Every finding on record at Hillsborough County Nursing Home

Based on observation, interview, and record review, the facility failed to ensure that Enhanced Barrier Precautions (EBP) were implemented for 1 of 2 residents reviewed for urinary catheters (Resident identifier is #77) and failed to have a water management plan that included all the necessary elements to prevent the growth and spread of Legionella and other opportunistic waterborne pathogens in a facility with a census of 243 residents. Findings include:Review on 5/7/26 of the facility's Water Management Plan, revised 3/2026, revealed the plan did not identify specific areas in the facility where Legionella could grow and spread. Further review revealed under Mitigation Plan that Shower [NAME] and Kitchen Hoses were to be replaced every 6 months. Interview on 5/7/26 at approximately 12:00 p.m. with Staff K (Administrator) confirmed that the Water Management Plan did not include the areas where waterborne pathogens could grow and spread. Review on 5/7/26 of a checklist titled Legionella – Spray Hose Cleaning revealed that the shower wands were last replaced on 9/22/25 (more that 6 months). There was no documentation provided that the kitchen hoses had been replaced. Interview on 5/7/26 at approximately 11:50 a.m. with Staff J (Maintenance Worker) confirmed the above mentioned checklist. Staff J was unable to provide documentation on when the kitchen hoses were last replaced. Resident #77 Review on 5/6/26 of the facility policy, revision date 7/25, revealed, .9. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and or indwelling medical devices regardless of MDRO colonization.12. Caution Triangle Sign is posted on the wall outside of the resident room indicating EBP is needed for the resident/patient. 13. The PPE is available in a hanging yellow precaution bag with the EBP sign on the bathroom door. Observation on 5/5/26 at approximately 9:42 a.m. in Resident #77's room revealed Resident #77 was in their room sitting in a wheelchair and a urinary catheter bag (indwelling medical device) was hanging on the left side of the wheelchair. Further observation revealed that there were no Personal Protective Equipment (PPE) supplies and signage indicating that Resident #77 was on any precautions. Review on 5/6/26 of Resident #77's foley catheter care plan, revision date 7/2/25, revealed an intervention for EBP. Interview on 5/6/26 at approximately 9:58 a.m. and 10:10 a.m. with Staff C (LNA) revealed that Resident #77 had a urinary catheter, and Staff C was not aware that Resident #77 was on EBP. Staff C also revealed that he/she provided morning care to Resident #77 that morning wearing gloves but did not use a gown as PPE. Further interview with Staff C revealed that residents on EBP had signage outside their door indicating their EBP status. Interview on 5/6/26 at approximately 10:03 a.m. with Staff A (Registered Nurse) revealed that Resident #77 should be on EBP due to the presence of a urinary catheter. Staff A also revealed that residents on EBP should have a caution triangle sign posted outside their room, along with PPE supplies and EBP signage placed on the resident's bathroom door.

Based on observation, interview, and record review, the facility failed to properly prepare insulin per manufacturer's instructions for 1 of 1 residents receiving insulin in 7 residents observed for medication administration. (Resident identifier is #218.)Findings include:Observation on 5/5/26 at approximately 12:00 p.m. of Staff H (Registered Nurse) during Resident #218's medication administration revealed Staff H turned the Humalog Kwikpen (insulin) dial to two units without priming the pen and proceeded to administer the dose to Resident #218. Interview on 5/5/26 at approximately 12:00 p.m. with Staff H confirmed that the insulin pen had not been primed according to manufacturer instructions before administering the dose to Resident #218. Review on 5/5/26 of Resident #218's Medication Administration Record revealed an order for Humalog Kwikpen Pen Injector 100 unit Inject before meals and at bedtime as per sliding scale: 120-149=0 150-199=2 200-249=4 250-299=6 300-349=8 350-399=10 [PHONE NUMBER]=12 and call MD. Further review revealed Resident #218 had a Capillary Blood Glucose (CBG) of 168 requiring 2 units of Lispro (Humalog) insulin per order. Review on 5/5/26 of Lispro manufacturer instructions titled 'INSTRUCTIONS FOR USE Insulin Lispro [pronunciation omitted] Kwikpen' revealed, .Priming your pen Prime before each injection Priming your pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Step 6. To prime your pen, turn the Dose Knob to select 2 units. Step 7. Hold your Pen with the needle pointing up. Tap the cartridge Holder gently to collect air bubbles at the top. Step 8. Continue holding your pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. -If you do not see insulin, repeat priming steps 6 to 8, no more than 4 times. -If you still do not see insulin, change the Needle and repeat priming steps 6 to 8.

Based on observation, interview, and record review, the facility failed to ensure medications were labeled with open expiration dates for 1 of 6 medication carts observed and failed to ensure that medications were stored at appropriate temperatures for 1 of 3 medication rooms observed. (Resident identifier is #78). Findings include:Unit B2 Medication Room Observation on 5/5/26 at 8:29 a.m. with Staff B (Registered Nurse) of Unit B2 Medication Room Refrigerator revealed that the thermometer in the refrigerator was reading 50 F (degrees Fahrenheit). Further observation revealed that there were unopened residents medications stored in the refrigerator, including Epoetin Alfa-epbx (Retacrit) recombinant, Lispro insulin (Humalog) and Lantus insulin. Interview on 5/5/26 at 8:29 a.m. with Staff B confirmed the above findings. Review on 5/5/26 of the manufacturer's instructions for the above medications revealed the following:Retacrit - Store refrigerated at 36 F to 46 F;Humalog lispro insulin - Store refrigerated at 36 F to 46 F until time of use;Lantus insulin - unopened Lantus devices should be stored in a refrigerator 36 F to 46 F. Review on 5/5/26 of Unit B2's Unit Emergency Equipment and Med [Medication] Room Log from April 2026 to May 2026 revealed the refrigerator temperatures above 46 F on the following dates: On 4/3/26, 4/4/26, 4/5/26, 4/6/26, 4/7/26, 4/13/26, 4/14/26, 4/15/26, 4/16/26, 4/17/26, 4/18/26, 4/19/26, 4/20/26, 4/21/26, and 5/1/26 (15 days) temperatures was logged at 48 F. Observation on 5/6/26 at 8:27 a.m. of the Unit B2 Medication Room Refrigerator with Staff B revealed two thermometers reading 50 F and 47 F. Interview on 5/6/26 at 8:27 a.m. with Staff A confirmed the temperatures were out of range. B2 Front Medication Cart Observation on 5/5/26 at 8:42 a.m. of Unit B2 Front Medication Cart with Staff I (Medication Nursing Assistant) revealed two open boxes of Fluticasone Furoate/Vilanterol Inhalation Powder (a combination medication used for the maintenance treatment of asthma and chronic obstructive pulmonary disease) for Resident #78. The first inhaler was dispensed by the pharmacy on 2/26/26 (9 weeks and 5 days) and the second on 3/19/26 (6 weeks and 5 days) with both having opened foil trays. There was no open dates or open expiration dates on the open boxes, open foil trays, or the inhalers. Review on 5/5/26 of the manufacturer's instructions on the above two inhaler boxes revealed, Discard the inhaler 6 weeks after opening the moisture-protective foil tray . Interview on 5/5/26 at 8:42 a.m. with Staff I confirmed the above medications were not labeled with open dates or open expiration dates. Review on 5/5/26 of Resident #78's May 2026 Medication Administration Record revealed that the above medication was administered daily. Review on 5/6/26 of the facility's policy titled Storage and Safety of Medications revised on 4/2023 revealed, Policy: 1. It is the policy of [facility] that: All medications and biologicals are stored in a safe manner and secure manner, including proper temperature control . Procedure: Medication Room Refrigerator: 1. The med [medication] room refrigerator temperature will be between 36 to 46 degrees . Medication Cart . 8. All opened vials, bottles, and nutritionals are to be dated when opened and initialed .

Based on observation, interview and record review, it was determined that the facility failed to follow medication administration instructions for and failed to handle medication according to professional standards for 1 of 5 residents observed for medication administration. (Resident identifier is #136.) Findings include: Standard: [NAME], P.A, [NAME], A.G., Stockhart, P.A., & Hall, A. (2021). Fundamentals of Nursing. Elsevier., page 640 . Skill 31.1 Administering Oral Medications, .Clean gloves (if handling an oral medication) Review on 4/2/25 of the Magnesium Lactate Extended Release manufacturer's instruction, dated 11/29/24, revealed .Warnings Follow all directions on your medicine label and package .Do not crush or chew an extended release tablet . Observation on 4/2/25 at approximately 8:10 a.m. during Resident #136's medication administration revealed that Staff A (Licensed Practical Nurse) crushed the Magnesium Lactate Extended Release (ER) 84 mg (milligrams) tablet. Further observation revealed the Magnesium Lactate ER 84 mg medication card had a pharmacy warning label that read Do not crush the medication. Observation also revealed that Staff A was putting his/her bare fingers in the medication cup to remove pills twice. Interview on 4/2/25 at approximately 8:10 a.m. with Staff A confirmed the above findings. Review on 4/2/25 of Resident #136's current physician orders revealed that Resident #136 did not have a physician's order to crush medication. Interview on 4/2/25 at approximately 9:40 a.m. with Staff B (Director of Nursing) confirmed that Resident #136 did not have a physician's order to crush his/her medications. Review on 4/2/25 of the facility policy titled, Medication Administration of P.O. (by mouth) Medications, Revision Date 1/13 revealed .2. Do not touch the oral solid medication with your bare hands .4. Some medications should not be crushed. 12. If a resident has difficulty swallowing pills whole, the practitioner will be notified, an order from the practitioner will be obtained if appropriate .

Based on observation, interview, and record review, it was determined that the facility failed to implement policies and procedures for 1 of 1 resident reviewed for Transmission Based Precaution (Resident identifier is #173). Findings include: Observation on 4/1/25 at approximately 8:30 a.m. on C4 unit revealed that Resident #173's room had a contact precaution signage outside the door. Interview on 4/1/25 at approximately 8:30 a.m. with Staff C (Registered Nurse) revealed that Resident #173 was on contact precaution for Clostridium Difficile (C-diff) infection. Observation on 4/1/25 at approximately 10:28 a.m. on C4 unit revealed that Staff D (housekeeper) was in Resident #173's room wearing a gown and gloves, wiped down Resident #173's bed rails, bedside table, and furniture with a cloth. When finished, Staff D exited the room, doffed the used gown and gloves, and used an Alcohol Based Hand Rub (ABHR). Staff D did not wash their hands with soap and water. Staff D donned new gloves, Staff D did not wear a gown, re-entered Resident #173's room, and mopped the floor. Staff D exited the room, doffed the used gloves, and used ABHR. Staff D did not wash their hands with soap and water. Interview on 4/1/25 at approximately 10:28 a.m. with Staff D confirmed the above observation. Observation on 4/2/25 at approximately 12:23 p.m. on C4 unit revealed that Staff E (Licensed Nursing Assistant) donned gown and gloves, entered Resident #173's room with a meal tray, placed the meal tray at the bedside table in front of Resident #173. Staff E exited the room, doffed the used gown and gloves, and used ABHR. Staff E did not wash their hands with soap and water. Interview on 4/2/25 at approximately 12:23 p.m. with Staff E confirmed the above observation. Review on 4/2/25 of Resident #173's provider note, dated 4/1/25, revealed reason for visit was C-diff which Resident #173 completed additional Vancomycin regimen last week for another recurrent C-diff infection and that Resident #173 reported that his/her loose stool has reoccurred. Further review of the provider note revealed a diagnostic statement of recurrent enterocolitis due to C-diff. The plan was to extend the Vancomycin regimen and follow up with infectious disease. Review on 4/2/25 of Resident #173's C-diff infection care plan, with a revision date of 3/14/25, revealed that Resident #173 was positive for C-diff on 1/6/25, 1/23/25, and 3/13/25 with an intervention that contact precautions was reinstated on 3/13/25. Review on 4/2/25 of the facility policy titled, Contact Precautions, with no date, revealed .Contact Precautions should be implemented for the following: .C. difficile .Gloves And Handwashing: .remove gloves before leaving resident's room and wash hands immediately .remove gown and observe hand hygiene before leaving the resident's room .References: Centers for disease control and prevention. Guideline for Isolation Precautions: Preventing Transmissions of Infectious Agents in Healthcare Settings .2007 . Interview on 4/2/25 at approximately 3:15 p.m. with Staff G (Infection Preventionist) stated that for contact precautions, staff can use ABHR when staff are in a resident room not providing care and gloves are not visibly soiled. Staff G confirmed the above policy and that the policy stated to wash hands. Review on 4/2/25 of the CDC guidelines titled, Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007), dated 11/27/23, revealed .perform hand hygiene ~ in the following clinical situations: .After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient .After removing gloves .Wash hands with non-antimicrobial soap and water or with antimicrobial soap and water if contact with spores (e.g., C. difficile or Bacillus anthracis) is likely to have occurred. The physical action of washing and rinsing hands under such circumstances is recommended because alcohols, chlorohexidine, iodophors, and other antiseptic agents have poor activity against spores .

Based on observation, interview, and policy review, it was determined that the facility failed to ensure that residents were assessed for the ability to self-administer medication for 1 out of 4 residents reviewed for choices in a final sample of 35 residents (Resident Identifier #116). Findings include: Observation on 4/29/24 at approximately 8:30 a.m. of Resident #116 revealed he/she was in bed administering medications to his/herself off of a napkin. The napkin contained approximately 5 pills. There was no staff present in the room. Interview on 4/29/24 at approximately 8:30 a.m. with Staff B (Licensed Practical Nurse) confirmed the above findings. Staff B revealed that this is his/her regular practice with Resident #116. Review on 4/30/24 of Resident #116's medical record, under physician orders, revealed that there was no order for Resident #116 to self-administer medications. Further review of Resident #116's medical record revealed that there was no assessment done with Resident #116 to self-administer medications. Review on 4/30/24 of the facility's policy titled Medication-Administration of Medications revision date 10/18 revealed: .7. Medications shall not be left at bedside .

Based on interview, observation, and record review, it was determined that the facility failed to ensure that residents with pressure ulcers had documentation of weekly assessments that contained measurements and descriptions of the pressure ulcer for 1 out of 3 residents reviewed for pressure ulcers in a final sample of 35 residents (Resident Identifier #114). Findings include: Review on 5/1/24 of Resident #114's medical record revealed that Resident #114 had a pressure ulcer on his/her coccyx. Review on 5/1/24 of Resident #114's weekly wound assessments revealed: 3/21/24 wound measurements 0.73 centimeters (cm) by (x) 0.99 cm (iimproving) 3/28/24 no documented wound assessment 4/4/24 wound measurements 1.29 cm x 0.4 cm (deteriorating) Interview on 5/1/24 at approximately 11:15 a.m. with Staff G (Wound Nurse) confirmed the above findings.

Based on record review, interview, and observation, it was determined that the facility failed to ensure licensed nurses had the competencies and skill sets in accordance with the facility assessment for 1 of 2 nurses reviewed for competencies. Finding include: Review on 4/30/24 of the facility assessment, dated 1/2024, revealed under the education section: .All nurses, MNAs [Medication Nursing Assistants], and LNAs [Licensed Nursing Assistant] will .have an annual Knowledge and Competency Testing form completed . The assessment further revealed Medication Management: Medication Administration RN [Registered Nurse]/LPN [Licensed Practical Nurse] were indicated. Review of Staff A's (RN) last Knowledge and Competency Documentation revealed a completion date of 2021. Interview on 5/1/24 at approximately 9:45 a.m. with Staff G (Staff Development Coordinator) revealed competencies are completed on hire. The interview further revealed that specifically for medication administration, competencies would not be done again unless there are identified medication errors or questionable medication pass techniques and observations of these would be by unit managers or staff development. 38218

Based on observation, interview, and policy review it was determined that the facility failed to maintain a clean environment for proper washing and sanitizing of dishes and utensils in the main kitchen and failed to ensure food was kept at the proper temperature in 6 of 6 kitchettes observed. Findings include: Main Kitchen Observation on 4/29/24 at approximately 8:00 a.m. in the kitchen dishwashing area with Staff H (Food Services Director) revealed two wall fans, with accumulated gray dust and grease debris, blowing air towards the clean dishes. Interview on 4/29/24 at approximately 8:00 a.m. with Staff H confirmed the above finding. Observation on 4/29/24 at approximately 8:05 a.m. with Staff H revealed a food mixer with built-up food debris and grease. Interview on 4/29/24 at approximately 8:05 a.m. with Staff H confirmed the above finding and revealed it had not been used since the day prior. Review on 4/29/24 of facility's policy titled Surface: Cleaning and Sanitization revealed: .Non-Food Contact Surfaces. Must be cleaned and rinsed .Examples: walls, floors, storage shelves, equipment exteriors .Food Contact Surfaces. Must be cleaned, rinsed, and sanitized .Examples: knives, cutting boards, pots and pans, prep tables, and other equipment that touches food . Unit Kitchenettes Review on 4/29/24 of the 6 kitchenette refrigerator temperature logs revealed no recorded temperatures on the following dates and locations: March 2024: Unit A-1: 3/21/24, 3/22/24, and 3/23/24 Unit A-2: 3/22/24 and 3/23/24 Unit B-2: 3/21/24, 3/22/24, and 3/23/24 Unit B-3: 3/21/24, 3/22/24, and 3/23/24 Unit C-3: 3/22/24 Unit C-4: 3/23/24 April 2024: Unit A-1: 4/21/24 and 4/30/24 Unit A-2: 4/30/24 Unit B-2: 4/21/24 and 4/30 Unit C-3: 4/20/24, 4/21/24, and 4/30/24 Unit C-4: 4/20/24, 4/21/24, and 4/30/24 Interview on 4/29/24 at approximately 8:30 a.m. with Staff H confirmed the above finding. Review on 4/29/24 of facility policy titled, Storing: Food and Equipment revealed: .Refrigerator and Freezer .An assigned team member will check the temperature of all refrigerators and freezers two times per day .

Based on interview and record review, it was determined that the facility failed to monitor a resident who was experiencing significant weight loss for 1 of 5 residents reviewed for nutrition in a final sample of 35 residents (Resident identifier is #224). Findings include: Review on 4/4/23 of Resident #224's medical record revealed that Resident #224 admitted to the facility on [DATE]. Review on 4/4/23 of Resident #224's Weights and Vitals Summary revealed the following weights; - 2/22/23 194.2 pounds - 2/23/23 195 pounds - 2/24/23 189 pounds. - 3/10/23 182.3 pounds. There were no additional weights recorded for Resident #224. Resident #224 had a 6.7 pound weight loss between 2/23/23 amd 2/24/23. Resident #224 experienced a 6.13 percent (%) weight loss in two weeks and five days. Review on 4/4/23 of Resident #224's Weight Change Note dated 3/14/23 revealed Weight Warning: Value: 182.3 . Date [3/10/23] . -5.0% change [6.1% .] Reweight pending, will monitor as available. This note was authored by Staff D (Registered Dietician). Interview on 4/6/23 at 12:34 p.m. with Staff C (Registered Nurse) stated that he/she will have residents reweighed if there is a 3 pound variance in weights. Staff C confirmed that a reweight had not been completed for Resident #224. Interview on 4/6/23 at 12:46 p.m. with Staff D revealed that he/she expected Resident #224 to have a reweight done based on the 3/14/23 above note. Staff D confirmed a reweight had not yet been done. Interview on 4/6/23 at 1:15 p.m. with Staff D revealed he/she would expect a reweight to be done within a week. Review on 4/6/23 of the facility's policy Vital Signs & Weights with a revision date of April 2021 revealed, .10. Weights will be taken at least monthly on each resident unless directed otherwise by the Head Nurse/designee, MD [Medical Doctor], or Dietician .

Based on observation, interview, and record review it was determined that the facility failed to ensure treatments were secured on 1 out of 6 units observed for 2 out of 20 B-2 Unit residents observed, and the facility failed to ensure proper storage of expired medications for 1 out of 3 medication rooms observed (Resident identifiers are #27, #61, #62 and #84). Findings include: Resident #61 (Unit B-2) Observations on 4/4/23 at 1:00 p.m. and 4/5/23 at 9:20 a.m. of Resident #61's shelf in the resident's room revealed one Preparation H 1 percent (%) ointment tube. Interview on 4/5/23 at 9:35 a.m. with Staff E (Licensed Practical Nurse) revealed that Staff E found the Preparation H tube was routinely stored in the resident's room. Interview on 4/5/23 at 3:00 p.m. with Staff F (Registered Nurse) revealed that the Preparation H tube should be secured in the treatment cart/medication room, as Resident #61 does not self-administer medications. Resident #27 (Unit B-2) Observations on 4/4/23 at 1:15 p.m. and 4/5/23 at 9:30 a.m. of Resident #27's shelf in the resident's room revealed one Antifungal Power with Miconazole Nitrate 2% bottle. Interview on 4/5/23 at 9:35 a.m. with Staff E revealed that the Antifungal Powder bottle was routinely stored in the resident's room. Interview on 4/5/23 at 3:00 p.m. with Staff F revealed that the Antifungal Powder bottle should be secured in the treatment cart/medication room, as Resident #27 does not self-administer medications, and confirmed the finding. Review on 4/6/23 of the facility's policy Storage and Safety of Medications with an origination date of 1/2015 revealed, .Oral medications, topical medications, treatments, eye drops and ear drops will be stored .on the medication room shelves. 45991 3C Medication Storage Room Resident #62 Observation on 4/4/23 at approximately 8:45 a.m. of the 3C medication storage room with Staff A (Registered Nurse) revealed Resident #62's Combivent Respimat Inhalation Aerosol Solution 20-100 micrograms/actuation (mcg/act) inhaler that had been used, with a pharmacy dispensed date of 12/14/22 and no open date, stored with stock medications. Further observation of the Combivent Respimat 20-100 mcg/act revealed manufacturer's instructions to discard at least 3 months after first use or when locking mechanism is engaged. Interview on 4/4/23 at approximately 8:45 a.m. of the 3C medication room with Staff A confirmed the above findings. Staff C stated that the Combivent Respimat inhaler should have been labeled with an open date to determine the discard date. Review on 4/5/23 of Resident #62's March and April 2023 Medication Administration Records (MAR) revealed an active PRN [as needed] order for Combivent Respimat 20-100 mcg/act inhaler, 1 puff every 4 hours for short [sic] of breath. Further review of Resident #62's March and April 2023 MAR's revealed that Resident #62 had not received Combivent Respimat 20-100 mcg/act inhaler. Resident # 84 Observation on 4/4/23 at approximately 9:00 a.m. with Staff A (Registered Nurse) revealed Resident #84's used Combivent Respimat Inhalation Aerosol Solution 20-100 (mcg/act) inhaler with an open date of 9/13/22. Further observation of the Combivent Respimat 20-100 mcg/act revealed manufacturer's instructions to discard at least 3 months after first use or when locking mechanism is engaged, and a pharmacy instruction label stating after opening do not use after 90 days. Interview on 4/4/23 at approximately 8:45 a.m. with Staff A confirmed the above findings. Staff C stated that the Combivent Respimat 20-100 mcg/act inhaler should have been discarded 90 days after being opened on 9/13/22. Interview on 4/5/23 at 9:30 a.m. with Staff B (Registered Nurse) confirmed that Resident #84 did not have a current order for Combivent Respimat 20-100 mcg/act inhaler. Resident #84's order for Combivent Respimat 20-100 mcg/act inhaler had been discontinued after returning from the hospital on 9/30/22. Review on 4/6/23 of the facility's policy Storage and Safety of Medications with an origination date of 1/2015 revealed, 7. Medications which are expired will be removed from the medication shelves and placed in the return to bag for pharmacy pickup.

Based on observation, interview, and record review, it was determined that the facility failed to obtain physician's orders to appropriately provide iVAP (intelligent Volume-Assured Pressure Support - a machine designed to detect changes in breathing throughout the night and adjust pressure) treatments to 1 of 3 resident reviewed for respiratory care in a final survey sample of 35 residents. (Resident identifier is #211.) Findings include: Standards: Potter, Patricia A., and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336- Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Observation on 5/17/22 at 12:51 p.m. revealed that Resident #211 had an iVAP machine on his/her bedside table. Interview on 5/17/22 at 12:51 p.m. with Resident #211 revealed that no one at the facility help him/her with the iVAP. Review on 5/18/22 of Resident #211's progress notes revealed the following nursing notes; -On 5/8/22 at 5:45 a.m a note that read .C-PAP [Continuous Positive Airway Pressure] on and supplemental oxygen on at 2 [liters] via [nasal cannula] . -On 5/9/22 at 12:47 a.m. a note that read .C-PAP on and supplement oxygen on at 2 [liters] . -On 5/9/22 at 10:53 p.m. a note that read . C-PAP on while in bed . [note: C-PAP terminology was used for iVAP] Review on 5/18/22 of Resident #211's care plan revealed a care plan, initiated on 4/15/22 and revised on 5/10/22, for use of the iVAP machine at bedtime. Further review revealed on 5/10/22 interventions were added that included the iVAP settings. Further review of the care plan revealed that Resident #211 admitted to the facility on [DATE]. Review on 5/18/22 of Resident #211's medical record (both electronic and paper) revealed that there were no physician's order for the iVAP, including ordered pressure settings. Interview on 5/18/22 at 1:28 p.m. with Staff A (Registered Nurse) confirmed that Resident #211 was using a iVAP machine that was brought from the resident's home, but did not have a physician's order for use or settings. Staff A was not sure how Resident #211 cleaned or cared for the machine, but would ask staff if he/she needed assitance. Review on 5/20/22 of the facility's policy titled Use of [CONDITION(S)] . Therapy revision date of 11/19, revealed . Objective: To safely provide pressurized air to a resident via maintenance of open airways and breathing assistance . Procedure: 1. [Oxygen] supplier will be notified of order for [CONDITION(S)] . machine and will supply equipment, set up [CONDITION(S)] . machine and adjust machine to physician ordered pressure settings along with appropriate fitting of mask. 2. Pressure settings are prescribed by the physician and documented in resident's medical record. 3. Ensure the [CONDITION(S)] . pressure is set per physician order prior to resident use .

Based on observation, interview, and record review it was determined that the facility failed to ensure that a bottle of rubbing alcohol was secured in 1 of 24 rooms toured on 1 out of 6 units observed. (C3 unit). Findings include: Observation on 5/17/22 at 12:22 p.m. of Resident #109's room on the C3 unit revealed a bottle of rubbing alcohol, 1/4 full, on the bedside table. There was also a spray bottle of wound cleanser next to it. The bottle could be visibly seen from the hallway. Interview on 5/17/22 with Resident #109 revealed that he/she used the rubbing alcohol on his/her ears (which were observed to have dried areas on them). Resident #109 was not sure why the spray bottle of wound cleanser was there. Observation on 5/18/22 at 1:20 p.m. revealed that the bottle of rubbing alcohol was on the bedside table. Interview on 5/18/22 at 1:21 p.m. with Staff D (Licensed Practical Nurse) confirmed that the rubbing alcohol should not be on the bedside table and removed it. Staff D confirmed that Resident #109 did not have a physician's order for the rubbing alcohol. Review on 5/18/22 at approximately 1:21 p.m. of the rubbing alcohol bottle revealed the following warnings; For external use only. If taken internally, serious gastric disturbance will result. Flammable. When using this product, do not get into eyes, do not apply over large areas of the body, do no use longer than one week unless directed by a doctor. Keep out of reach of children. In case of ingestion get medical help or contact a poison control center right away. Review on 5/19/22 of the facility's policy titled Medication - Resident Self-Administration of Medications, revised on 6/05, revealed, .Objective: To enable resident to safely and effectively administer their own medications .The facility acknowledges the right of each resident to self-administer medications unless the nursing staff or physician has evaluated that resident and judged that self-administration would present a danger to the resident and/or others .

Based on observation and interview, the facility failed to adhere to infection control practices for minimizing airflow from a COVID-19 positive room to common areas with residents that are not COVID-19 positive recommended by the Centers for Disease Control and Prevention (CDC) for 1 of 3 units observed with COVID-19 positive residents on Transmission Based Precautions. Findings include: Observation on 5/17/22 at approximately 9:36 a.m. of A2 unit revealed room [ROOM NUMBER] and room [ROOM NUMBER] with room doors open with plastic coverings over the door way and an isolation room sign outside each door. Further observation revealed room [ROOM NUMBER] to have the window open and a fan on in room [ROOM NUMBER]. Both plastic coverings for the doorways were moving outward into the hallway. Interview on 5/17/22 at approximately 9:36 a.m. with Staff B (Licensed Practical Nurse) confirmed the above findings. Staff B stated that room [ROOM NUMBER] and 220 were on isolation for COVID-19. Observation on 5/17/22 at 12:00 p.m. of A2 unit revealed room [ROOM NUMBER] door open with plastic covering over the door way and an isolation room sign outside. Further observation of room [ROOM NUMBER] revealed an air conditioner unit to be on inside room [ROOM NUMBER] and the plastic door covering to be movingt outward intothe hallway. Interview on 5/17/22 at 12:00 p.m with Staff C (Health Unit Coordinator) confirmed room [ROOM NUMBER] door was open and air conditioner was on. Staff B stated that room [ROOM NUMBER] was on isolation for COVID-19. Review on 5/17/22 of the CDC (Center for Disease Control and Prevention) website titled, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV2 Spread in Nursing Homes, updated February 2,2022, retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html revealed .Manage Residents with Suspected or Confirmed [CONDITION(S)]-CoV-2 Infection .In general, it is recommended that the door to the room remain closed to reduce transmission of [CONDITION(S)]-CoV-2. This is especially important for residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection being cared for outside of the COVID-19 care unit. However, in some circumstances (e.g., memory care units), keeping the door closed may pose resident safety risks and the door might need to remain open. If doors must remain open, work with facility engineers to implement strategies to minimize airflow into the hallway . Review on 5/17/22 of the CDC website titled, Ventilation in Buildings, updated June 2, 2021, retrieved from https://www.cdc.gov/coronavirus/2019-ncov/community/ventilation.html#fans revealed .Avoid placing fans in a way that could potentially cause contaminated air to flow directly from one person to another .As with all fan use during the COVID-19 pandemic, take care to minimize the potential to create air patterns that flow directly across one person onto another: Avoid the use of the high-speed settings, Use ceiling fans at low velocity and potentially in the reverse-flow direction (so that air is pulled up toward the ceiling), Direct the fan discharge towards an unoccupied corner and wall spaces or up above the occupied zone. Fans can also enable clean-to-less-clean directional airflow. Such applications should be evaluated closely to avoid unintended consequences and only adopted when supported by a safety risk assessment .

Based on observation, interview and review of manufacturer's instructions, it was determined that the facility failed to ensure nutritional shakes were properly labeled and dated in 4 out of 6 kitchenettes observed. Findings include: Review on 4/27/21 of the manufacturer's instructions on the nutritional shakes revealed: Store frozen. Thaw under refrigeration (40 degrees or below). After thawing, keep refrigerated. Use within 14 days after thawing. Unit C3 Kitchenette Observation on 4/27/21 at approximately 9:15 a.m. on Unit C3 kitchenette revealed approximately 20 thawed nutritional shakes in a loose bin on the shelf in the refrigerator without any thawed dates on them. Unit C4 Kitchenette Observation on 4/27/21 at approximately 10:30am on Unit C4 kitchenette revealed a drawer full of thawed nutritional shakes in the refrigerator of which 2 of them which had no thawed date on them. Interview on 4/27/21 12:45 p.m. with Staff A (Food Service Director) revelaed that the nutritional shakes arrive frozen to the facility and are placed in a walk in cooler to thaw. The outside of the box in the walk in cooler was dated, but the individual nutritional shakes were not dated. Staff A confirmed that the nutritional shakes were not dated, but should be dated. Unit A1 Kitchenette Observation on 4/27/21 at approximately 1:00 p.m. of Unit A kitchenette revealed a refrigerator bin filled with thawed nutritional shakes with no thawed date on them. Unit B2 Kitchenette Observation on 4/27/21 at 10:10 a.m. of the B-2 unit kitchenette revealed that there were 11 thawed nutritional shakes that did not have a use by or thaw dates on the cartons. Interview on 4/27/21 at 10:10 a.m. with Staff F (Licensed Practical Nurse) confirmed that the nutritional shakes did not have a thawed date and was not sure when they had been thawed or brought to the unit. Staff F stated the shakes come to the unit thawed.

Based on observation, interview, and policy review, it was determined that the facility failed to adhere to infection control practices for Personal Protective Equipment (PPE) recommended by the Centers for Disease Control and Prevention (CDC) on 2 units in the facility. Findings include: Unit B-2 Observation on 4/28/21 at approximately 7:15 a.m. on Unit B-2 in the hallway revealed Staff D (Licensed Nursing Assistant (LNA)) had a surgical mask below his/her nose. Interview on 4/28/21 at approximately 7:15 a.m. with Staff D confirmed that surgical mask was below his/her nose, I just got here. Interview on 4/29/21 at approximately 2:00 p.m. with Staff B reviewed the above findings. Review on 4/29/21 of the facility policy titled, Droplet Precautions, revision date 4/21 revealed: .Policy .d. For residents with Corona Virus, [CONDITION(S)], Avian influenza, or pandemic influenza, refer to the CDC and DPH (Department of Public Health) for current guidelines Review of CDC guidance titled: Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated Feb. 23, 2021 and retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-after-vaccination.html read, in part: .Implement Universal Use of Personal Protective Equipment .The fit of the medical device used to cover the wearer's mouth and nose is a critical factor in the level of source control (preventing exposure of others) and level of the wearer's exposure to infectious particles. .-Eye protection should be worn during patient care encounters to ensure the eyes are also protected from exposure to respiratory secretions. Review on 5/7/21 of the CDC's guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronaviurs Disease 2019 (COVID-19) Pandemic, updated 2/23/21, and retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#print, read, in part, .2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection Eye Protection - Put on eye protection (i.e., goggles or a face shield that covers the front and sides of the face) upon entry to the patient room or care area . Review of Resident #229's care plan dated 4/20/21 read, in part, . has had a potential exposure to Covid 19, [sic] has not acquired Optimal immunity s/p [status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions . Nsg [nursing] to maintain droplet precautions . Observation on 4/27/21 at 1:39 p.m. of Resident #229 (with a face mask on) wheeled him/herself out of his/her room. Staff H (Registered Nurse) was observed talking and assisting Resident #229 back to his/her room. Staff H was not wearing eye protection (goggles or face shield). Interview on 4/27/21 at 1:39 p.m. with Staff H confirmed that he/she did not have on eye protection when assisting Resident #229. Staff H stated that Resident #229 was on precautions due to being exposed to someone who had tested positive to COVID-19. Staff H stated that he/she should be wearing eye protection when in contact with Resident #229, and that the facility's policy was to wear eye protection when in close contact with residents. Interview on 4/29/21 at 12:45 p.m. with Staff B (Director of Nursing) confirmed that staff should be wearing eye protection to protect the staff from potential exposure to COVID-19 when with 6 feet of Resident #229. Review of the facility's continuing education for COVID-19 titled Transmission Prevention dated 12/7/20 read, in part, . Protocol for use of face shield remains the same. Face shield are to be utilized with all resident contact and interaction. Staff H signed that he/she attended this education on 12/7/20.

Based on interview and medical record review, it was determined that the facility failed to have a written agreement for hospice care with 1 of 3 hospice organizations contracts reviewed. (Hospice Agency #1.) Finding include: Review on 4/28/21 of Resident #234's medical record revealed that Resident #234 was admitted to hospice agency #1 (name omitted) on 4/20/20. Review on 4/29/21 of Resident #209's medical record revealed that Resident #209 was admitted to hospice agency #1 on 4/7/21. Review on 4/28/21 of the contract between the facility and hospice agency #1 revealed that the agreement was made on 10/18/2016 and signed by hospice agency #1 on 10/19/2016 and the facility on 10/18/2016. Continued review of this contract read, in part, . The terms of this Agreement shall be for a period of three (3) years commencing December 1, 2016. It is expressly agreed and understood that this Agreement may be terminated by either party for any reason at any time by giving thirty (30) day prior written notice to the other party Further review of the contact did not reveal any written statement that the contract went beyond the three years. Interview on 4/28/21 at 02:30 p.m. with Staff G (Administrator) confirmed the contract with hospice agency #1 was written for a 3 year term and that it was beyond the 3 years since it was signed. Interview on 4/28/21 at 4:00 p.m. with Staff G revealed the facility did not have an updated contract with the hospice agency. Review on 4/29/21 of the facility's policy and procedure titled Hospice Program revised on 1/2019 read, in part, .Procedure: 1. Facility has a contractual agreement for Hospice Services to provide services to residents who are eligible to receive hospice services and wish to receive hospice services

Based on observation, interview and policy review it is determine that the facility failed to maintain infection control practices in regards to wound dressing change, Personal Protective Equipment (PPE) and handwashing for 1 out of 4 residents observed during wound dressing changes. (Resident identifier is #209) Findings include: Policy: Review on 9/11/18 of the facility's policy on Personal Protective Equipment (PPE) revision date was on 8/14 revealed that .Gloves: .2. Handwashing to be done before and after wearing gloves .4. Gloves are worn when it is reasonably anticipated that employees will have direct contact with patients, blood, bodily fluids . Review on 9/11/18 of the facility's policy on Skin and Wound Care Management revision date was on 3/17 revealed that .Basic Treatment Guidelines: .4. Apply gloves. Change gloves as needed if gloves become soiled during the dressing change . (Page 5). Review on 9/11/18 of the facility's policy on Handwashing revision date was on 5/11, revealed that .Healthcare Personnel Handwashing and Hand Antisepsis: Hands must be washed under the following conditions: .g. After removing gloves .The following is a list of some situations that require hand hygiene: .i. Before and after changing a dressing .r. After removing gloves or aprons . Observation on 9/11/18 at 11:00 a.m. of Resident #209's wound dressing change revealed that Staff A (Registered Nurse) obtained gloves from the medication cart and placed the gloves in their pocket with medication cart keys and proceeded to obtain Santyl ointment and an unopened package of cotton swabs from the medication cart. Observation on 9/11/18 at 11:03 a.m. of Resident #209's wound dressing change revealed that Staff A obtained a half opened package of [MEDICATION NAME] dressing and cleansing spray from Resident #209's shelf and placed the supplies on Resident #209's bedside table. Staff A donned gloves from their pocket, removed Resident #209's pants and adult brief, then proceeded to remove Resident #209's wound dressing. Staff A removed their gloves and washed their hands with soap and water then dried their hands with paper towel. Staff A obtained gauze pads from Resident #209's shelf and proceeded to cleansed the wound with cleansing spray and patted the wound dry with gauze pads. Staff A removed their gloves then obtained scissors from their pocket and proceeded to cut one-third of [MEDICATION NAME] dressing from the opened package. Staff A applied Santyl to wound with cotton swabs from the unopened package then covered the wound with the one-third [MEDICATION NAME] dressing and transparent film dressing with their bare hands. Staff A's bare hands were touching the resident's surrounding skin and the adhesive side of the transparent film dressing. Interview on 9/11/18 at 11:10 a.m. with Staff A revealed that Staff A removes their gloves when applying transparent film dressing because the gloves stick to the transparent film dressing and is difficult to apply on skin. Staff A confirmed that this is their standard practice for wound dressing changes.

Based on observation, record review and interview, it was determined that the facility failed to ensure that the medication error rate was not greater than 5% during 32 medication pass observations. (Resident identifier is #217.) Findings include: Resident #217 Observation on 9/6/18 at approximately 11:06 a.m. during medication pass revealed that Resident #217 received the following scheduled 9:00 A.M. medications; Aspirin 81 mg (milligrams) (1 tablet) by mouth one time a day, [MEDICATION NAME] 40 mg (1 tablet) by mouth one time a day, ROPINIRole HCI 1 mg (1 tablet) by mouth one time a day, [MEDICATION NAME] HCI 100 mg (1 tablet) by mouth one time a day, [MEDICATION NAME] HCI 25 mg (1 tablet) by mouth one time a day, [MEDICATION NAME] 50 mg by mouth (two times a day), and Micro-K Extended Release 10 MEQ (milliequivalents) 2 capsule by mouth two times a day. Review on 9/6/18 of Resident #217's (MONTH) (YEAR) Medication Administration Record [REDACTED] Interview on 9/6/18 at approximately 11:10 a.m. with Staff D(Licensed Practical Nurse) confirmed that Staff D had administered Aspirin 81 mg (milligrams) (1 tablet) by mouth one time a day, [MEDICATION NAME] 40 mg (1 tablet) by mouth one time a day, ROPINIRole HCI 1 mg (1 tablet) by mouth one time a day, [MEDICATION NAME] HCI 100 mg (1 tablet) by mouth one time a day, [MEDICATION NAME] HCI 25 mg (1 tablet) by mouth one time a day, [MEDICATION NAME] 50 mg by mouth (two times a day), and Micro-K Extended Release10 MEQ (milliequivalents) 2 capsule by mouth two times a day 2 hours after the scheduled prescribed time. In total there were 7 medication errors, 1 for Resident #217, out of a total of 32 medication pass opportunities resulting in a 21.87% error rate.

Based on record review and interview, it was determined that the facility failed to to maintain medical records for pressure ulcers that are complete for 2 of 4 residents with pressure ulcers in a final sample of 36 residents. (Resident identifiers are #230 and #288.) Findings include: Resident #230 Review on 9/7/18 at 12:21 p.m. of Resident #230's progress notes dated 8/30/18 revealed Resident #230 had a non-healing stage 4 pressure ulcer on their coccyx. Review on 9/11/18 at 8:37 a.m. of Resident #230's skin notes from (MONTH) and (MONTH) (YEAR) revealed that the most recent pressure ulcer measurement was dated 8/21/18. Interview on 9/11/18 at 8:46 a.m. with Staff B (A2 Unit Manager) revealed that the wound team had discontinued wound measurements on Resident #230's coccyx wound on 8/21/18. Interview on 9/11/18 at approximately 2:00 p.m. with Staff C (Wound Nurse) confirmed that Resident #230's coccyx wound was no longer being measured. Resident #288 Review on 9/7/18 at 09:02 a.m. of Resident #288's skin note dated 8/23/18 revealed Resident #288 had an unstageable left heel pressure wound with no measurements. Further review of skin notes revealed that Resident #288's most recent assessment wound measurement was documented in the skin note dated 8/14/18. Review of Resident #288's progress note dated 8/23/18 revealed that Resident #288 was to be discharged from wound rounds by the wound team and would be assessed by facility unit staff. Interview 9/11/18 at approximately 2:00 p.m. with Staff C confirmed that Resident #288's left heel wound is no longer being measured.