Every finding on record at Hillcrest Post Acute

Based on observation, interview, and record review the facility failed to implement an infection prevention and control program when:Personal Protective Equipment (PPE-specialized clothing or equipment used to provide a barrier and reduce exposure to hazards or infections) was not disposed correctly outside of Resident 67's room.Seven of seven residents (Resident 18, 24, 32, 45, 52, 66, and 73) were on Enhanced Barrier Precaution (EBP-infection control intervention used to prevent the spread of MDROs- bacteria that is resistant to most antibiotics) and did not have PPE available immediately outside the resident's room in accordance with The Center for Disease Control and Prevention (CDC) guidelines.These failures had the potential to place residents at risk for cross contamination that could lead to illness.Findings: 1.During a review of Resident 67’s “admission Record,” dated 9/10/25, the “admission Record” indicated Resident 67 was admitted to the facility on [DATE] with a diagnosis of COVID-19. During an observation on 9/8/25 at 2:16 p.m. outside of Resident 67's room (room [ROOM NUMBER]), there was a face shield hanging on the back side of the resident’s door, facing towards the inside of the room. The face shield had unlabeled and undated. Resident 67's room did not have a sign indicating the resident was on any isolation precautions (preventative measures used to prevent the spread of germs by creating barriers and implementing safe practices). During an interview on 9/10/25 at 2:55 p.m. with the Licensed Vocation Nurse (LVN) 1, LVN 1 stated Resident 67 was positive for COVID-19 upon admission to the facility, but had been cleared to come off isolation precautions. LVN 1 stated the face shield should have been removed after Resident 67 was taken off of isolation precautions for COVID-19. During an interview on 9/11/25 at 10:48 a.m. with the Infection Preventionist (IP), the IP stated the face shield in Resident 67's room should have been discarded since Resident 67 was cleared from isolation precautions. The IP further stated the face shield could have led to cross-contamination. During a review of the facility policy and procedure (P&P) titled, Isolation - Initiating Transmission-Based Precautions, the undated P&P indicated, .When Transmission-Based Precautions are implemented, the Infection Preventionist .clearly identifies the type of precautions, the anticipated duration and the personal protective equipment that must be used .Transmission-Based Precautions remain in effect until the Attending Physician or Infection Preventionist discontinues them, which occurs after criteria for discontinuation are met . 2. During an observation on 9/8/25 at 1:53 p.m. Resident 18, 24, 32, 45, 52, 66 and 73 had EBP signs posted on the wall above the resident name tags. In addition, there was no PPE posted outside of Resident 18, 24, 32, 45, 52, 66 and 73’s room (Rooms 5, 6, 8, 10, 12, 14, and 16). During a concurrent interview and record review on 9/9/25 at 3:32 p.m. with the Infection Preventionist (IP), the Director of Nursing (DON) and the Administrator (Admin), the following documents were reviewed: -The “California Department of Public Health (CDPH)’s All Facilities Letter (AFL) 24-15,” dated 6/13/24, the document indicated, “California SNFs [Skilled Nursing Facilities] should refer to the CDC website on Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) . for guidance and tools for implementing EBP…” -CDC’s “Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs),” dated 4/2/24, the document indicated, “When implementing… Enhanced Barrier Precautions, it is critical to ensure staff have… access to appropriate supplies. To accomplish this… Make PPE, including gowns and gloves, available immediately outside of the resident room…” The IP, DON, and Admin confirmed the PPE was not available immediately outside Resident 18, 24, 32, 45, 52, 66 and 73’s room (Rooms 5, 6, 8, 10, 12, 14, and 16). The IP, DON and Admin further stated the PPE should have been available immediately outside of the resident rooms. During a review of the facility’s policy and procedure (P&P) titled, “Enhanced Barrier Precautions,” dated December 2024, the P&P indicated, “Personal protective equipment and alcohol-based hand-rub are readily accessible to staff…”

Based on observation, interview, and record review, the facility failed to ensure three of four outside dumpsters' were covered. This failure had the potential to attract pests and/or rodents that carried diseases and could result in food borne illness (a sickness caused by consuming food, or drinks contaminated with harmful substances) in a medically fragile population of 56 residents.Findings:During a concurrent observation and interview on 9/8/25 at 1:30 p.m. with the Dietary Manager (DM) outside of the building near the kitchen, there were three dumpsters with overflowing garbage that were uncovered. There was foul odor and many flies coming from the dumpsters. The DM stated the dumpsters should have been covered.During a follow up interview on 9/11/25 at 10:37 a.m. with the DM, the DM stated the maintenance department was responsible for ensuring the dumpsters were maintained and closed. The DM further stated dumpsters needed to remain closed to prevent an attraction of pests that could lead to contamination of food. During a review of the facility's policy and procedure (P&P) titled Food-Related Garbage and Refuse Disposal dated October 2017, the P&P indicated, .Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter .

Based on observation, interview, and record review, the facility failed to maintain a sanitary and comfortable homelike environment for one of 25 resident rooms when:1. room [ROOM NUMBER] bed A's privacy curtain was visibly soiled with a thick brown substance.2. room [ROOM NUMBER]'s ceiling vent had visible accumulation of a thick brown dripping substance.These failures had the potential to result in the spread of infection in four medically fragile residents that resided in room [ROOM NUMBER].Findings:1.During a concurrent observation and interview on 9/9/25 at 9:24 a.m. with Maintenance Assistant (MA) in room [ROOM NUMBER], Bed A's privacy curtain, closest to the closet, had numerous areas of a thick black substance dripping down. The MA confirmed the privacy curtain was dirty and stated he needed to replace it. During an interview on 9/9/25 at 3:45 p.m. with the Administrator (Admin), the Admin stated she had gone and viewed room [ROOM NUMBER] Bed A's privacy curtain and confirmed it was dirty. The Admin stated the privacy curtain should have been changed.During a review of the facility's policy and procedure (P&P) titled, Cleaning/Repairing Carpeting and Cloth Furnishings, dated December 2009, the P&P indicated, .cloth furnishings shall be cleaned regularly and repaired promptly.2.During a concurrent observation and interview on 9/9/25 at 9:24 a.m. with MA, in room [ROOM NUMBER], the ceiling vent above bed C had visible accumulation of a thick brown dripping substance. MA confirmed the ceiling vent was dirty and stated it needed to be cleaned.During an interview on 9/9/25 at 3:44 p.m. with the Admin, the Admin stated she had gone and viewed the ceiling vent, and confirmed it was dirty. The Admin stated it was maintenance department's responsibility to clean the ceiling vents, and it should have been completed.Facility did not provide a policy and procedure for cleaning the vents in resident rooms.

Based on interview and record review, the facility failed to ensure one of five Certified Nursing Assistants (CNA) underwent a background check prior to employment. This failure had the potential to result in the facility not preventing individuals with a criminal history of abuse, neglect and exploitation to provide care to a medically vulnerable population of 56 residents.Findings:During a concurrent interview and record review on 9/10/25 at 3:26 p.m. with the Administrator (Admin), CNA 1's employee file was reviewed. CNA 1's employee file was missing a background check. The Admin confirmed with HR (human resources) that CNA 1 did not have a background check completed. The Admin stated all employees were supposed to go through the background check process to ensure the facility did not hire an individual that had a criminal history because it could impact the resident's safety.During a review of the facility's policy and procedure (P&P) titled, Background Screening Investigations, dated March 2019, the P&P indicated, Our facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on all applicants for positions with direct access to residents. background and criminal checks are initiated within two days of an offer of employment or contract agreement, and completed prior to employment.

Based on interview and record review, the facility failed to assess and submit accurate data for one of 14 sampled residents (Resident 27) when the Minimum Data Set (MDS- an assessment tool used to guide resident care) did not reflect Resident 27's current status. This failure resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS).Findings: During a concurrent interview and record review on 9/11/25 at 11:20 a.m. with Minimum Data Set Coordinator (MDSC), Resident 27's MDS 3.0 Section I- Active Diagnoses, dated 8/1/25, and Active Orders, undated, were reviewed. Resident 27's MDS 3.0 Section I- Active Diagnoses indicated under infections Resident 27 had an active diagnosis of viral hepatitis (an infection that damages the liver). Resident 27's Active Orders indicated there was no treatment for viral hepatitis. The MDSC stated Resident 27 was admitted to the facility with a previous diagnosis of Chronic Viral Hepatitis C and confirmed Resident 27 had not received any treatment or medication for Chronic Viral Hepatitis C. During an interview on 9/11/25 at 11:40 a.m. with the Administrator (ADMIN), the ADMIN stated Resident 27's Chronic Viral Hepatitis C should not have been coded in MDS under active diagnoses because he was not receiving any treatment or medication for that diagnosis. During a review of CMS Long-Term Care Facility [LTCF] Resident Assessment Instrument [RAI] 3.0 User's Manual, dated October 2024, CMS LTCF RAI 3.0 User's Manual indicated, Code disease that have a documented diagnosis in the last 60 days and have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments . Example of inactive Diagnoses . the resident has recovered . with no residual effects and no continued treatment .

Based on observation, interview and record review, the facility failed to ensure one of 14 sampled residents (Resident 43) received a shower or bed bath for 16 days. This failure resulted in Resident 43 expressing a level of dissatisfaction with grooming and wanting to be groomed more often.Findings:During a review of Resident 43's admission Record, dated 9/11/25, the admission Record indicated Resident 43 was admitted to the facility on [DATE] with a diagnosis of hemiplegia following cerebral infarction affecting right dominant side (loss of ability to move the right side of the body due to loss of oxygen to the brain).During a review of Resident 43's Minimum Data Set (MDS- an assessment tool used to guide resident care) Section GG- Functional Abilities, dated 9/5/25, the MDS Section GG indicated Resident 43 required maximal assistance (when a resident requires 50-75% of help from staff) for showering/bathing.During a concurrent observation and interview on 9/8/25 at 4:08 p.m. with Resident 43, Resident 43 had an accumulation of dirt underneath her fingernails and dry flaky skin to the palm of her right hand. Resident 43 stated she only received a couple of bed baths in the past month. Resident 43 further stated she did not receive consistent showers and would like to shower more.During a concurrent interview and record review on 9/11/25 at 9:45 a.m. with the Director of Nursing (DON) the following documents were reviewed:-the facility's Shower Schedule, undated, the facility Shower Schedule indicated Resident 43 was scheduled to be showered on Wednesday's and Sunday's PM (evening) shift.-Resident 43's Task: Shower, dated 8/13/25 to 9/11/25, the Task: Shower indicated Resident 43 did not receive a shower or bed bath for 16 days, during the period of 8/18/25 to 9/2/25.The DON confirmed there was no documentation of Resident 43 refusing a shower or bed bath. The DON stated Resident 43 should have received four showers or bed baths within the 16-day period.During a review of the facility's policy and procedure (P&P) titled, Quality of Life- Dignity, dated February 2020, the P&P indicated, Resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction . residents are groomed as they wish to be groomed .

Based on observation, interview, and record review, the facility failed to ensure the prescribed left hand roll (rolled up wash cloth or towel used to support and position the hand and wrist to prevent contractures-permanent shortening or tightening of muscles resulting in limited range of motion and stiffness in the hand) was applied as ordered by the physician for one of 14 sampled residents (Resident 54). This failure had the potential to result in Resident 54's decline in functional abilities.Findings:During a review of Resident 54's admission Record, dated 9/11/25, Resident 54's admission Record indicated Resident 54 was admitted to the facility on [DATE] with a diagnosis of left-hand contracture.During a review of Resident 54's Care Plan Report, dated 3/4/18, the Care Plan Report indicated, [Resident 54] has an ADL [Activities of Daily Living-basic personal tasks] self-care performance deficit r/t [related to] limited mobility, Dementia [progressive decline in cognitive abilities], contracture of left hand (admitted with). Requires total care with all ADLs . is not able to initiate needs request and requires staff support to have needs are and concrete addressed and met by staff . CONTRACTURES: has contracture of the left hand . Left Hand roll on in AM and off in PM .During multiple observations on 9/8/25 between 1:39 p.m. to 2:52 p.m. in Resident 54's room, Resident 54 was sitting in a Geri-chair (specialized recliner designed for individuals with limited mobility) with left wrist bent at a downward angle. Resident 54's left hand did not contain a brace, splint or hand roll.During multiple observations on 9/9/25 between 8:45 a.m. to 4:21 p.m. in Resident 54's room, Resident 54 was sitting in a Geri-chair with left wrist bent at a downward angle. Resident 54's left hand did not contain a brace, splint or hand roll.During a concurrent observation and interview on 9/9/25 at 4:21 p.m. with the Infection Preventionist (IP), in Resident 54's room, Resident 54 was sitting in her Geri-chair with left wrist bent downward at an angle and did not contain a brace, splint or hand roll. IP stated Resident 54 should have had a hand roll in her left hand.During a concurrent interview and record review on 9/9/25 at 4:30 p.m. with the Director of Nursing (DON), Resident 54's Physician Order, dated 4/5/21 was reviewed. Resident 54's Physician Order indicated Place Hand Roll in Left Hand, On in the Morning and off at Night. Approximately 8 hours. The DON stated Resident 54 should have had a hand roll applied to her left hand.During an interview on 9/10/25 at 10:03 a.m. with the Director of Rehabilitation (DOR), the DOR stated Resident 54's preventative measure for worsening of the contracture was to follow the physician order and apply the hand roll daily.Facility did not provide a policy and procedure for following physician orders.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5 percent when one of two licensed nurses were observed and made the following medication errors:1. Resident 74 did not receive the correct dosage of Baclofen (muscle relaxant medication used to treat muscle stiffness, spasms and pain) in accordance with the physician order.2. Metformin (medication used to treat type 2 diabetes- chronic condition when the body does not regulate blood sugars) was not given with breakfast in accordance with the physician order for Resident 12.These failures resulted in two identified medication errors out of 30 opportunities for medication administration. The facility's overall medication error rate was 6%.Findings:1.During a review of Resident 74's admission Record, dated 9/11/25, the admission Record indicated Resident 74 was admitted to the facility on [DATE] with a diagnosis of chronic pain syndrome (consistent pain that significantly interferes with daily life).During a concurrent observation and interview on 9/9/25 at 9:50 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 removed 1 tablet of baclofen 10mg (milligram- unit of measurement) from the blister pack (packaging of medication that is individually sealed in plastic with cardboard backing), cut the tablet in half and added it to a medicine cup containing eight pills. LVN 1 counted all medications in the medicine cup and stated there was a total of ten pills, including the medication that was cut in half. LVN 1 then administered all medications to Resident 74.During a concurrent interview and record review on 9/9/25 at 12:38 p.m. with LVN 1, Resident 74's Physician Order, dated 9/3/25 was reviewed. The Physician Order indicated, Baclofen Oral Tablet 15 MG, Give 1 tablet by mouth three times a day for muscle spasms. LVN 1 confirmed he administered only 10 mg of Baclofen to Resident 74 and stated he should have given an additional half tablet of baclofen to equal the physician order of 15 mg.During an interview on 9/9/25 at 3:29 p.m. with the Director of Nursing (DON), the DON stated the expectation for nurses administering medication, was to confirm the dosage given with the physician order.During a review of the facility's policy and procedure (P&P) titled, Medication Administration Oral, dated November 2017, the P&P indicated, Review and confirm medication orders for each individual resident on the Medication Administration Record PRIOR to administering medication. Pour the correct number of tablets or capsules into the medication cup.2.During a review of Resident 12's admission Record, dated 9/11/25, admission Record indicated Resident 12 was admitted to the facility on [DATE] with a diagnosis of type 2 diabetes.During an observation on 9/9/25 at 9:43 a.m., Resident 12 was in her room and no breakfast tray was observed. LVN 1 removed 1 tablet of Metformin 500 mg from the blister pack that had a label Give 1 tablet by mouth with Breakfast and Dinner. LVN 1 then administered the Metformin to Resident 12 without breakfast.During a concurrent interview and record review on 9/9/25 at 12:26 p.m. with LVN 1, Resident 12's Physician Order, dated 12/11/23 was reviewed. The Physician Order indicated, metFORMIN. Give 500 mg by mouth two times a day related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA with breakfast and dinner. LVN 1 confirmed Resident 12 ate breakfast prior to medication administration and stated breakfast meal trays were distributed at 7 a.m. LVN 1 further stated Resident 12's Metformin should have been given within 30 minutes of eating breakfast.During an interview on 9/9/25 at 3:31 p.m. with the DON, the DON stated when medication was ordered to be administered with breakfast, the medication was expected to be administered while eating breakfast.During an interview on 9/11/25 at 11:14 a.m. with the Pharmacist (Pharm), the Pharm stated manufacturer recommends to administer Metformin with food to prevent GI (gastrointestinal- stomach) discomfort.During a review of the facility's policy and procedure (P&P) titled, Medication Administration Oral, dated November 2017, the P&P indicated, Medications that require specific instructions for administration are administered in a way that complies with manufacturer's recommendations.

Based on observation, interview, and record review the facility failed to safely store drugs in accordance with acceptable standards of practice when Resident 30's Naloxone (fast-acting medication that reverses an opioid [pain medication] overdose) had an expiration date of [DATE] and stored in a medication cart. This failure had the potential for Resident 30 to be administered an expired medication.Findings:During a review of Resident 30's admission Record, dated [DATE], admission Record indicated Resident 30 was admitted to the facility on [DATE] with a diagnosis of diverticulitis (inflammation and/or infection of the large intestines that can cause sudden or intense pain).During a concurrent observation and interview on [DATE] at 5:05 p.m. with Licensed Vocational Nurse (LVN) 2, Resident 30's naloxone nasal spray had an expiration date of 7/2025 in a medication cart. LVN 2 stated the naloxone should have been discarded.During an interview on [DATE] at 4:21 p.m. with the DON, the DON stated all medications that were expired should have been discarded.During a review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, dated February 2023, the P&P indicated, If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.

Based on interview and record review, the facility failed to provide a Report of the results of their investigations to the State Survey Agency, within 5 working days of the incident. This was for one of one reports of alleged elder abuse. This failure has the potential for the facility to miss data and not make the needed changes to prevent abuse. Findings: During a review on 3/17/25 at 9:00 a.m., the report of suspected dependent adult/elder abuse, dated 3/14/25, was reviewed. The document indicated the alleged incident occurred on 3/14/25. During an interview on 3/17/25 at 10:25 a.m., the Administrator stated the 5-day report was in process and acknowledged that the 5-day report needed to be completed and sent to the department in one or two days. During record review on 3/24/25 at 9:20 a.m., the 5-day report from the facility about their investigation into the alleged abuse, was not available. The Department sent an email to the facility administrator on 3/24/25 at 9:20a.m., to request a copy of the 5-day report and documentation that the report had been sent timely. During an interview on 3/24/25 3:00 p.m., Administrator stated that she was busy with personal business and forgot to send in the 5-day report to the department. Administrator stated she would send the report as soon as possible. During a review of emails, paper mail, and attachments in the federal electronic program, on 3/27/25 at 9:30 a.m., the 5-day report was not available.

Based on observation, interview and record review, the facility failed to ensure the posted daily staffing schedule had an additional required information such as census (number of residents in the facility), the total numbers of Licensed and Unlicensed staff and the actual hours worked individually, reflect staff absences on that shift due to call-outs and illness, and clearly identify the staff's name in a clear and readable format. This failure had the potential to result in poor and inadequate care that compromised the health and safety of residents. Findings: During a concurrent observation and interview on 4/18/24 at 4 p.m. with the Administrator (ADM), during a tour to the nurses' station where the daily staffing was located, the daily staffing for Licensed and Unlicensed nurse was located inside a binder. ADM stated that the daily staffing was readily available to read to all visitors, staff, and residents. During a concurrent interview and record review on 4/18/24 at 4 p.m. at the nurses' station, when Administrator (ADM) was asked do you have the census written on the daily staffing, ADM answered no. When asked ADM, how do you differentiate the staff's name listed on the daily staff list as there were no last name or last name initial, since you have multiple staff with the same first name, ADM answered, yes, she does not see the last name. ADM stated, she would change the format of the posting for daily staff assignments.

Based on observation, interview and record review, the facility failed to provide a fully credentialed Infection Preventionist (nurse who surveys and monitors infection prevention and control). This failure had the potential for Residents to obtain infections and be placed on unnecessary medications due to lack of infection control surveillance. During an interview with the DON on 4/16/24 at 10:30 a.m., DON queried as to who the Infection Preventionist is for the facility. DON stated, the nurse who has been working as the Infection Preventionist (Licensed Staff H) resigned 12/29/23. DON stated, Licensed Staff H and Licensed Staff I have been filling in. DON queried for the facility's staffing sign in sheets for Licensed Staff H and Licensed Staff I from 1/3/24 to 4/15/24. DON also queried for the timecard accounting for License Staff H and Licensed Staff I from 1/3/24 to 4/15/24. During a record review of Licensed Staff H's timecard for the time frame 1/3/24 to 4/15/24. License Staff H's worked day shift on 1/19/24, 1/25/24, 2/1/24, 2/5/24, 2/8/24, 2/18/24, 2/19/24, 2/23/24, and 2/29/24. During a record review of Licensed Staff H's Staffing Sign in sheets for 1/19/24, 1/25/24, 2/1/24, 2/5/24, 2/8/24, 2/18/24, 2/19/24, 2/23/24, and 2/29/24, Licensed Staff H's timecard revealed that none of these dates was Licensed Staff H signed in to work as the Infection Preventionist. During a record review of Licensed Staff H's HR File, Certificate of Training for Infection Prevention 2-Day Course from CDPH (California Department of Public Health), dated, 9/12/19. No other Infection Preventionist training was found in Licensed Staff H's file as well as no annual continuing education CEU's. During a record review of Licensed Staff I's timecard for the time frame of 1/3/24 to 4/15/24, Licensed Staff I worked day shift on 1/4/24, 1/11/,24, 1/12/24, 1/16/24, 1/17/24, 1/25/24, 2/1/24, 2/5/24, 2/6/24, 2/12/24, 2/18/24, 2/20/24, 2/22/24, 2/26/24, 3/26/24 and was signed in on the Staffing Sign In sheets as the Infection Preventionist. Licensed Staff I worked as an Infection Preventionist from 1/3/24 -4/15/24 for a total of 15 shifts. During a record review of Licensed Staff I's HR File, Certificate of Training for infection Prevention 2-Day Course from CDPH, dated, March 1, 2024. This Certificate was 2.5 months after License Staff H resigned. Licensed Staff I started working as an Infection Preventionist on 1/4/23 without Infection Preventionist certification. No other credentialing prior to March 1, 2024, was found in Licensed Staff I's HR File. During an interview with the DON on 4/15/24 at 10:30 a.m., DON queried for the facility's policy for Infection Preventionist. No policy received. DON queried if both the DON position and the DSD position required a full-time nurse. DON responded, yes. During a review of the CDPH's Entrance Conference Worksheet, dated 4/15/24, Line 21, indicated, Name of facility's infection preventionist (IP). Documentation of the IP's primary professional training and evidence of completion of specialized training in infection prevention and control. This information was requested in writing from the ADM but no name or certification was received for the facility's Infection Preventionist. During a review of the facility's policy and procedure titled, Antibiotic Stewardship - Staff and Clinician Training and Roles Revised 2016, indicated, The facility will educate and train staff and practitioners about the facility Antibiotic Stewardship Program, including appropriate prescribing, monitoring and surveillance of antibiotic use and outcomes. Nursing and Direct Care Licensed Staff - Nurses will receive initial orientation and ongoing training on: The facility's Antibiotic Stewardship Program, including the need for judicious use of antibiotics; how to utilize the standardized assessment and communication tool for resident suspected of having an infection; How to communicate with resident and family about the need for appropriate use of antibiotic; specific information that should be reported to the physician or provider upon identifying sign and symptoms of possible infection and specific information that should be obtained when an order for an antibiotic is received. Director of Nursing and the Infection Preventionist - Administration and management personnel with clinical oversight responsibilities will receive initial orientation and ongoing training on: the facility's antibiotic Stewardship Program; the rationale for judicious use of antibiotics; how to use surveillance tools to monitor infection rates, antibiotic usage patterns and outcomes; how and when to gather data to present to the Infection Prevention and Control Committee for scheduled meetings; and individual roles and responsibilities in maintain antibiotic stewardship. The DON will monitor individual resident antibiotic regimens, including reviewing clinical documentation supporting antibiotic orders; and compliance with start/stop dates and/or days of therapy. The IP will audit, and the DON will provide feedback to providers on antibiotic prescribing practices. IP will monitor over time and report to the IPCC. a) measures of antibiotic start, resident days, and days of therapy. b) antibiotic susceptibility patterns (antibiogram data for specific timeframe) and c) negative outcomes or events related to antibiotic use for example C difficile infections, adverse drug event and antibiotic resistance rates. The IP will obtain, and the DON will provide to healthcare practitioners, educational resources and materials about antibiotic resistance and opportunities for improved antibiotic use. During a review of the facility's policy and procedure titled, Facility Assessment revised, April 2023, A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations. Determining our capacity to meet the needs of and care for our residents during emergencies is included in this assessment. The team responsible for conducting, reviewing, and updating the facility assessment includes the following: Administrator, A representative of the governing body, Medical Director, DON, and Infection Preventionist. Once the reviews of the resident needs and the facility resources are conducted, the facility assessment consists of systematically evaluating how well aligned these are. Each department provides input on current or potential gaps in care or services due to possible misalignment or lack of appropriate resources. The facility assessment is intended to help our facility plan for and respond to changes in the needs of our resident population and helps to determine budget, staffing, training, equipment and supplies needed. This assessment is based on information acquired during a facility-based infection control risk assessment, as well as a community-based risk assessment. During a review of the facility's policy and procedure titled, Administrative Management (Governing Board) Revised April 2023, indicated, The governing board shall be responsible for the management and operation of the facility. The facility's governing board is the supreme authority and has full legal authority and responsibility for the management and operation of our facility. The administrator is appointed by and accountable to the governing board. The governing board is responsible for but is not limited to: Oversight of facility care and services in accordance with professional standards of practice and principles. Establishment and ongoing review of all administrative programs governing facility management and operations, including Corporate Compliance Program .Quality Assurance and Performance Improvement program, and Staff orientation, training and development programs. Creation of and participation in the annual facility-wide assessment: Provision of a safe physical environment equipped and staffed to maintain the facility and services. During a review of the DON's job description, revised October 2020, indicated, Safety and Sanitation Ensure that nursing services personnel follow established infection prevention and control procedures. During a review of the Infection Preventionists job description, revised October 2020, indicated, Primary Purpose of this position is to plan, organize develop, coordinate, and direct the facility infection prevention and control program and its activities in accordance with the current federal, state, and local standards, guidelines and regulations that govern such programs and as directed by the Administrator and the infection Prevention and Control Committee. Administrative Functions: Plan develop, implement, evaluate and oversee the infection prevention and control program in accordance with current regulations and guidelines governing skilled nursing facilities. Establish and maintain an infection surveillance program that is based on standardized definitions of infections. Review, summarize and report data relative to key infection prevention and control initiatives including antibiotic stewardship, healthcare acquired infections, immunization programs and outbreaks. Present findings from special investigations and make recommendations to the Infection Prevention and Control Committee. Participate in the annual facility assessment, perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc., as necessary.

Based on interviews and records review, the facility failed to assess and monitor for signs of after surgery complications for one of 15 sampled residents (Resident 20) when Resident 20 had left eye surgery. This failure had the potential for Resident 20 to develop an unidentified bacterial eye infection which could result in Resident 20's discomfort. Findings: A review of the document titled Admission Record indicated Resident 20 was admitted on [DATE] with diagnosis including but not limited to Parkinson's Disease (disorder of the central nervous system that affects movement) and Diabetes Mellitus (disease that result in too much sugar in the blood). A review of the document titled Physician's Progress Notes dated 4/09/24 indicated Resident 20 had a left eye surgery for silicone oil (often used as a retinal [a layer at the back of the eyeball] tamponade [function by keeping the hole in the retina dry] after complex retinal detachment [a painless but serious eye condition] repair) removal and retention. During an interview and concurrent record review with Licensed Staff D on 4/19/24 at 10:07 a.m., when Licensed Staff D was asked about the facility policy for resident's who had a change of condition (COC), Licensed Staff D stated nurses would monitor the resident for any complications from the COC. Licensed Staff D concurred that Resident 20's left eye surgery was considered a COC. When Licensed Staff D was asked what should the nurses monitor after Resident 20's eye surgery, Licensed Staff D stated nurses would monitor for signs of eye infection like eye discharges, redness, itching and eye discomfort. During an interview with the Director of Nursing (DON) on 4/19/24 at 10:36 a.m., when the DON was asked about her expectation from the nurses after Resident 20 had eye surgery, the DON stated she expected the nurses to assess and monitor for any signs of complications from the eye surgery, like eye infection and pain every shift for seventy two (72) hours as standard practice and document their observations. After review of the nurses' progress notes from 4/9/24 to 4/19/24 with the DON, the DON stated there was no documentation from the nurses to show Resident 20 was assessed and monitored for signs of complications after the eye surgery. Review of the Facility policy and procedure titled Acute Condition Changes - Clinical Protocol revised on March 2018 under Monitoring and Follow-up indicated, The staff will monitor and document the resident/patient's progress and responses to treatment, and the physician will adjust treatment accordingly.

Based on interviews and records review, the facility failed to ensure Ophthalmic (pertaining to the eye) medications were administered according to the doctor's order for two of 15 sampled residents (Resident 20 and Resident 41) when: 1. a. Resident 20 who had left eye surgery did not receive the ordered Ofloxacin Ophthalmic Solution 0.3%, (an antibiotic used to treat bacterial infections of the eye) three days after the medication was ordered, and (b) Resident 20 did not receive the medication according to the ordered administration time. These failures had the potential risk for Resident 20 to develop bacterial eye infection and eye discomfort. (Cross reference F684) 2. Resident 41 who had a diagnosis of Glaucoma (an eye diseases that can cause vision loss and blindness) did not receive his eye medications according to the ordered administration time. These failure had the potential risk for Resident 41 to experience eye pain and deterioration of visual function. Findings: Resident 20 During an interview with Resident 20 on 4/15/24 at 4:02 p.m., Resident 20 stated he had a new order for eyedrop after his eye surgery and did not get the medication until after two days. Resident 20 stated he was supposed to have the eyedrops at 8:00 a.m.; 12:00 p.m.; 4:00 p.m.; and 8:00 p.m. but the nurses were late in giving his eye drops. A review of the document titled Admission Record indicated Resident 20 was admitted on [DATE] with diagnosis including but not limited to Parkinson's Disease (disorder of the central nervous system that affects movement) and Diabetes Mellitus (disease that result in too much sugar in the blood). A review of the document titled Physician's Progress Notes dated 4/09/24 indicated Resident 20 had a left eye surgery for silicone oil (often used as a retinal [a layer at the back of the eyeball] tamponade [function by keeping the hole in the retina dry] after complex retinal detachment [a painless but serious eye condition] repair) removal and retention. A review of the document titled Order Summary Report indicated a Physician's Order written on 4/10/24 for Ofloxacin Ophthalmic Solution 0.3%, to give one drop in left eye four times a day. a. A review of the document titled Pharmaceuticals Shipping Manifest dated 4/14/24 indicated the Ofloxacin 0.3% eye drop was received on 4/14/24 at 10:53 p.m. During an interview and concurrent record review with Licensed Staff D on 4/19/24 at 10:07 a.m., Licensed Staff D stated Resident 20 had left eye surgery and currently receiving antibiotic eye drops. A review of the Medication Administration Record (MAR) for Resident 20 with Licensed Staff D from 4/10/24 to 4/13/24 indicated 3 with the nurse's initials under the Ofloxacin order. When Licensed Staff D was asked what 3 stand for, she stated to hold (an order to suspend the medication administration under specific conditions) the medication and to see nurses' notes for reason of holding the medication. However, after review of the nurses' progress note with Licensed Staff D, Licensed Staff D stated the progress note did not indicate reason for holding the medication. She stated the medicine could be unavailable. When Licensed Staff D was asked about the risks for Resident 20 for the delayed administration of eye antibiotic after his eye surgery, she stated Resident 20 could be at risk for eye infection and eye pain. During a review of the MAR for Resident 20 and concurrent interview with Licensed Staff C on 4/19/24 at 10:31 a.m., Licensed Staff C verified the order for Ofloxacin was written on 4/10/24 and that nurses documented 3 from 4/10/24 to 4/13/24. When Licensed Staff C was asked why was the eye antibiotic not given for three days, Licensed Staff C stated she called the pharmacy and was told the medicine won't be delivered until 4/16/24 due to Resident 20's medical insurance. When Licensed Staff C was asked if Resident 20's physician was notified that the medicine won't be delivered until 4/16/24, she stated she was not sure if Resident 20's physician was notified. When Licensed Staff C was asked about the risks for Resident 20 for the delayed administration of the eye antibiotic, Licensed Staff C stated Resident 20 had the potential risk for eye infection, swelling, redness, pain and burning sensation. During an interview with the Director of Nursing (DON) on 4/19/24 at 10:36 a.m., when the DON was asked about the facility's medication administration policy for new ordered antibiotic, the DON stated antibiotic medications should be given as soon as possible, within 4 hours. When the DON was asked if she was aware that the Ofloxacin delivery was delayed due to Resident 20's medical insurance, the DON stated no. She stated if she was notified that the medicine could not be delivered on time, she could fill up an authorization form to expedite the process to avoid the delay. The DON stated risks for delayed treatment would be eye infection. b. A review of the document titled Medication Administration Audit Report indicated Resident 20 received Ofloxacin Ophthalmic Solution 0.3% one drop to his left eye on the following dates and times: - On 4/15/24, Resident 20 received the medication at 12:22 p.m. for the scheduled 8:00 a.m. dose. - On 4/16/24, Resident 20 received the medication at 10:15 a.m. for the scheduled 8:00 a.m. dose; and 6:00 p.m. for the scheduled 4:00 p.m. dose. - On 4/17/24, Resident 20 received the medication at 11:04 a.m. for the scheduled 8:00 a.m. dose; and 6:28 p.m. for the scheduled 4:00 p.m. dose. - On 4/19/24, Resident 20 received the medication at 1:57 p.m. for the scheduled 8:00 a.m. dose; and 6:14 p.m. for the scheduled 4:00 p.m. dose. - On 4/20/24, Resident 20 received the medication at 10:04 a.m. for the scheduled 8:00 a.m. dose; 6:31 p.m. for the scheduled 4:00 p.m. dose; and 10:55 p.m. for the scheduled 8:00 p.m. dose. - On 4/21/24, Resident 20 received the medication at 4:40 p.m. for the scheduled 12:00 p.m. dose. During an interview with Licensed Staff D on 4/22/24 at 1:34 p.m., when asked about the facility's policy for medication administration, Licensed Staff D stated nurses could administer scheduled medications an hour early or an hour late and expected to document on the resident's MAR immediately after administering the medications. Resident 41 During an interview with Resident 41 on 4/15/24 at 3:38 p.m., Resident 41 stated he often gets his medicines including his eye drops a couple of hours late. He stated he was supposed to get the eyedrops three times a day in the morning, at noon and at night. A review of the document titled Admission Record indicated Resident 41 was admitted on [DATE] with diagnosis including but not limited to Glaucoma (a condition of increased pressure within the eyeball, causing gradual loss of sight) and Hypertension (High Blood Pressure). A review of the document titled Order Summary Report indicated a Physician's Order written on 2/26/24 for Prolensa Ophthalmic Solution 0.07% (used to treat pain or swelling of the eye following cataract surgery [a procedure to remove the lens of the eye] to give one drop in right eye two times a day for Glaucoma; a Physician's Order written on 3/19/24 for Brinzolamide-Brimonidine Ophthalmic Suspension 1-0.2% (used to treat increased pressure in the eye caused by glaucoma) to give one drop in right eye two times a day for Glaucoma, and Timolol Maleate Ophthalmic Solution 0.5% (used to treat high pressure inside the eye due to glaucoma) to give one drop in right eye two times a day for Glaucoma. A review of the document titled Medication Administration Audit Report indicated Resident 41 received Brinzolamide-Brimonidine Ophthalmic Suspension 1-0.2%; Timolol Maleate Ophthalmic Solution 0.5%; and Prolensa Ophthalmic Solution 0.07% on the following dates and times: - On 4/16/24, Resident 41 received the medications at 10:19 a.m. for the scheduled 8:00 a.m. dose. - On 4/17/24, Resident 41 received the medications at 11:45 a.m. for the scheduled 8:00 a.m. dose. - On 4/20/24, Resident 41 received the medications at 10:13 a.m. for the scheduled 8:00 a.m. dose. - On 4/21/24, Resident 41 received the medications at 4:40 p.m. for the scheduled 12:00 p.m. dose. During an interview with the DON on 4/23/24 at 1:41 p.m., when the DON was asked about the facility's policy for medication administration, she stated nurses have one hour before and one hour after the scheduled time to give the medications and nurses were expected to document as soon as the medications were given to the residents. Review of the Facility policy and procedure titled Medication Administration General Guidelines dated 9/2018 indicated, Medications are administered in accordance with written orders of the prescriber . Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center.

Based on observation, interview and record review, the facility failed to ensure two of two residents, Resident 9 and Resident 19, received action, obtain feedback, and conduct systematic investigations to improve quality of care, quality of life and resident's safety during Quality Assurance and Performance Improvement (QAPI) meetings when: 1) The Director of Staff Development (DSD) did not report an incident reported by an Ombudsman of verbal abuse and mocking (imitating behavior) towards Resident 9 by Unlicensed Staff L. DSD did not inform the Administrator of the abuse allegation. ADM was the abuse coordinator. 2) Resident 19 attempted to complain to DSD regarding an alleged verbal abuse by Unlicensed Staff M & Unlicensed Staff N . DSD did not follow up with Resident 19 about the allegation and did not inform ADM nor the Inter Department team (IDT) during their daily IDT meeting & monthly meetings of QAPI. Findings: (1) During a concurrent interview and record review on 4/19/24 at 9:39 a.m. the Director of Staff Development (DSD) stated that she was the supervisors for the Certified Nursing Assistance (CNA). When asked the DSD if an Ombudsman reported to her about a CNA who was verbally aggressive to a resident, DSD answered yes. DSD stated that the Ombudsman reported to her about a staff who was imitating a resident. DSD filled out a form titled Employee warning/coaching documentation for Unlicensed Staff L (CNA). A review of the form dated 2/26/24 indicated that Ombudsman notified DSD/DON (Director of Nursing) Under Action taken verbal warning, corrective action by employee was an in-service title residents/patients' rights and will not imitate noise of resident's voice/sound. When asked DSD, did you inform the Administrator (ADM) regarding the alleged verbal abuse incident, DSD answered not sure, maybe I have. DSD stated she knew that the Director of Nursing (DON) was aware of this alleged abuse. When asked DSD, did you notify a law enforcement and State Agency, DSD answered No. During an interview on 4/1824 at 11:32 a.m., the administrator (ADM) stated that she was the Abuse Coordinator. ADM stated her managers made rounds once per week, talked with residents, report any type of abuse to social worker, managers, to reach out to family or conservator. ADM stated that all types of abuse was to be reported to her. ADM stated that once she received any allegation of abuse that she would investigate, interview resident, staff to determine if abuse occurred. ADM stated that part of the abuse was to report to State Agency, Ombudsman, Law enforcement, and Medical Doctor. When asked ADM, did you know about an incident happened between Unlicensed staff L allegedly imitating the noise that Resident 9 made, ADM stated, she was not aware of that incident. ADM stated that no one had informed her. When asked ADM, what was your expectation from your management when there was an alleged abuse, DM stated that she expected her management to inform her of alleged abuse. ADM stated that they meet Monday thru Friday in the morning for management meeting. When asked ADM if she recalled any report about this incident between Unlicensed Staff L and Resident 19 during the daily meeting, ADM stated No. (2) During a concurrent interview and record review on 4/17/24 at 12:44 p.m., in Resident 19's room, Resident 19 stated that Unlicensed Staff M and N scolded her saying you are stressing me out. Resident 19 stated that she was upset from being scolded, so she said that she yelled at them back. Resident 19 stated that she informed the DSD briefly and DSD said that she would be back, it happened approximately last week, not sure of the exact date. Resident 19 stated that she did not hear back from DSD. Resident 19 stated that Unlicensed Staff M & N were not assigned to her anymore. During an interview on 4/18/24 at 11:32 a.m. ADM stated that she was not aware that Resident 19 had a verbal altercation with the Unlicensed Staff M & N. ADM stated that DSD did not mention it to her. ADM stated that she met with the Management Team (IDT) from Monday through Friday to discussed new issues. When asked ADM, do you recall when your Management Team discussed these verbal altercations between Unlicensed nurses L, M & N and Residents 9 and Resident 19, ADM stated No, she was not aware. During an interview on 4/19/24 at 10:30 a.m. with the DSD, DSD stated Resident 19 requested to speak to her for an alleged verbal altercation between resident and staff. DSD stated, she recalled that Resident 19 wanted to speak to her, but she was not able to go back to Resident 19's room. When asked DSD, did you inform another management or ADM that Resident 19 would like to report a verbal altercation, DSD stated No. During a concurrent interview and record review on 4/22/24 at 1:19 p.m. ADM stated that if a resident complains, it would be discussed in management (IDT) meeting. ADM stated that during IDT meeting daily, the abuse events were discussed or reported. ADM stated that the Ombudsman never informed her regarding abuse that involved Resident 9 and Unlicensed Staff L. ADM stated that the Ombudsman asked her about a specific last name of an Unlicensed Staff, but she never told her why. ADM stated that the topic or issues discussed during QAPI, personnel improvement plan and employee health files. When asked ADM, during your QAPI meeting, had any of your management mentioned anything about alleged verbal altercation or abuse, ADM stated, No, there were no discussion. A review of the facility's Policy & Procedure titled Quality Assurance and Performance Improvement (QAPI) Plan revised 4/2014 indicated This facility shall develop, implement and maintain an ongoing, facility-wide QAPI Plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolved identified problems Under objectives, 1) Provide a means to identify and resolve present and potential naive outcomes related to resident care and services: 3) Provide structure and processes to correct identified utility and/or safety deficiencies: 4) Establish and implement plans to correct deficiencies, and to monitor the effects of these action plans on resident outcome; 5) Help departments, consultants, and ancillary services that provide direct or indirect care to residents to communicate effectively ad to delineate lines of authority, responsibility and accountability. Under Authority: 1) The owner and/or governing board (body) of our facility shall be ultimately responsible for the QAPI Program. 2) The Administrator is responsible for assuring that this facility's QAPI Program complies with federal, state, and local regulatory agency requirements.

Based on interviews and records review, the facility failed to develop and implement person-centered care plans for one of 15 sampled residents (Resident 20) when Resident 20 had left eye surgery. This failure resulted in a lack of communication between disciplines and care givers that could potentially cause negative outcomes for Resident 20. (Cross reference F684) Findings: A review of the document titled Admission Record indicated Resident 20 was admitted on [DATE] with diagnosis including but not limited to Parkinson's Disease (disorder of the central nervous system that affects movement) and Diabetes Mellitus (disease that result in too much sugar in the blood). A review of the document titled Physician's Progress Notes dated 4/09/24 indicated Resident 20 had a left eye surgery for silicone oil (often used as a retinal [a layer at the back of the eyeball] tamponade [function by keeping the hole in the retina dry] after complex retinal detachment [a painless but serious eye condition] repair) removal and retention. During an interview and concurrent record review with the Director of Nursing (DON) on 4/19/24 at 10:36 a.m., when the DON was asked about the facility's policy for care planning, the DON stated resident's change of condition should have care plan. She stated nurses in charge of the resident should initiate a care plan then the Interdisciplinary Team (IDT - group of health care professionals who work together toward the goals of the resident) including the DON were responsible to review and make sure the care plan was in place. After review of Resident 20's electronic record, the DON stated there was no care plan developed for Resident 20 to address the care needed after his left eye surgery. During an interview and concurrent record review with Licensed Staff D on 4/19/24 at 10:07 a.m., when Licensed Staff D was asked about the facility's policy for care planning, Licensed Staff D stated nurses were expected to initiate a care plan should a resident have a change of condition. A review of the Facility policy and procedure titled Care Plans, Comprehensive Person-Centered revised on March 2022 indicated, The comprehensive, person-centered care plan: a) includes measurable objectives and time frames; b) describes the services that are to be furnished to obtain or maintain the residents highest practicable physical, mental, and psychosocial well-being.; . e) reflects currently recognized standards of practice for problem areas and conditions.

Based on observation interview and record review, the facility failed to follow their Medication Storage Policy, when 3 expired COVID 19 Vaccines and 1 box of Arginaid (wound healing nutrition) were found in the facility's Medication Storage room and another expired box of Arginaid was found in Medication Cart 1. This failure had the potential to result in Residents being injected with an expired ineffective COVID 19 vaccine resulting in an unvaccinated status as well as expired deteriorated Arginaid being ineffective for wound healing. Findings: During an observation on [DATE] at 12:55 p.m., in Medication Cart 1, observed 1 box of Arginaid to be expired with an expiration date of [DATE]. During an observation on [DATE] at 12:59 p.m., in the Medication Storage room, observed 1 box of Arginaid to be expired with an expiration date of [DATE]. During an observation on [DATE] at 1 p.m., in the Medication Storage room, 3 expired Covid 19 vaccines were observed with an expiration date of [DATE] in the medication refrigerator as well as 1 box of expired Arginaid found on the shelf with an expiration of [DATE]. During an interview with Licensed Staff C on [DATE] at 1:10 p.m., Licensed Staff C queried as to the risk to Resident safety if the Resident were to receive an expired Covid 19 vaccine. Licensed Staff C stated, she thinks the risks would be the Resident would not be effectively vaccinated due to the deterioration of the COVID 19 medication in the vial. Licensed Staff C queried as to what the risks would be to Resident safety if the Resident were to receive expired Arginaid for their wound. Licensed Staff C responded, she doesn't believe the expired Arginaid would be beneficial to support wound healing and the wound could get larger. During a review of the facility's policy and procedure titled, Medication Storage dated, 2007, indicated, Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal. Medication storage conditions are monitored on a regular basis as a random quality assurance check. During a review of the Infection Preventionist Job Description, Revised [DATE], indicated, monitor the designated shelf life of sterizlied and packaged supplies; reprocess as necessary. Order inventories of vaccines to be adminsitered to staff and residents in a timely manner.

Based on observation, interview, and record review the facility failed to adhere to safe injection practices when one Licensed Nurse (Licensed Nurse A) was observed recapping an insulin needle before injecting one Resident (Resident 1). This failure put the Licensed Nurse in danger of a needlestick injury which has the potential to cause a blood borne pathogen infection. Findings: During a med pass observation on 5/10/23 at 12:10 p.m. Licensed Nurse A drew up 2 units (a measurement) of insulin (medication used for diabetic persons) for Resident 1. Licensed Nurse A withdrew the needle from the insulin vial and then recapped the insulin needle with the orange cap using both hands. During an interview with the Assistant Director of Nurses on 5/10/23 at 12:24 p.m. when asked what her expectation was regarding the disposal of used needles, she stated, We cap them for safety and dispose in our sharps container. During a review of the facility's policy titled Standard Precautions, revised September 2022, indicated Standard precautions are used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status. Standard Precautions presume that all blood, body fluids, secretions and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. 8. Safe Needle Handling a. Used needles are never recapped or otherwise manipulated using two hands, or any other technique that involves directing the point of a needle toward any part of the body. A review of CDC/NIOSH (Centers for Disease Control/National Institute for Occupational Safety and Health) guidelines titled, Needlestick Injuries are Preventable, dated 2/1/21, indicated, Healthcare Personnel who use or may be exposed to needles are at increased risk of needlestick injury. Needlestick injuries can lead to serious or fatal infections with blood borne pathogens such as Hepatitis B virus, Hepatitis C virus, or HIV. The guidelines further indicated that needlestick injuries can be avoided by eliminating the unnecessary use of needles, using devices with safety features, and promoting education and safe working practices for handling needles and related systems . Avoiding recapping needles. (https://www.cdc.gov/niosh/newsroom/feature/needlestick_disposal.html)

Based on interviews and record reviews, the facility failed provide pharmaceutical services that meet the needs of the residents when one of four sampled residents (Resident 1) did not receive four doses of Epoetin (a medication used to treat anemia, or low red blood cells, in people with serious kidney diseases), as ordered by the physician, over an eight-week period. This failure had the potential for Resident 1 to develop anemia, characterized by feeling weak or tired more often than usual, lightheadedness, and fast, irregular heartbeats, as the body does not get enough oxygen-rich blood. Findings: Record review revealed Resident 1 was admitted to the facility with diagnoses including acute and chronic respiratory failure with hypoxia (a long-term condition of failure in oxygen exchange in the lungs resulting in not enough oxygen in a person ' s blood), generalized muscle weakness, and chronic kidney disease. (When kidneys are damaged, they produce less erythropoietin [EPO], a hormone that signals your bone marrow-the spongy tissue inside most of your bones-to make red blood cells. With less EPO, your body makes fewer red blood cells, and less oxygen is delivered to your organs and tissues. - https://www.niddk.nih.gov). A review of Resident 1 ' s Medication Administration Records (MARs), dated [DATE] and [DATE], on 2/21/23 at 12:45 p.m., indicated an order for Epoetin Alfa Injection Solution every Tuesday, with codes marked on the following scheduled doses: 1. 1/3/23 = [check mark] 2. 1/10/23 = [check mark] 3. 1/17/23 = 7 4. 1/23/23 = 7 5. 1/31/23 = 7 6. 2/7/23 = [check mark] 7. 2/14/23 = 7, and 8. 2/21/23 = [check mark] Further review of the MARs revealed a Chart Codes/Follow Up Codes, indicating, [Check Mark] = Administered, 7= Other/See Nurse Notes. During an interview and concurrent review of Resident 1 ' s MARs on 2/21/23 at 1:15 p.m., Director of Nursing (DON) confirmed four of eight scheduled doses for Epoetin were marked 7, meaning Other/See Nurse Notes. During a concurrent review of Resident 1 ' s Progress Notes, DON stated she was unable to locate any nurse's notes corresponding to the Epoetin doses that were marked 7. DON stated she was unable to confirm if the medications marked 7 were administered, adding, The medication should have a check mark if it was given. During an interview and concurrent review of Resident 1 ' s January and February MARs on 3/27/23 at 1:50 p.m., Licensed Staff A confirmed she marked Resident 1 ' s Epoetin dose with 7 on 1/17/23. Licensed Staff A stated she could not recall the medication nor why the dose was marked 7. When asked if the dose was given to Resident 1, Licensed Staff A stated, I ' m not sure. Licensed Staff A stated 7 meant See Nurse Note but during a concurrent review of Resident 1 ' s Nursing Progress Notes, Licensed Staff A was unable to locate a corresponding note. Licensed Staff A stated there should have been a note when the dose was marked 7. During an interview on 3/27/23 at 2:20 p.m., DON stated Resident 1 did not receive four Epoetin doses, with three nurses not administering the medications as ordered, from 1/1/23 to 2/21/23. DON stated there should have been documentation on why medications were not given, for example if the doses were not held or refused by the resident. DON stated if the medications were not available it should have been documented and endorsed to the following shift. DON stated she expected staff to notify the physician and the pharmacy of the missed dose. During an interview on 3/27/23 at 2:30 p.m., Administrator stated she expected medications to be given as it was ordered. Administrator stated, There should have been more follow up,,adding Resident 1 ' s Epoetin was scheduled once a week and could have been given as soon as the missed dose was caught. During an interview on 3/28/23 at 3:27 p.m., Medical Director stated Epoetin was an important medication to help residents keep their red blood cell levels up which helps more oxygen to be delivered to their organs of the body. Medical Director stated this helped residents ' quality of life, to be more alert and active with decreased weakness. Medical Director stated he expected nurses to carry out and administer medications to residents as order by the physician. Medical Director stated he expected staff to identify why the medications were not administered and to notify and the pharmacy when medications were not given, adding, Then we could adjust the order so we could make up for it [missed dose] and have the medication administered as it becomes available. Medical Director stated he expected staff to make all efforts to provide the residents the medications they needed. A review of the facility policy titled, Documentation of Medication Administration, dated April 2007, indicated, A nurse or certified medication aide (where applicable) shall document all medications administered to each resident on the resident ' s medication administration record (MAR) . Documentation must include, as a minimum: .e. reason(s) why a medication was withheld, not administered or refused (as applicable) .

Based on observation, interview and record review, the facility failed to ensure immediate access to residents by family members and failed to ensure the rights of residents to receive visitors when the facility implemented a visitation policy in which family and visitors were asked to schedule visitation appointments, the visitation was restricted to certain hours of the day and family and visitors had no access to residents in their rooms, with visitation occurring only in the dining room. This failure created barriers for family and visitors to visit residents and had the potential for all residents who wished to receive visitors not to have visitors at the time and place of their choosing. Findings: A review of the Centers for Medicare & Medicaid Services (CMS) guidance QSO-20-39-NH titled Nursing Home Visitation - COVID-19, Revised 9/23/22, indicated: Facilities must allow indoor visitation at all times and for all residents . While previously acceptable during the PHR [Public Health Emergency], facilities can no longer limit the frequency and length of visits for residents, the number of visitors, or require advance scheduling of visits. During an interview on 1/12/23, at 8:05 a.m., the family of Confidential Resident 1 stated they had been prevented from visiting their relative at the facility because of visitation restrictions imposed by the facility. They stated in order to visit their relative the facility required visitors to (1) call the facility and make appointments 24 hours in advance; (2) visits could only take place from 9:30 a.m. to 11 a.m. and from 1 p.m. to 4:30 p.m. and (3) visits were only allowed in the dining room. The family stated these restrictions prevented them from visiting their relative because (1) facility staff did not always pick up the phone when they called to make visit appointment and/or they could not reach the person responsible for the appointments and/or (2) the family had other engagements during the allowed daily visitation hours. The family also reported because they were not allowed access to their relative in their room this prevented them from monitoring the care their relative was receiving at the facility, since they had to wait to for the resident at the dining room while staff got the resident ready for the visit. They further reported these restrictions prevented them from visiting during mealtimes, in which they could help their relative eat and which the resident enjoyed. They also stated their relative had dementia and it was important for their relative to see family often lest the relative forgot who their family were. They stated during a few visits their relative could not recognize them because the facility's visitation restrictions prevented them from visiting more frequently. During an interview on 1/12/23, at 9:45 a.m., the Administrator stated the facility had no current or recent COVID-19 outbreaks. The Administrator stated the last covid-19 outbreak at the facility was six months ago. During an interview on 1/12/23, at 10:08 a.m., Confidential Resident 2 stated they received visitors. They stated visitors and family were required to schedule visits in advance and could only visit during certain hours in the morning and afternoon and could not visit in their room, only in the dining room. During an interview on 1/12/23, at 10:15 a.m., Confidential Residents 3 and 4 stated both received visitors, but visitation was only allowed with prior appointments, which needed to be made with the activities department 24 hours in advance, visitation was only allowed from 10-11 a.m. and 1-4 p.m. and visitation was only allowed in the dining room, lobby or outdoors, not in resident rooms. During an interview on 1/12/23, at 10:20 a.m., Confidential Resident 5 stated they received visitors, but their visitors were required to make appointments in order to visit and could only visit during a few hours in the morning and afternoon and could only visit in the dining room. During an interview on 1/12/23, at 10:30 a.m., Confidential Resident 6 stated they received visitors. They stated family and visitors had to call ahead and could only come during certain hours, I believe 9-5, and had to visit in the dining room. During an interview on 1/12/23, at 11:35 a.m., Confidential Resident 7 stated they received visitors, but visitors had to make prior appointments and visits could only take place during limited hours and had to take place in the dining room. During an observation on 1/12/23, at 10:38 a.m., in front of the dining room, the Activities Assistant (AA) was transporting a resident on a wheelchair to the dining room. The AA stated she was taking this resident to a scheduled family visit in the dining room. The AA was asked to describe the process of visiting residents at the facility. The AA stated the facility asked family and visitors of residents to visit between 10-11 a.m. and 1-4:45 p.m. daily. The AA stated visits only took place in the dining room, not in resident rooms. The AA stated visitors were asked to call ahead 24 hours before they wanted to visit so staff could get the resident ready for the visits. The AA stated the scheduled visits for each day were listed on a board in the nurse's station and pointed to a board in the nurse's station. A review of this board indicated the date of 1/12/23 and six scheduled resident visits: at 9:30 a.m., 10 a.m., 10:30 a.m., and 1 p.m., 2 p.m. and 3 p.m. During an interview on 1/12/23, at 11 a.m., the family of Confidential Resident 8 stated in order to visit their relative they had to call 24 hours in advance and make an appointment. They stated it was a problem because it was hard to get a hold of staff on the phone to make the appointments. They stated several times they wanted to visit, but they were not able because no one answered the phone when they called to make the appointment. They stated as a result they missed their relative's birthday they intended to celebrate at the facility. They stated visit appointments were only available from 10-11 a.m. and from 1-4 p.m. They stated these limited hours many times conflicted with their other engagements, and they could not sometimes visit as a result. They stated they were not allowed to visit in the relative's room, which they preferred, instead they had to wait for staff to bring their relative to the dining room. During an interview on 1/12/23, at 11:25 a.m., the family of Confidential Resident 9 stated they had to call 24 hours in advance to schedule appointments to visit and then the staff either said Yes or No. They stated visits were only allowed from 10-11 a.m. and from 1-4 p.m. and they are not allowed to visit in the resident room, only in the dining room. During an interview on 1/12/23, at 11:45 a.m., the Administrator, Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were asked to describe the facility's visitation policy. The ADON stated family and visitors were asked to call in advance to let the facility know when they were coming so staff could get the residents ready for the visit. The ADON stated they preferred visits from 9 to 11:30 a.m. and from 1 to 4:45 p.m. and asked family and visitors to visit in the dining room as to not disturb other residents. The Administrator, DON, and ADON were asked if there was a clinical or safety reason for these visitation restrictions. The ADON stated they were based on an All Facilities Letter (AFL) issued by the Department and provided AFL 22-07.1, dated 11/6/22, titled Guidance for Limiting the Transmission of COVID-19 in Skilled Nursing Facilities (SNFs). A review of this AFL did not indicate facilities could require advance scheduling of visits, could limit visitation to certain hours and certain places or could prevent visitors to visiting residents in their rooms. A review of facility policy titled Visitation, dated August 2022, indicated: Residents are permitted to have visitors of their choosing at the time or their choosing .The facility provides 24-hour access to individuals vising with the consent of the resident.