Every finding on record at Ivy Hall Nursing Home

Based on facility policy review, medical record review, and interview the facility failed to prevent a fall for 1 resident (Resident #20) of 3 residents reviewed for falls. The findings include: Review of the facility policy titled, .Fall Prevention Program . dated 10/1/2021, revealed .The Fall Prevention Program is designed to ensure a safe environment for all Residents. Each Resident is evaluated by an RN [Registered Nurse]/ LPN [Licensed Practical Nurse] to assess his/her individual level of risk . Resident #20 was admitted to the facility on [DATE] with diagnoses including Chronic [CONDITION(S)], Heart Failure, and History of Falling. Continued medical record review of the resident Plan of Care original date 2/20/2018 revealed .fall risk .I may fall because of muscle weakness, fall history . Record review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #20 required extensive assist of 2 staff for transfer. Review of a facility investigation dated 12/8/2021, revealed .CNA [Certified Nursing Assistant] was attempting to transfer resident .with 1 assist when resident became weak and fall [fell ] .nurse assessment noted no visible injuries and resident had no complaints of pain . Interview with the Assistant Director of Nursing (ADON) on 2/16/2022 at 8:17 AM, in the ADON office, confirmed the CNA transferred resident without assistance resulting in the fall. Interview with CNA #2 on 2/16/2022 at 10:02 AM, by phone, confirmed the CNA had attempted to transfer resident without assistance and the resident fell . Interview with the Director of Nursing (DON) on 2/16/2022 at 11:08 AM, in the conference room, confirmed the facility policy on falls was not followed.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure a splint was in place to prevent worsening of contractures for 1 resident (Resident #42) of 4 residents reviewed for splints. The findings include: Review of the facility policy titled, .Brace/Immobilizers/Splints .date revised 2/1/2022 revealed .Apply brace/immobilizer/splint to appropriate extremity per MD [medical doctor] order/Therapist instructions . Resident #42 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of the Active Orders Report revealed an order dated 8/10/2021, for OT (occupational therapist) splint order resident to wear LT (left) resting hand splint day time hours on day shift. Medical record review of an OT discharge order dated 1/28/2022, revealed discharge recommendations splint/brace .restorative program established/ trained . Observation on 2/14/2022 at 3:05 PM, 2/15/2022 at 7:50 AM, and 9:35 AM, revealed resident resting in bed without the LT splint in place. Continued observation and interview on 2/15/2022 at 9:38 AM, with Certified Nursing Assistant (CNA) #1, in the resident room, revealed the splint on a bookcase and not on the resident. Continued interview with CNA #1 revealed the therapy staff were responsible for ensuring splints were on. Interview on 2/15/2022 at 9:40 AM, with Charge Nurse #1, on the 300 hall revealed therapy staff placed the splint for Resident #42. Interview on 2/15/2022 at 9:45 AM, with the OT, in the therapy room, revealed the OT discharged the resident 3 weeks ago and was being seen by Restorative Nursing currently. Interview with the Restorative Aid on 2/15/2022 at 9:50 AM, outside the therapy room, revealed the Restorative Aid was responsible for ensuring the splint for Resident #42 was in place. Continued interview confirmed the Restorative Aid failed to put the splint in place yesterday (2/14/2022) until 5:30 PM and failed to put the splint in place today (2/15/2022) . Interview with the Director of Nursing (DON) on 2/16/2022 at 11:10 AM, in the conference room, confirmed the facility policy on splints was not followed for Resident #42.

Based on review of Centers For Disease Control (CDC) guidelines, review of BINAX COVID-19 AG card (rapid [MEDICATION NAME] test for detecting active infections of COVID-19/coronavirus [MEDICAL CONDITION] that causes a respiratory illness) guidelines, review of N95 Particulate Respirator (face mask that filters at least 95% of airborne particles) manufacturer's instructions, facility policy review, review of the facility's testing documentation, review of the facility's Nursing Staff Tracking sheets, review of facility's employee screening sheets, review of the facility's census, observation, and interview, the facility failed to ensure staff adhered to proper infection control practices to prevent the spread of COVID-19, potentially affecting all 68 residents in the facility. The findings include: Review of CDC guidelines titled, Preparing for COVID-19 In Nursing Homes, updated 11/20/2020, showed, .As part of routine practice, ask HCP (Health Care Personnel) (including consultant personnel and ancillary staff such as environmental and dietary services) to regularly monitor themselves for fever and symptoms consistent with COVID-19. Remind HCP to stay home when they are ill. If HCP develop fever (T (Temperature) (greater than or equal to) 100.0 F (Fahrenheit)) or symptoms consistent with COVID-19 while at work they should inform their supervisor and leave the workplace .Screen all HCP at the beginning of their shift for fever and symptoms of COVID-19 .If they are ill, have them .leave the workplace .Develop (or review existing) plans to mitigate staffing shortages from illness or absenteeism . Review of the CDC guidelines titled, Strategies to Mitigate Healthcare Personnel Staffing Shortages, updated 12/14/2020, showed, .Contingency Capacity Strategies to Mitigate Staffing Shortages .HCP should still report temperature and absence of symptoms each day before starting work .If HCP develop even mild symptoms consistent with COVID-19, they must cease patient care activities and notify their supervisor or occupational health services prior to leaving work .Crisis Capacity Strategies to Mitigate Staffing Shortages .When staffing shortages are occurring, healthcare facilities .may need to implement crisis capacity strategies to continue to provide patient care. When there are no longer enough staff to provide safe patient care: -Implement regional plans to transfer patients with COVID-19 to designated healthcare facilities, or alternate care sites with adequate staffing -If not already done, implement plans .to allow asymptomatic HCP who have had a high-risk unprotected exposure to [DIAGNOSES REDACTED]-CoV-2 (COVID-19) but are not known to be infected to continue to work. -If HCP are tested and found to be infected with [DIAGNOSES REDACTED]-CoV-2, they should be excluded from work until they meet all Return to Work Criteria (unless they are allowed to work as described below). -If shortages continue despite other mitigation strategies, as a last resort consider implementing criteria to allow HCP with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection who are well enough and willing to work but have not met all Return to Work Criteria to work. If HCP are allowed to work before meeting all criteria .facilities should consider prioritizing their duties in the following order: 1. If not already done, allow HCP with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection to perform job duties where they do not interact with others (e.g., patients or other HCP), such as in telemedicine services. 2. Allow HCP with confirmed [DIAGNOSES REDACTED]-CoV-2 infection to provide direct care only for patients with confirmed [DIAGNOSES REDACTED]-CoV-2 infection, preferably in a cohort setting. 3. Allow HCP with confirmed [DIAGNOSES REDACTED]-CoV-2 infection to provide direct care for patients with suspected [DIAGNOSES REDACTED]-CoV-2 infection. 4. As a last resort, allow HCP with confirmed [DIAGNOSES REDACTED]-CoV-2 infection to provide direct care for patients without suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection. If this is being considered, this should be used only as a bridge to longer term strategies that do involve care of uninfected patients by potentially infectious HCP. If HCP are permitted to return to work before meeting all Return to Work Criteria, they should still adhere to all Return to Work Practices and Work Restrictions recommendations described in that guidance. These include .They should self-monitor for symptoms and seeking re-evaluation from occupational health if respiratory symptoms recur or worsen . Review of the CDC guidelines titled, Criteria for Return to Work for Healthcare Personnel with [DIAGNOSES REDACTED]-CoV-2 Infection (Interim Guidance), updated 8/10/2020, showed, .HCP with mild to moderate illness .At least 10 days have passed since symptoms first appeared and At least 24 hours have passed since last fever without the use of fever-reducing medications and Symptoms (e.g., cough, shortness of breath) have improved .HCP with severe to critical illness .At least 10 days and up to 20 days have passed since symptoms first appeared. At least 24 hours have passed since last fever without the use of fever-reducing medications and Symptoms (e.g., cough, shortness of breath) have improved . Review of the CDC guidelines titled, Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens for COVID-19, updated 12/30/2020, showed .For healthcare providers collecting specimens or working within 6 feet of patients suspected to be infected with [DIAGNOSES REDACTED]-CoV-2, maintain proper infection control and use recommended personal protective equipment (PPE), which includes an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and a gown, when collecting specimens . Review of CDC guidelines titles Respirator On/Respirator Off, dated 6/9/2020, showed .The top strap .goes over and rests at the top back of your head. The bottom strap is positioned around the neck and below the ears . Review of the BinaxNOW (Trademark) (name of point of care test for COVID-19) COVID-19 Ag Card and NAVICA (Trademark) App Set-Up and Training, undated, showed .Wear appropriate personal protection equipment and gloves when running each test and handling patient specimens. Change gloves between handling of specimens suspected of COVID-19. Visit the CDC website for PPE guidance or contact your local Department of Public Health . Review of the manufacturer's guidelines,N95 Particulate Respirator, undated, showed .check before use .check if elastic bands are in good condition and are not damaged .Wearing instructions .Place elastic bands around the neck and head respectively .cautions and limitations .Failure to properly use and maintain this product could result in injury or death .Never substitute, modify, add, or omit parts . Review of the facility policy titled, Hand Hygiene, last reviewed 3/2020, showed .This facility considers hand hygiene to be the single most important factor in the control of infection .Use an alcohol-based hand rub containing at least 62% alcohol: or, alternatively, soap and water for the following .after contact with objects .in the immediate vicinity of the resident . Review of the facility's policy titled, Laundry/Linen, last reviewed 8/2020, showed .Place contaminated laundry in a bag or container at the location where it is used .Place and transport contaminated laundry in bags or containers . Review of the facility's policy titled, COVID-19, last revised 8/18/2020, showed .All staff will enter the facility through a designated main door. The staff member will have a temperature check and answer a questionnaire on the presence of COVID-19 symptoms .Any staff member with a temp of 100.0 or greater or answers yes to any of the questions on the questionnaire will not be permitted to enter the facility and the Executive Director will be notified for further instructions . Review of the facility's testing documentation showed Certified Nurse Assistant (CNA) #5 tested positive for COVID-19 on 12/23/2020. Review of the Daily Nursing Tracking Sheets showed CNA #5 had worked on the COVID unit on 12/23/2020, 12/25/2020, 12/28/2020, 12/29/2020, 12/30/2020, 1/1/2021, 1/2/2021, and 1/3/2021. Review of the employee screening sheets showed no documentation CNA #5 had filled out an employee screening sheet to report any symptoms of COVID-19 for any of the above listed days she had worked in the facility while COVID-19 positive. Review of the facility's testing documentation showed Licensed Practical Nurse (LPN) #3 tested positive for COVID-19 on 12/25/2020. Review of the Daily Nursing Tracking Sheets showed LPN #3 had worked on the COVID unit on 12/28/2020 and 1/3/2021. Review of the employee screening sheets showed LPN #3 had reported on 12/28/2020, symptoms of congestion or runny nose and on 1/3/2021, symptoms of cough. Review of the facility's testing documentation showed Registered Nurse (RN) #3 tested positive for COVID-19 on 12/25/2020. Review of the Daily Nursing Tracking Sheets showed RN #3 had worked on the COVID unit on 12/26/2020, 12/27/2020, 12/29/2020, 12/30/2020, and 1/2/2021, and worked on the B-wing non-COVID unit on 1/4/2021. Review of the facility census showed 16 residents resided on the B-wing (Non-COVID unit) as of 1/4/2021. Review of the employee screening sheets showed RN #3 had reported: 12/26/2020 symptoms of cough, head or body aches and, Diarrhea/Nausea/Vomiting 12/27/2020 symptoms of cough, fever or chills, congestion or runny nose and, head or body aches 12/29/2020 symptoms of cough, congestion or runny nose, and sore throat 12/30/2020 symptoms of cough, congestion or runny nose, head or body aches and, Diarrhea/Nausea/Vomiting 1/2/ symptoms of cough, congestion or runny nose, sore throat, head or body aches, and Diarrhea/Nausea/Vomiting 1/4/2021 symptoms of congestion or runny nose and sore throat Review of the facility's testing documentation showed LPN #4 tested positive for COVID-19 on 12/26/2020. Review of the Daily Nursing Tracking Sheets showed LPN #4 had worked on the COVID unit on 12/27/2020, 12/29/2020, 12/30/2020, 1/1/2021, 1/2/2021, and 1/4/2021. Review of the employee screening sheets showed LPN #4 had reported: 12/27/2020 symptoms of cough, congestion or runny nose, and head or body aches 12/29/2020 symptoms of cough, congestion or runny nose, sore throat, and loss of taste or smell 12/30/2020 symptoms of cough, congestion or runny nose, and loss of taste or smell 1/1/2021 symptoms of cough, congestion or runny nose, and loss of taste or smell 1/2/2021 symptoms of cough, congestion or runny nose, and loss of taste or smell 1/4/2021 symptoms of cough, congestion or runny nose, and loss of taste or smell Review of the facility's testing documentation showed LPN #2 tested positive for COVID-19 on 12/26/2020. Review of the Daily Nursing Tracking Sheets showed LPN #2 had worked on the COVID unit on 12/27/2020, 12/29/2020, 12/30/2020, 1/1/2021, 1/2/2021, and 1/3/2021. Review of the employee screening sheets showed LPN #2 had reported: 12/27/2020 symptoms of congestion or runny nose 12/29/2020 symptoms of cough and congestion or runny nose 12/30/2020 symptoms of congestion or runny nose 1/1/2021 symptoms of congestion or runny nose and loss of taste or smell 1/2/2021 symptoms of congestion or runny nose and loss of taste or smell 1/3/2021 symptoms of congestion or runny nose and loss of taste or smell Review of the facility's testing documentation showed CNA #6 tested positive for COVID-19 on 12/30/2020. Review of the Daily Nursing Tracking Sheets showed CNA #6 had worked on the COVID unit on 1/1/2021, 1/2/2021, and 1/3/2021. Review of the employee screening sheets showed CNA #6 had reported: 1/1/2021 symptoms of cough, congestion or runny nose, Shortness of Breath, head or body aches, and loss of taste or smell 1/2/2021 symptoms of cough, congestion or runny nose, Shortness of Breath, sore throat, head or body aches, and loss of taste or smell 1/3/2021 symptoms of cough, congestion or runny nose, Shortness of Breath, sore throat, head or body aches, and loss of taste or smell Observation on 1/4/2021 at 12:58 PM, showed CNA #1 was wearing an N95 respirator. Both elastic bands were placed below the CNA's ears, around the back of the neck. During an interview on 1/4/2021 at 12:59 PM, CNA #1 confirmed both elastic bands of the N95 respirator she wore were placed below her ears, around the back of her neck. The CNA was aware of the proper position for the elastic bands and correctly moved the top band to the back of her head, above her ears. Observation of employee COVID-19 testing on 1/4/2021 at 1:56 PM, showed LPN #1 wore gloves, N95 respirator, and a face shield, while swabbing the nares of another employee. She then removed her gloves and sanitized her hands. No gown was worn during the procedure. During an interview on 1/4/2021 at 2:00 PM, LPN #1 confirmed she did not wear a gown during the testing of employees for COVID-19 and was not aware of the need to wear a gown during the testing procedure. During an interview on 1/4/2021 at 2:19 PM, the Assistant Administrator stated the B-wing of the facility was a hallway used to place new admissions and residents who had recently been moved from the COVID unit. She also stated residents with isolation precaution (precautions used to prevent the spread of infectious disease) signs on the doors required staff to use gowns, gloves, masks, and face shields when entering the rooms. She was unsure which residents residing on the B-wing were currently under isolation precautions. During an interview on 1/4/2021 at 2:47 PM, RN #1 stated all the residents residing on the B-wing were in isolation precautions and required the use of gown, gloves, face mask, and face shield when entering the rooms. Observation on 1/4/2021 at 2:58 PM, showed Housekeeper #1 wore an N95 respirator with the elastic bands cut and tied behind her ears, creating ear loops for the mask. During an interview on 1/4/2021 at 2:59 PM, Housekeeper #1 confirmed she had cut the elastic bands on the N95 respirator and tied them behind her ears because the bands kept sliding down and she had seen other employees tie the elastic bands behind their ears. She stated she was not aware whether she could do this. Observation on 1/4/2021 at 3:12 PM, showed CNA #2 entered a resident room on the B-wing with an N95 respirator and a face shield on. The CNA did not put gloves or a gown on prior to entering the room. The CNA then exited the room and went to the linen closet where she obtained a blanket. She re-entered the resident room, moved the resident's table from over her chair, placed the blanket on the resident, and moved the table back into place. CNA #2 exited the room and entered another resident room, without performing hand hygiene. CNA #2 did not put on gloves or a gown prior to entering the room. She made the resident's bed, picked up soiled linen from the floor with ungloved hands, and carried the unbagged soiled linen down the hallway to the soiled linen room. Isolation precaution signs were on the doors of both resident rooms the CNA had entered. During an interview on 1/4/2021 at 3:16 PM, CNA #2 confirmed she had not worn gloves or gown into the resident rooms of the B-wing. She confirmed she had exited one resident room and went directly into the next resident room without performing any type of hand hygiene. CNA #2 confirmed both rooms had isolation precaution signs on the doors. She confirmed she had picked up soiled linen from the floor with ungloved hands and had carried the unbagged linen down the hallway to the linen room. CNA #2 stated they did not have bags to place the linen in prior to carrying it to the linen room. Observation on 1/5/2021 at 8:04 AM, showed CNA #1 and Nursing Assistant (NA) #1 entered a resident room on the B-wing. Both employees wore N95 respirators and a face shield. Neither employee put on a gown or gloves prior to entering the room. An isolation precautions sign was on the door of the room. CNA #1 exited the bathroom holding a soiled disposable brief in ungloved hands, re-entered the bathroom, exited the bathroom without the brief, adjusted the bed linens, then exited the room and sanitized her hands. NA #1 was observed with the straps of the N95 respirator cut and tied behind her ears, creating ear loops. During an interview on 1/5/2021 at 8:07 AM, CNA #1 confirmed she had entered a resident room on the B-wing and had not put on a gown or gloves prior to entering the room. She confirmed she had exited the bathroom with a soiled disposable brief in ungloved hands. She stated she was in a hurry and forgot to put gloves on. She confirmed gloves were available on the wall inside the resident's room. She confirmed an isolation precautions sign was on the door to the room indicating the need for gown and gloves prior to entry but stated the PPE carts had been removed from the hallway. She stated she was unsure if the resident was in isolation precautions and had not asked the nurse because the nurses .usually don't know either . During an interview on 1/5/2021 at 8:11 AM, NA #1 confirmed she had cut the elastic bands on the N95 respirator she wore and tied the bands behind her ear to make ear loops on the mask. NA #1 further confirmed she had not received training on the proper application of the N95 respirator and she had altered the N95 respirator because she had seen other employees tie the bands behind their ears. Observation on 1/5/2021 at 8:14 AM, showed Physical Therapy Assistant (PTA) #1 wore an N95 respirator with the elastic bands around his ears, creating ear loops for the mask. During an interview on 1/5/2021 at 8:15 AM, PTA #1 confirmed he had altered the N95 respirator he was wearing to create ear loops on the mask because he had seen other employees who had done the same thing and .figured it was ok . PTA #1 confirmed he had received training on the application of the N95 respirator and was aware of the proper application of the N95 respirator, with one elastic band over the head, above the ears, and the other band behind the neck, under the ears. Observation on 1/5/2021 at 8:29 AM, showed CNA #3 wore an N95 respirator with the elastic bands tied behind her ears, creating ear loops for the mask. Observation on 1/5/2021 at 8:35 AM, showed CNA #4 wore an N95 respirator with the elastic straps tied behind her ears, creating ear loops for the mask. During an interview on 1/5/2021 at 8:36 AM, CNA #4 confirmed she was wearing an N95 respirator and had received training on the proper application. She confirmed she had not worn the N95 respirator properly. She confirmed she had cut the elastic bands and tied them behind her ears, creating ear loops for the mask, because she had seen other employees do that and it was more comfortable because the nose piece of the mask hurt the bridge of her nose. Observation on 1/5/2021 at 8:37 AM, showed RN #2 wore an N95 respirator with the elastic straps tied behind her ears, creating ear loops for the mask. During an interview on 1/5/2021 at 9:01 AM, RN #2 confirmed she wore an N95 respirator with the elastic straps tied behind her ears. She confirmed she had received training on the proper application but had altered the N95 respirator to create ear loops for comfort because the nose piece had been hurting her nose. RN #2 stated she thought she was allowed to alter the N95 respirator to create the ear loops. During an interview and review of employee screening sheets on 1/5/2021 at 9:56 AM, the Assistant Administrator confirmed the facility had allowed COVID-19 positive employees who were having symptoms to work on the COVID unit. She further confirmed she had not been aware the COVID-19 positive employees had worked while having symptoms of COVID-19. During an interview on 1/5/2021 at 11:30 AM, the Infection Preventionist (IP) confirmed she was aware of the guidelines for a facility to allow employees who had tested positive for COVID-19 to work if they were not having any symptoms of COVID-19. The IP confirmed she had contacted the local health department for approval to work COVID-19 positive employees. She stated the local Health department informed the facility that symptoms of runny nose and loss of taste and smell could linger and it was okay to allow COVID-19 positive employees with those symptoms to work. The IP confirmed she had not been aware employees who had tested positive for COVID-19 had been working while having symptoms of COVID-19. The IP stated the employees had been instructed to notify her of any symptoms and she would not have allowed them to work if she had known they were having symptoms. She confirmed it was her expectation that employees who had tested positive for COVID-19 and were having symptoms to have notified her prior to working their shift. The IP confirmed the B-wing had been the hall where new admission residents were placed, but currently there were no new admission residents on that hall. She further confirmed only 1 resident on that hall was in isolation precautions and isolation signs should not be on the doors of the other rooms. The IP confirmed it was her expectation for staff to perform hand hygiene after contact with objects in a resident's room and before entering another resident's room. The IP confirmed it was her expectation for soiled linens to not be placed on the floor; for staff to wear gloves when handling soiled linen; for soiled linen to be placed in a plastic bag prior to transport in the hallway to the linen room; and for staff to wear gloves when handling soiled disposable briefs. The IP confirmed she normally performs the employee COVID-19 testing but had been absent on 1/4/2021 when LPN #1 was performing the employee COVID-19 testing. The IP further confirmed she (the IP) does not always wear a gown when performing the employee COVID-19 testing because she was not aware of the need to wear a gown during specimen collection using the BINAX cards. The IP confirmed she had provided education to the staff for the proper application of the N95 respirators and it was her expectation for staff to wear them correctly. During an interview on 1/5/2021 at 2:18 PM, the Regional Staff Development Coordinator at the local health department confirmed the IP had contacted her on 12/15/2020 to report the need to work COVID-19 positive employees. She had instructed the IP to contact the health department's Medical Director for guidance. The Medical Director did approve for the facility to work COVID positive employees who were not having symptoms. She stated neither she nor the Medical Director had given the facility permission to work COVID positive employees who were having symptoms. She stated the symptoms of runny nose and loss of taste and smell will often linger past 10 days but did not tell the facility it was okay to work COVID-19 positive employees with those symptoms prior to 10 days from a positive test result. During a phone interview on 1/5/2021 at 2:40 PM, LPN #2 confirmed she had tested positive for COVID-19 on 12/26/2020 and had agreed to continue to work on the COVID unit while she was positive. She stated the facility told her she could work if she felt like it. LPN #2 stated she had reported her symptoms (runny nose, cough, and loss of taste and smell) on the employee screening sheets she filled out at the beginning of her shifts, but had not been told to report the symptoms to the facility prior to working her shift. She stated she had not been told she could no longer work if she began having any symptoms. During an interview on 1/5/2021 at 2:46 PM, the Assistant Administrator confirmed she would normally audit the employee screening sheets daily to ensure all employees had been screened for symptoms of COVID-19 prior to their shift, and to ensure no employees were reporting symptoms. The Assistant Administrator confirmed CNA #5 had not been screened for symptoms of COVID-19 since she had tested positive for COVID-19 on 12/25/2020. During a phone interview on 1/5/2021 at 2:50 PM, LPN #3 confirmed he had tested positive for COVID-19 on 12/25/2020 and had agreed to continue working on the COVID unit while positive. He confirmed he had congestion on 12/28/2020, as reported on his employee screening sheet, and had a cough on 1/3/2021, prior to coming in to work. LPN #3 confirmed he had not been told by the facility that he would not be able to work if he was having symptoms. He confirmed prior to testing positive for COVID-19, if he had circled yes to any of the symptoms on the employee screening sheet, he would have notified the IP of the symptoms prior to starting his shift, but was not aware to do so after testing positive. During a phone interview on 1/5/2021 at 3:01 PM, LPN #4 confirmed she had tested positive for COVID-19 on 12/26/2020 and had agreed to continue to work on the COVID unit while she was positive. LPN #4 confirmed she had to call in to work for one of her shifts because she was achy and could not walk. She confirmed the facility had told her she could not work if she had a fever but had not told her she could not work if she developed other symptoms. LPN #4 confirmed she had reported symptoms on the employee screening sheets but had not called to report the symptoms to the IP prior to working her shifts. During a phone interview on 1/6/2021 at 7:22 AM, CNA #5 confirmed she had tested positive for COVID-19 on 12/23/2020 and had agreed to continue to work on the COVID unit while positive. She confirmed the facility told her she could work if she .felt like it . CNA #5 confirmed she had worked often with symptoms such as body aches, coughing, shortness of breath, and fever. CNA #5 confirmed she had reported her symptoms to the Assistant Director of Nursing (ADON) and had told the IP she was feeling .pretty bad . CNA #5 confirmed she had asked to leave her shift early on one occasion, but had not been able to leave early because there had been no other staff members to work in her place. CNA #5 further confirmed she had not filled out the employee screening sheets since she tested positive for COVID-19 because the Director of Nursing (DON) had told her she no longer needed to. During an interview on 1/7/2021 at 9:36 AM, RN #3 confirmed she had tested positive for COVID-19 on 12/23/2020. She had begun to feel bad at work that night (worked 10:00 PM - 6:00 AM) and had been tested at work. She stated she had agreed to continue to work on the COVID unit if she .didn't feel like crap . She called in to work on 12/31/2020 because she felt too bad to work. Her next scheduled shift was on 1/2/2021 and she stated she had told the ADON she was still feeling crappy but would work if they needed her, and she did work that night. On 1/4/2021 she was scheduled to work on the B-wing (a non-COVID hall) and she was concerned because of her COVID positive status but did work that shift. She stated she screened herself upon arrival to work on 1/4/2021 and did report having a runny nose and sore throat on the employee screening sheet but was feeling better than she had been feeling. RN #3 confirmed no one from the facility had contacted her on 1/4/2021 to see if she still had symptoms prior to her working on the B-wing.

Based on facility policy review, observations and staff interviews, the facility failed to ensure the proper concentration of sanitizer in the containers used for disinfecting the counter tops in the food preparation area. The findings included: Review of the facility policy for sanitizer use concentrations for food service and food production provided by the dietary manager (DM) #1 on 5/16/17 at 1:00 p.m., updated 9/2011, revealed, Sanitation buckets must be established with appropriate sanitizing solution, generally for bleach, 50-100 ppm (parts per million) or quaternary solution, 150-400 ppm or 200 ppm depending on the product used and manufacturer guidelines. Observation of the main kitchen on 5/16/17 at 10:23 AM, revealed sanitizer container was located underneath one of the food preparation tables. Dietary Aide #2 tested the sanitizer liquid. There was no sanitizer concentration reading noted, and the sanitizer liquid was not changed. Continued observation revealed a second sanitizer container was located underneath the juice station. Continued observation revealed when this bucket was tested during the observation there was no sanitizer concentration reading, and the staff did not change the sanitizer liquid. An interview was conducted with the Dietary Aide #2 on 5/16/17 at 10:23 AM. When asked how often the sanitizer container liquid was changed, she said it was changed out every two hours, and confirmed there was no sanitizer reading for both of the sanitizer containers observed. The Registered Dietitian (RD) #3 was interviewed on 5/16/17 at 10:28 AM. When asked what the next step should be after the lack of concentration level was identified in the sanitation containers, she said they should have changed the sanitizer liquid, and check the sanitizer concentration. She then asked the staff to change the liquid with fresh sanitizer. She confirmed there was no monitoring of the sanitizing containers. Interview with the DM #1 on 5/16/17 at 12:46 PM, revealed, the sanitizer liquid was filled that morning at 4:00 AM. Continued interview confirmed the concentration had read 200 ppm and indicated the sanitizer containers were used for the countertops and equipment and was to be changed out after each meal. Continued interview confirmed the sanitizer liquid needed to read 200 ppm. She verified the concentration of the liquid was not monitored and indicated they probably needed a form to monitor the concentration.

Based on medical record review, observation, and interview the facility failed to accurately assess dental status for 1 Resident (#51) of 2 residents reviewed for dental status of 23 residents reviewed. The findings included: Medical record review revealed Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) Admission assessment dated [DATE] revealed Resident #51's oral/dental status was assessed as .No natural teeth or tooth fragment(s) (edentulous) .none of the above were present . (box checked) . Observation of Resident #51 on 5/24/16 at 9:21 AM, in the resident's room revealed the resident was edentulous. Interview with the resident on 5/24/16 at 9:21 AM, in the resident's room revealed the resident had no natural teeth. Interview with MDS Coordinator on 05/24/16 at 3:00 PM, in the MDS office confirmed Resident #51 was edentulous and the MDS Admission Assessment for oral/dental status for Resident #51 was inaccurate.

Based on medical record review and interview, the facility failed to obtain a laboratory test as ordered by the physician for 1 resident (#72) of 34 residents reviewed. The findings included: Medical record review revealed Resident #72 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Medical record review revealed no documentation the BMP had been completed on 2/18/15. Interview with the Director of Nursing on 6/16/15 at 2:20 PM, in the conference room confirmed the BMP had not been obtained as ordered by the physician.

Based on review of facility policy, observation, and interview, the facility failed to utilize proper hand washing in between resident care for 3 residents on 1 hallway of 5 hallways observed and to prevent the spread of cross contamination with unlabeled hair combs and brushes for 2 of 7 shower rooms observed. The findings included: Review of facility policy, Hand Washing, revised 9/08 revealed .all employees shall utilize proper hand washing.before .serving food.after contact with a resident. Review of facility policy, Infection Control, revised 7/14 revealed .proper hand washing.before and after providing Resident care, prior to eating. Observation of Certified Nursing Assistant (CNA) #1 on 6/15/15 from 7:45 AM to 7:55 AM, on the C Wing Hallway, during breakfast service revealed tne following: CNA #1 entered a resident's room with a breakfast tray, cut up the food, touched the scrub top, touched the top of the hair, exited the room without washing the hands, entered another resident's room, picked up a walker and placed it in front of the resident, exited the room without washing the hands, retrieved another tray, poured coffee, placed a lid on the coffee cup, entered a third resident's room, retrieved the resident's eyeglasses from a drawer, placed the socks on the resident, and then cut the food on the breakfast tray without washing the hands. Interview with CNA #1 on 6/15/15 at 7:55 AM, on the C Wing Hallway confirmed the CNA had not completed hand washing in between contact with 3 residents and serving breakfast trays. Interview with the Director of Nursing on 6/15/15 at 8:00 AM, on the C Wing Hallway confirmed the facility staff failed to utilize proper hand washing in between resident care. Observation with CNA #3 on 6/15/15 at 10:35 AM, of the C Wing Female Shower Room revealed a basin containing 2 unlabeled hairbrushes with gray strands of hair. Observation with CNA #7 on 6/15/15 at 10:50 AM, in the B Wing Shower Room revealed a basin containing 3 unlabeled combs and 1 unlabeled hairbrush, all with gray strands of hair. Interview with the DON on 6/16/15 at 8:05 AM, at the B Wing nursing station confirmed the facility failed to follow infection control guidelines for cross contamination.

Based on review of facility policy, medical record review, observation, and interview, the facility failed to provide a privacy cover for a urinary drainage bag for 1 resident of 5 residents reviewed. The findings included: Review of facility policy, Catheter Care, revised 7/14 revealed .the drainage bag is to stored in a privacy cover. Medical record review revealed Resident #6 was admitted on [DATE] with [DIAGNOSES REDACTED]. Observation on 6/15/15 at 7:30 AM, on the C Wing Hallway outside the resident's room and visible from the hallway, revealed a urinary catheter collection bag with yellow colored urine attached to the bedframe without a privacy cover. Interview with the Director of Nursing on 6/15/15 at 7:45 AM, on the C Wing Hallway outside the resident's room, confirmed the facility failed to provide a privacy cover for the urinary catheter bag.

Based on medical record review, review of facility policy, and interview, the facility had failed to complete behavioral management documents, pain flow sheets, and medication administration records for three of seven residents (#98, #46, #82) of thirty-six residents reviewed. The findings included: Resident (#98) was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set, dated dated dated [DATE], revealed the resident was moderately cognitively impaired, and required assistance with activities of daily living. Medical record review of the Behavioral Monthly Flow Records for January 2014, and February 2014 , revealed "...pacing...pulling hair...monthly total...(blank)...nurses progress notes (blank)...nurse signature...(blank)..." Review of the facility policy Psychopharmacological Medications effective January 2000, reviewed September 2008 revealed, "...nursing will initiate the Behavior Monitoring Form...complete the appropriate sections every shift...total all columns at the end of each month..." Resident #46 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of Medication Administration Records (MARS) for the months of February and March 2014, revealed nurse initials for each date a medication was administered. Continued review of the MARS revealed no nurse signature on the back of the MARS which identified the nurse who administered the medications. Medical record review of Psychoative Medication Monthly Flow records for the months of February and March 2014, revealed no nurse signatures on the records. Resident #82 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of Medication Administration Records (MARS) for the months of February and March 2014, revealed nurse initials for each date a medication was administered. Continued review of the MARS revealed no nurse signature on the back of the MARS which identified which nurse administered the medications. Medical record review of Pain Flow Sheets for the months of February and March 2014 revealed pain level documentation by nurses which were documented with a nurse's initials. Continued review of the Pain Flow Sheets revealed no documentation of which scale the nurses had utilized to document the resident's pain level. Further review of the Pain Flow Sheets revealed no nurse signatures on the flow sheets. Interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on March 13, 2014, at 4:49 p.m., in the ADON's office confirmed the forms were to have included the nurse signatures, and monthly totals. Continued interview confirmed the facility had failed to complete the forms.

Based on observation, review of facility policy and interview, the facility had failed to maintain infection control protocol by not wearing gloves during medication administration for one resident, (#54), of six residents observed. The findings included: Observation on March 10, 2014, at 3:43 p.m., during medication pass on the A -200 hall revealed, Licensed Practical Nurse (LPN #1) accessed resident #54's gastrostomy tube (a surgically implanted tube in the abdomen for the administration of nutrition and medications into the stomach) administered medications through the tube, flushed the tube with water, and closed the tube access port, without wearing gloves. Review of the facility policy Medication Administration: Feeding Tube, effective February 1998, reviewed June 2013, revealed, "...Procedure...wash hands...put on gloves..." Interview with LPN #1, on March 10, 2014, at 3:50 p.m., outside the resident's room, confirmed LPN #1 had not worn gloves, gloves were to have been worn during the procedure, and the facility failed to maintain infection control protocol during the medication pass.

Based on observation, medical record review, and interview, the facility had failed to complete a Significant Change Minimum Data Set (MDS) in a timely fashion for one resident (#82), of thirty sampled residents. The findings included: Resident #82 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation of the resident on March 12, 2014, at 7:56 a.m., in the Main Dining Room, revealed the resident sitting in a wheelchair and being fed by staff. Observation of the resident on March 12, 2014, at 3:30 p.m., in the resident's room, revealed the resident laying in a low bed, with oxygen running by nasal canula. Continued observation and attempted interview of the resident, revealed the resident was oriented to person only, and was very confused. Observation of the resident on March 13, 2014, at 8:30 a.m., in the resident's room, revealed the resident laying in a low bed, talking and mumbling to self. Medical record review of a Discharge Assessment MDS dated [DATE], revealed the resident scored a 12 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact, required extensive assistance with all Activities of Daily Living (ADLs), required supervision with eating, and was always continent of bladder. Medical record review of a psychiatric consult note dated February 4, 2014, revealed the resident was seen by the consultant psychiatrist "...nearly unresponsive today, a stark contrast to our session two weeks ago when (resident) indicated that...was looking forward to the homework I left (resident) (breathing excercises) ...per nurse note pt picking at (resident's) blanket stating (resident) is plucking chickens...also stated there was a cat under (resident's) bed..." Medical record review of a physician progress notes [REDACTED]., and spitting out the medications. Continued review revealed the resident was documented as "...poor prognosis..." Interview with the resident's physician on March 12, 2014, at 10:30 a.m., in the Assistant Director of Nursing's office, revealed the resident has had a severe decline in functional and cognitive status. Continued interview confirmed the resident's family had been contacted to consider hospice for the resident. Interview with the MDS Coordinator on March 13, 2014, at 9:10 a.m., in the MDS Coordinator's office, revealed the MDS Coordinator had not completed a significant change MDS. Continued interview revealed the MDS Coordinator had not completed the significant change MDS due to the MDS Coordinator did not believe the resident's functional status had changed in three areas or more. Interview with the MDS Coordinator on March 13, 2014, at 9:55 a.m., at the C-Wing Nurse Station, revealed the MDS Coordinator was not aware a significant change MDS was required for a resident with a decline in functional status in only one area of ADLs. Continued interview with the MDS Coordinator confirmed a significant change MDS should have been completed for the resident.

Based on review of the facilty's Abuse Protocol policy, and interview, the facility had failed to follow their policy by not reporting an allegation of abuse in accordance with State law, within five (5) working days of the incident for one resident (#15), of thirty residents reviewed. The findings included: Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Interview with Resident #15 on March 11, 2014, at 11:06 a.m., in the resident's room, revealed the resident, "...saw a resident's hand slapped...happened shortly after I came...here a year this past November...reported...the person no longer here..." Interview with Resident #15 on March 12, 2014, at 3:15 p.m., in the resident's room, revealed the resident does not remember the staff member the incident was reported to, the time of the day of the incident, or the name of the staff member involved in the incident. Review of the facility's Abuse Protocol, effective March 1993 and last reviewed August 2012, revealed, "...The administrator will notify the following of any/all...reports...The appropriate State Health Department office...in accordance with specific state regulations and time frames..." Interview with the Abuse Coordinator and the Administrator, on March 13, 2014, at 11:22 a.m., in the Administrator's office, confirmed the facility did investigate, but did not report the alleged incident to the State Agency,and failed to follow their Abuse Policy. The Administrator stated, "I take full responsibility for the decision to not report the incident."

Based on the facility's investigation reports and interviews, the facility had failed to report an alleged allegation of abuse in accordance with State law within five (5) working days of the incident for one resident, (#15), of thirty residents reviewed. The findings included: Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Interview with Resident #15 on March 11, 2014, at 11:06 a.m., in the resident's room, revealed the resident, "...saw a resident's hand slapped...happened shortly after I came...here a year this past November...reported...the person no longer here..." Interview with Resident #15 on March 12, 2014, at 3:15 p.m., in the resident's room, revealed the resident did not remember the staff member the incident was reported to, the time of the day of the incident, or the name of the staff member involved in the incident. Interview with the Abuse Coordinator, and the Administrator on March 13, 2014, at 11:22 a.m., in the Administrator's office, confirmed the facility did not report the alleged incident to the State Agency. The Administrator stated, "I take full responsibility for the decision to not report the incident."

Based on observation, review of facility policy, and interview, the facility failed to label medications with the resident's name in one of three medication rooms; failed to maintain the proper temperature in one of three medication refrigerators; and failed to separate cleaning wipes from medications on four of six medication carts observed. The findings included: Observation in the B building medication room, on February 11, 2013, at 3:30 p.m., with Licensed Practical Nurse (LPN) #2, revealed one bottle of Magnesium Citrate, 1/2 full, stored on the counter. Further observation revealed the medication label did not contain the resident's name or date. Continued observation of of the medication room on the refrigerator revealed the thermometer was measured to be 29 degrees Fahrenheit. Interview with LPN #2 at the time verified the refrigerator temperature was not within normal range. Continued observation of the B wing medication cart (1 of 1) revealed a plastic dispensing container of bleach wipes was stored with the residents' powdered medications in the same compartment. Review of the facility policy titled Storage of Drugs, revised on March 2009, states, "...refrigerator and a temperature of between 36 Fahrenheit and 46 Fahrenheit shall be maintained..." Interview on February 11, 2013, at 3:45 p.m., in the B building medication room, with LPN #2, confirmed the medication was not labeled with a resident's name, and confirmed the bleach wipes were not separated from the residents' medications and stored in the same compartment. Observation of the C wing medication cart #1 (1 of 3) on February 11, 2013, at 2:00 p.m., with LPN #1, revealed a plastic container of bleach wipes was stored with several bottles of residents' liquid medications in the same compartment. Interview on the C wing, on February 11, 2013, at 2:15 p.m., with LPN #1, confirmed the bleach wipes were not separated from the residents' medications. Observation of the A Wing medication cart #1 (1of 2) on February 12, 2013, at 8:15 a.m., with LPN #3, revealed a bottle of bleach wipes was stored with the residents' medication bottles in the same compartment. Interview on the A Wing , on February 12, 2013, at 8:15 a.m., with LPN #3, confirmed the bleach wipes were not separated from the residents' medications. Observation of the A Wing medication cart #2 (2 of 2) on February 12, 2013, at 8:30 a.m., with LPN #3, revealed a bottle of bleach wipes was stored with the residents' medication bottles in the same compartment. Interview on the 200 hallway, on February 12, 2013, at 8:30 a.m., with LPN #3, confirmed the facility failed to separate the bleach wipes from the residents' medications.

Based on observation, medical record review, and interview, the facility failed to appropriately administer medications in three of fifty-one opportunities, resulting in a 5.88% medication error rate. The findings included: Observation on June 14, 2011, at 8:16 a.m., revealed Licensed Practical Nurse (LPN) #2 administering medications to resident #21. Continued observation revealed resident #21 was completing the breakfast meal. Continued observation revealed LPN #2 administered [MEDICATION NAME] (medication for [MEDICAL CONDITION] reflux disease) 5 mg (milligrams), and [MEDICATION NAME] (medication for [MEDICAL CONDITION] reflux disease) 20 mg to the resident. Medical record review of the June 2011, physician's recapitulation orders revealed "[MEDICATION NAME] cap (capsule) 20 mg one capsule PO (by mouth) before breakfast...Metoclopram tab (tablet) 5 mg one tablet PO before meals and at bedtime..." Interview on June 14, 2011, at 8:20 a.m., with LPN #2, in the hallway, confirmed the [MEDICATION NAME] and the [MEDICATION NAME] were not administered before breakfast as ordered by the physician. Observation on June 15, 2011, at 8:10 a.m., revealed LPN #1 administering medications to resident #22. Continued observation revealed LPN #1 administered [MEDICATION NAME] LA (medication for overactive bladder) 4 mg to resident #22. Medical record review of a physician's orders [REDACTED]. Interview on June 15, 2011, at 8:20 a.m., with LPN #1, in the hallway, confirmed the [MEDICATION NAME] LA was administered in error.

Based on medical record review, observation, and interview, the facility failed to implement the care plan for one (#7) of twenty-two residents reviewed. The findings included: Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Plan of Care reviewed on May 18, 2011, revealed the resident had a history of [REDACTED]. Observation on June 15, 2011, at 8:20 a.m., revealed the resident sitting in a wheelchair, near the nursing station. Continued observation revealed the resident was dressed with a short sleeve top, without the geri-sleeves applied. Observation and interview, on June 15, 2011, at 8:40 a.m., with the Director of Nursing, at the nursing station, revealed the resident sitting in the wheelchair, near the nursing station, and confirmed the geri-sleeves were not applied to the resident's arms.

Based on medical record review, review of the facility policy, observation, and interview, the facility failed to prevent a significant medication error for one (#9) of twenty-two residents reviewed. The findings included: Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the nursing note dated (December 17, 2010) revealed, "...VS (vital signs) P (pulse) 76 R (respirations) 14 B/P (blood pressure) 98/62...This nurse was called by CNA (certified nursing assistant) to smoking room to observe pt (patient) who was exhibiting a change in physical coordination and lethargy...notified (named physician)-sent to ER (emergency room )..." Medical record review of the Emergency Department Initial History assessment dated [DATE], revealed, "...Chief Complaint/Initial Assessment: Given wrong meds...re-evaluation...improved...may return to NH (nursing home) for observation..." Medical record review of the nursing note dated December 17, (2010), revealed, "...meds [MEDICATION NAME] 0.5 mg (milligrams) (anti-anxiety), [MEDICATION NAME] 0.5mg (anti-[MEDICAL CONDITION]), [MEDICATION NAME] 5mg (pain), [MEDICATION NAME] 50mg (Antidepressant), [MEDICATION NAME] 150mg (anti-ulcer), [MEDICATION NAME] 15mg (skeletal muscle relaxer)..." Medical record review of the nursing note dated December 18, 2010, revealed, "...1:30 A (a.m.)...R 20 P 79 B/P 117/68. Resident returned via (ambulance), no acute distress noted..." Review of the facility policy, Medication Administration-Unit Dose Cart System, revealed, "...to correctly administer medications as prescribed ...push cart to resident area. Call resident by name and inform him/her of medication and check identification...Read label three times before administering medication..." Observation on June 13, 2011, at 12:45 p.m., revealed the resident lying on the bed with eyes closed. Interview on June 14, 2011, at 2:45 p.m., in the conference room, with LPN (Licensed Practical Nurse) #3, confirmed the [MEDICATION NAME], [MEDICATION NAME] and [MEDICATION NAME] were administered to the resident in error. Interview on June 16, 2011, at 12:45 p.m., with the Assistant Director of Nursing, in the conference room, confirmed a significant medication error had occurred when the medications had been administered.

Based on medical record review, facility document review, review of facility policy, and interview, the facility failed to ensure vital signs were obtained prior to administration of antihypertensive medication and failed to provide care of a pacemaker for one resident (#18) of twenty-six residents reviewed. The findings included: Medical record review revealed resident #18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Continued medical record review of the Nurse's Notes revealed resident #18 had vital signs recorded on the following days as: September 16, 17, 18, 19, 20, 21, 22, 23, 24, 26, 27, 29, and 30, 2009; October 1, 3, 4, 5, 6, 7, and 8, 2009; and November 17, 2009. Continued medical record review revealed the Vital Sign/Weight History had vital signs recorded as follows: September 2009, week 3 - vital signs (v/s) recorded once; October 2009, week 2 - v/s recorded once; November 2009, week 1 - v/s recorded once; December 2009, - week 2, 3, and 4 - v/s recorded once each week; January 2010 - week 1, 2, and 3 - v/s recorded once each week; February 2010 - week 1, 2, and 3 - v/s recorded once each week; and March 2010 - week 1, 2, 3, and 4 - v/s recorded once each week. Interview in the conference room with the attending Physician on May 12, 2010, at 1:30 p.m., confirmed the physician would have expected vital signs, especially the blood pressure, to be taken before administering the antihypertensive medications for residents on antihypertensive medications. Interview in the conference room with the Director of Nursing on May 12, 2010, at 12:30 p.m., confirmed vital signs, especially blood pressure, are to be taken before the administration of an antihypertensive medication unless the Physician ordered otherwise. Continued interview confirmed the vital signs were not taken before the administration of the antihypertensive medications for this resident. Medical record review revealed resident #18 had a cardiac pacemaker upon admission to the facility on [DATE]. Review of the facility policy "Pacemaker Care..." revealed "...Check function of the pacemaker according to the manufacturer's recommendations..." Medical record review revealed no documentation of the resident's pacemaker being checked since the resident was admitted on [DATE]. Interview with the Director of Nursing in the office of the Director of Nursing on May 12, 2010, at 8:10 a.m., confirmed the resident's pacemaker had not been checked and the DON was unsure what the manufacturer's recommendations were for the frequency of checking the pacemaker. C/O #

Based on medical record review, and interviews, the facility failed to ensure a safety device was in place for one resident (#3) of twenty-six residents reviewed. The findings included: Resident #3 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Medical record review of a Plan of Care, dated February 10, 2010, revealed, the resident had a history of [REDACTED]. Medical record review of facility documentation dated, May 3, 2010, revealed, "...Notified by CNA (Certified Nursing Assistant) to res. (resident) room. Res. up in W/C (wheelchair) @ (at) this time...Skin tear observed 3 in. (inch) long on top (R) forearm..." Continued review of facility documentation revealed, "...Plan: Educate staff to ensure geri-sleeve is worn to (R) arm." Interview with CNA #1 (on duty at the time of the skin tear) and the Director of Nursing, on May 11, 2010, at 10:05 a.m., in the 400 hall nurse's station, confirmed the geri-sleeve was not in place on May 3, 2010, when the resident sustained [REDACTED].

Based on medical record review and interview, the facility failed to ensure physician ordered medications were given to two residents (#15, #18), and failed to ensure medication not ordered was not given for two residents (#16, #18), of twenty-six residents reviewed. The findings included: Resident #15 was readmitted to the facility from the hospital on March 31, 2010, with [DIAGNOSES REDACTED]. Medical record review of the Medication Reconciliation List dated and signed by the Physician on March 31, 2010, revealed "...Klorcon(potassium supplement) 8meq(milli equivilents)..." Medical record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Medical record review of the physician's orders [REDACTED]. D/C Potassium ..." Medical record review of the laboratory report dated April 30, 2010, revealed "potassium 3.9 (normal 3.5 to 5.1)" Interview with the Director of Nursing on May 11, 2010, at 4:15 p.m. at the 400 Nursing Station, confirmed upon readmission to the facility on [DATE], the Klorcon was not transcribed and the resident did not receive the Klorcon from April 1 through April 29, 2010. Upon discovery on April 29, 2010, the Physician was notified and the Physician discontinued the Klorcon. Medical record review revealed resident #18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Continued review of the March 1 - 31, 2010 MAR indicated [REDACTED]. Review of facility documents, dated March 22, 2010, at 10:30 a.m., revealed "...wrong meds (medications) given to pt (patient) [MEDICATION NAME] (antihypertensive) 10 mg, [MEDICATION NAME] (treatment for [REDACTED]. Medical record review revealed the Director of Nursing (DON), the attending Physician, the family, and the pharmacist were notified on March 22, 2010, after the resident received the incorrect medications. Interview in the conference room with the attending Physician on May 12, 2010, at 1:30 p.m., revealed the medications given were reviewed by the physician and determined to have a possible outcome of [MEDICAL CONDITION] for this resident. Continued interview revealed the resident did not experience any untoward side-effects from the medication. Interview by phone with the pharmacist on May 12, 2010, at 9:05 a.m., confirmed the pharmacist reviewed the resident medications and the incorrect medications the resident was given. Continued interview revealed there was no expected outcome other than possible [MEDICAL CONDITION] from the one time dose of the incorrect medications given to the resident. Interview with the DON in the office of the DON on May 12, 2010, at 9:20 a.m., confirmed the resident did not receive their scheduled 8:00 a.m. medications on March 22, 2010 but received medications ordered for another resident. Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the admission physician's orders [REDACTED]. Continued review of the admission physician's orders [REDACTED]. Continued review of the admitting physician's orders [REDACTED]. Medical record review of a physician's orders [REDACTED]. Medical record review of the February 2010, Diabetic Control Record revealed the following: the resident was not to receive insulin related to the blood sugar checks; on February 3, 2010, at 11:00 a.m., the resident's blood sugar was 183 and 4 units of regular insulin was administered; on February 7, 2010, at 11:00 a.m., the resident's blood sugar was 244 and 6 units of regular insulin was administered. Medical record review of the February 2010, Diabetic Control Record revealed the following blood sugar levels: 116 on February 3, 2010, at 4:00 p.m.; and 120 on February 7, 2010, at 4:00 p.m. Interview on May 12, 2010, at 9:40 a.m., with Licensed Practical Nurse (LPN) #1 (LPN who administered the regular insulin on February 3, and 7, 2010), in the nursing station, confirmed the resident did not have a physician's orders [REDACTED]. C/O #