 then performed hand hygiene. CNA #1 delivered a meal tray to Resident #83, adjusted the bed, and continued to set up the tray without performing hand hygiene. Dining observations in the West 2 Hall on 1/13/19 beginning at 12:31 PM, revealed CNA #2 delivered a meal tray to Resident #138, assisted the resident up in bed, adjusted the bed, and continued to set up the meal tray without performing hand hygiene. CNA #2 then performed hand hygiene. CNA #2 delivered a meal tray to Resident #136, adjusted her bed, and continued to set up the meal tray, without performing hand hygiene. CNA #1 delivered a meal tray to Resident #34, assisted the resident up in bed, and continued to set up the meal tray without performing hand hygiene. Observations in Resident #69's room on 1/13/18 at 12:55 PM revealed, CNA #3 picked up a roll with her bare hands and fed Resident #69. Observations in Resident #69's room on 1/14/19 at 8:20 AM, revealed CNA #4 moved a chair and sat to feed Resident #69 without performing hand hygiene. Interview with the Director of Nursing (DON) on 1/15/19 at 10:20 AM, in the Conference Room, the DON was asked what should staff do after assisting residents, adjusting the bed, and touching objects prior to preparing the tray for the resident and serving trays to other residents. The DON stated, Should wash their hands. Interview with the DON on 1/15/19 at 11:50 AM, in the Conference Room, the DON was asked if it was acceptable to touch food with bare hands while feeding a resident. The DON stated, We wouldn't want to touch any food with bare hands.

Based on policy review, medical record review, and interview, the facility failed to have an order for [REDACTED]. The findings include: The facility's [MEDICAL TREATMENT]: TREATMENT PROT[NAME]OL policy dated 8/19/02 and updated 9/18 documented, Monitor shunt site for thrill and bruit every shift, if absent report to [MEDICAL TREATMENT] clinic . Medical record review revealed Resident #56 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 11/5/18 documented, .[MEDICAL TREATMENT] 3x (times) weekly - due to [MEDICAL CONDITION] . The progress note dated 10/19/18 at 1:56 AM documented, .[MEDICAL TREATMENT] 3x wkly (weekly) . Review of the admission orders [REDACTED]. The facility was unable to provide documentation of an order for [REDACTED].>Review of the INTERDISCIPLINARY PROGRESS NOTES dated 10/17/18 - 1/14/19 revealed the shunt site was monitored for thrill and bruit on one of two shifts on the following dates: 10/18, 10/20, 10/23, 10/25, 10/27, 10/30, 11/1, 11/4, 11/6, 11/8, 11/10, 11/13, 11/15, 11/17-11/20, 11/22, 11/27-11/29, 12/1-12/4, 12/6-12/8, 12/10, 12/11, 12/13, 12/15-12/18, 12/20-12/23/18 and 1/3/19. There was no documentation the shunt site was monitored for thrill and bruit on either shift on the following dates: 10/19, 10/21, 10/22, 10/24, 10/26, 10/28, 10/29, 10/31, 11/2, 11/3, 11/5, 11/7, 11/9, 11/11, 11/12, 11/14, 11/16, 11/21, 11/24-11/26, 11/30, 12/5, 12/9, 12/12, 12/14, 12/19/18, 1/4/19, 1/5/19 and 1/14/19. Interview with the Director of Nursing (DON) on 1/15/19 at 9:48 AM, at the North nurses station, the DON was asked if the nurses should be monitoring the [MEDICAL TREATMENT] shunt site for the thrill and bruit. The DON stated, They should be. The DON was asked if she could be sure the nurses were monitoring the site if it was not documented. The DON stated, No. Interview with the DON on 1/15/19 at 11:30 AM, in the conference room, the DON was asked if an order should have been written for [MEDICAL TREATMENT]. The DON stated. Yes .

Based on policy review, observation, and interview, 2 of 7 (Licensed Practical Nurse (LPN) #1 and 2) nurses failed to follow infection control measures to prevent the potential spread of infection and cross-contamination while performing blood glucose monitoring and wound care. The findings included: 1. The facility's HAND HYGIENE policy documented, .When to Wash Your Hands .Before touching wounds, changing dressings, obtaining specimen collections and providing catheter care .Before and after the use of gloves, gowns and masks . 2. Observations in the South hallway on 2/21/18 at 10:54 AM, revealed LPN #1 donned gloves, prepared the glucometer, entered Resident #30's room, performed a blood glucose check, walked into the hallway, cleaned the glucometer, removed her gloves and placed them on a rolling cart with the blood glucose monitoring supplies, donned gloves without performing hand hygiene, prepared the glucometer, entered Resident #31's room, performed a blood glucose check, walked into the hallway, cleaned the glucometer, removed the gloves, disposed of both pairs of gloves without performing hand hygiene, then went to the medication cart to record blood glucose results. Observations in Resident #34's room on 2/21/18 at 5:17 PM, revealed LPN #2 applied gloves, removed a soiled dressing, changed gloves, cleansed the wound and applied the dressing. LPN #2 failed to perform hand hygiene between glove changes and during the wound care. Interview with the Director of Nursing (DON) on 2/22/17 at 2:25 PM, in the DON office, the DON was asked if it was acceptable not to perform hand hygiene between glove changes. The DON stated, No .

Based on policy review, medical record review, observation, and interview, the facility failed to ensure assessments were performed for a pressure ulcer for 1 of 3 (Resident #208) sampled residents reviewed of the 7 residents with pressure ulcers. The findings included: The facility's WOUND CARE policy documented, .Action - 1. All wounds will be assessed, with treatment, beginning upon orders from a physician. This will primarily be done by nurse assigned to wound care but in instances where wound care nurse is not available, it will be the responsibility of the charge nurse . Medical record review revealed Resident #208 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 11/7/16 admission Minimum Data Set (MDS) documented an unstageable pressure ulcer with slough/eschar, that was present on admission. The current physician's orders [REDACTED].Clean sacral wound with Phase one wound cleanser, pack with [MEDICATION NAME] Flex, cover with [MEDICATION NAME] dressing. Change Q (every) 3 days. R/T (related to) Unstageable P.U. (pressure ulcer) . Review of the wound assessments revealed weekly wound assessments were completed 11/1/16, 11/3/16, 11/10/16, 11/17/16, 12/1/16, and 12/8/16. There was no weekly wound assessment completed the week of 11/24/16. Observations in Resident #208's room on 12/14/16 at 10:36 AM, revealed a quarter size pressure ulcer to the sacrum, with a very small amount of depth, pink wound bed with very small amount yellow to center. There was no redness or [MEDICAL CONDITION] noted. Interview with LPN #2 (the Treatment Nurse) on 12/14/16 at 11:54 AM, in her office, LPN #2 was asked about the wound assessment for the week of 11/24/16. LPN #2 stated, .that was the week I was off, the nurses were doing the treatments . LPN #2 was asked if the nurses would asses the wound. She stated, They usually don't .

Based on policy review, medical record review, observation, and interview, the facility failed to ensure 1 of 6 (Licensed Practical Nurse (LPN) #1) medication nurses administered medications with a medication error rate of less than 5 percent (%). There were 2 medication errors made out of 27 opportunities for error which resulted in a medication error rate of 7XXX 7%. The findings included: 1. The facility's TECHNIQUE FOR PROPER USE OF METERED DOSE INHALERS documented, .9. Repeat steps 3-8 (steps of administering the inhaler) if additional puffs are needed (waiting 1-2 minutes between puffs) .**Section 483.25 (m) of the Center for Medicare & (and) Medicaid Services (CMS) Guidance to Surveyors for skilled nursing facilities states, If more than one puff is required, (whether the same medication or a different medication) wait approximately a minute between puffs . 2. Medical record review revealed Resident #43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] (160MCG (micrograms) - 4.5MCG) .2 puffs Inhalation Twice Daily . Observations in Resident #43's room on 12/13/16 at 8:45 AM, revealed LPN #1 administered 2 puffs of [MEDICATION NAME] to this resident and did not wait 1 minute between puffs. The failure to wait 1 minute between puffs resulted in medication error #1. 3 Medical record review revealed Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The current physician's orders [REDACTED].[MEDICATION NAME] (160MCG - 4.5MCG) .2 puffs Inhalation Twice Daily . Observations in Resident #59's room on 12/13/16 at 9:04 AM, revealed LPN #1 administered 2 puffs of [MEDICATION NAME] to this resident and did not wait 1 minute between puffs. The failure to wait 1 minute between puffs resulted in medication error #2. Interview with the Director of Nursing (DON) on 12/14/16 at 11:31 AM, in the conference room, the DON was asked how long should you wait between puffs of an inhaler. The DON stated, If it is a different medicine, then 5 minutes . She was asked how long between puffs of the same inhaler. The DON stated, Well, I would think for at least 1 minute .

Based on policy review, medical record review and interview, the facility failed to ensure a resident at risk for falls had appropriate interventions in place to prevent potential falls for 1 of 6 (Resident #1) sampled residents. The facility's failure to immediately implement an individualized fall prevention care plan for Resident #1 resulted in actual harm when Resident #1 fell and sustained a skin tear to the left elbow and left rib fractures. The findings included: Review of the Falls Prevention policy and procedure documented, POLICY: All patients well be assessed to determine their risk for falls and a plan of care implemented based on the patient's assessed needs. PROCEDURE . 3. Individualized care plan interventions will be implemented for those patients who are determined high risk for falls. Resident and family will be included in care plan meetings . Medical record review for Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the hospital History and Physical dated 8/8/15 documented, History of present illness: Patient is bought in by family and honestly doesn't want to come into the hospital or even to the ER (emergency room ). They (family) found her neck it (naked) laying in the floor of her house . Review of the Nursing History and Assessment dated 8/12/15 documented the resident had sustained a fall in the last month prior to admission to the facility. Review of the Fall Risk Assessment dated 8/12/15 documented a total score of 15 and, INSTRUCTIONS . If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. A prevention plan should be initiated immediately and documented in the care plan. The Admission Care Plan dated 8/12/15 had no documented preventative interventions for potential falls for a resident being assessed as a high risk for falls. Review of the Nurse's Notes dated 8/13/15 at 12:30 AM documented, CNA (Certified Nurse Assistant #1) entered room to check on pts (patient) and resident was laying in (on) floor beside B bed. Received trauma to left hand and skin tear to left elbow. (Name of physician) notified . At 12:40 AM documented, Supervisor notified of residents fall upon examination she recalled (physician) and received orders to send to ER (emergency room ). Family notified . admitted to (name of hospital) for acute respiratory failure. Review of the hospital chest X-Ray dated 8/13/15 documented, ADDENDUM In the body of the report it should read there are new left rib fractures involving ribs 6, 7, 8, 9 and possibly T10. Cannot exclude nondisplaced right rib fracture. Review of the facility's Resident Incident/Accident Report dated 8/13/15 documented the resident had a change in mental status before the fall; she was alert with confusion. The resident had gotten up without assistance. Interview via phone with Nurse #2 on 8/24/15 at 2:30 PM, Nurse #2 stated the last time she administered medications to the resident was around 9:30 PM on 8/12/15, the resident was alert with confusion. The facility's failure to immediately implement an individualized fall prevention care plan for Resident #1, who had a history of [REDACTED].#1 fell and sustained a skin tear to the left elbow and left rib fractures.

Intakes: TN 120 Based on policy review, medical record review, review of an incident / accident report and interview, the facility failed to document and/or implement individualized care plan interventions for falls for 4 of 6 (Residents #1, 2, 4 and 5) sampled residents. The facility's failure to immediately implement and document an individualized fall prevention care plan for Resident #1, resulted in actual harm when Resident #1 fell and sustained a skin tear to the left elbow and left rib fractures. The findings included: 1. Review of the Falls Prevention policy and procedure documented, POLICY: All patients well be assessed to determine their risk for falls and a plan of care implemented based on the patient's assessed needs. PROCEDURE . 3. Individualized care plan interventions will be implemented for those patients who are determined high risk for falls. Resident and family will be included in care plan meetings . 2. Medical record review for Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the hospital History and Physical dated 8/8/15 documented, History of present illness: Patient is bought in by family and honestly doesn't want to come into the hospital or even to the ER (emergency room ). They (family) found her neck it (naked) laying in (on) the floor of her house . Review of the Nursing History and Assessment dated 8/12/15 documented the resident had sustained a fall in the last month prior to admission to the facility. Review of the Fall Risk Assessment dated 8/12/15 documented a total score of 15 and, INSTRUCTIONS . If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. A prevention plan should be initiated immediately and documented in the care plan. The Admission Care Plan dated 8/12/15 had no documented preventative interventions for potential falls for a resident being assessed as a high risk for falls. Review of the Nurse's Notes dated 8/13/15 at 12:30 AM documented, CNA (Certified Nurse Assistant #1) entered room to check on pts (patient) and resident was laying in (on) floor beside B bed. Received trauma to left hand and skin tear to left elbow. (Name of physician) notified . At 12:40 AM documented, Supervisor notified of residents fall upon examination she recalled (physician) and received orders to send to ER (emergency room ). Family notified . admitted to (name of hospital) for acute [MEDICAL CONDITION]. Review of the hospital chest X-Ray dated 8/13/15 documented, ADDENDUM In the body of the report it should read there are new left rib fractures involving ribs 6, 7, 8, 9 and possibly T10. Cannot exclude nondisplaced right rib fracture. Review of the Resident Incident/Accident Report dated 8/13/15 documented the resident had a change in mental status before the fall; she was alert with confusion. The resident had gotten up without assistance. Interview via phone with Nurse #2 on 8/24/15 at 2:30 PM, Nurse #2 stated the last time she administered medications to the resident was around 9:30 PM on 8/12/15, the resident was alert with confusion. The facility's failure to immediately implement an individualized fall prevention plan related to the resident's history of a fall resulted in actual harm when Resident #1 fell and sustained a skin tear to left elbow and left rib fractures. 3. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Fall Risk Assessment dated 8/13/15 documented a total score of 16, indicating a high risk for falls. The Admission Care Plan dated 8/13/15 had no documented preventative interventions for potential falls for a resident being assessed as a high risk for falls. 4. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the hospital History and Physical dated 5/13/15 documented, .presented to the ER via EMS (emergency medical service) with complaints of right leg pain after falling . Review of the Fall Risk Assessment dated 5/18/15 documented a total score of 13, indicating a high risk for falls. The Admission Care Plan dated 5/18/15 had no documented preventative interventions for potential for falls for a resident being assessed as a high risk for falls. 5. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the hospital History and Physical dated 7/3/15 documented, .comes to the ER today for evaluation after a traumatic fall . Review of the Fall Risk Assessment dated 7/7/15 documented a total score of 17, indicating a high risk for falls. The Admission Care Plan dated 7/7/15 had no documented preventative interventions for potential for fall for a resident being assessed as a high risk for potential falls.