Every finding on record at Kershaw Health Karesh Long Term Care

Based on observations, interviews, and facility policy review, the facility failed to date, label, and/or cover food products stored in the kitchen. This failure had the potential to create an environment for food-borne illnesses which could affect 122 of 126 residents who consumed food prepared from the facility's kitchen.Findings include:Review of the facility's policy titled, Dietary Operations, dated 01/01/25, in the section titled Storage of Food and Supplies section five, revealed that: Staple, frozen, and refrigerated foods are stored with the new product to the back of older products. Foods removed from the original packaging will be labeled with the received date, either individually or as a unit. During a tour of the kitchen on 07/27/26 at 9:20 AM, observation of the main walk-in freezer revealed the following: -An open, undated box contained an open, undated bag of 48 pieces of frozen chicken-fried steaks. -An open, undated box contained an open, undated bag of 15 frozen pieces of cordon bleu chicken breasts. -An open, undated box contained two uncovered frozen turkey legs, covered with ice crystals. -An open, undated box contained an undated bag of eight frozen hot dogs. The hot dogs were sticking out of the plastic bag and were covered with ice crystals. -An open, undated box contained an open, undated bag of four loose frozen hamburger patties. The hamburger patties were covered with ice crystals. During an interview on 07/27/26 at 9:45 AM, the Dietary Manager (DM) confirmed the above observations and stated that all products should be in closed packaging and dated by staff. The DM confirmed that all products should be used before the date expired. The DM also stated that there was no schedule for food to be checked for dates or expiration.

Based on observation, interview, and record review, the facility failed to complete a fall risk assessment on admission and quarterly thereafter for Resident (R)1, for 1 of 1 resident reviewed after a fall with major injury. Findings include:Review of R1's Face Sheet revealed that R1 was admitted to the facility on [DATE], with diagnoses that included but was not limited to, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Type 2 Diabetes Mellitus, and hallucinations.Review of R1's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/05/26, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicates no cognitive impairment.Review of the Assessment tab in the Electronic Medical Record (EMR) on 06/11/26 revealed, R1 had a required fall risk evaluation completed on 01/22/26, which revealed R1 was at high risk for falls. The following fall risk evaluation was due on 04/22/26. Further review of the Assessment tab revealed that the scheduled fall risk evaluation for 04/22/26 was not completed.Review of R1's Progress Notes tab in the EMR revealed, R1 experienced a fall with resulting closed fracture of distal end of left femur on 03/26/26.Review of the Fall Log revealed, R1 experienced a fall on 05/04/26 with no injury.During an interview on 06/11/26 at approximately 7:00 PM, the Director of Nursing (DON) revealed, that fall risk evaluations are completed when residents are admitted and after every fall. The DON stated, There is no written policy. The MDS nurses just know to do the assessments.During an interview on 06/11/26 at approximately 7:45PM, the DON revealed, that she misspoke earlier and stated fall risk assessments are completed when residents are admitted and quarterly with the MDS. There has not been a fall risk assessment completed for R1 since 01/22/26. The fall risk evaluation scheduled for 04/22/26 was not completed.During an interview on 06/11/26 at approximately 8:00 PM, the MDS Coordinator stated that assessment was mine. I do not know how I missed that assessment.

Based on review of facility policy, observation, record review, and interview, the facility failed to ensure proper precautions utilizing hand hygiene and personal protective equipment (PPE) while retrieving a lunch tray from Resident (R)4, who was on Transmission Based Precautions for 1 of 1 residents observed. Furthermore, the facility failed to maintain the personal protective equipment carts in a sanitary and reliable condition to avoid damage and contamination for 5 of 6 personal protective equipment carts observed. Findings include:Review of the facility policy titled, Clostridium difficile, reviewed on 02/11/22 revealed, Gown and gloves to be utilized upon entering room. Perform hand hygiene prior to entering room. Wash/sanitize hands after removing gloves and before leaving room.Review of the Enteric Precautions sign posted on R4's room door revealed, Gloves and gown when entering the room regardless of activity. All staff must follow precautions when entering. Use soap and water.Review of R4's admission Minimum Data Set (MDS) revealed that R4 was admitted on [DATE], with diagnoses including but not limited to, cellulitis of left lower limb, diabetes mellitus type 2, atrial fibrillation and Congestive Heart Failure. During an observation on 06/11/26 at 12:05 PM, during a facility tour revealed, R4 on transmission-based precautions specifically enteric precautions as recognized by a sign on the resident's room door. Certified Nursing Assistant (CNA)1 was collecting resident lunch trays. She did not wash her hands or apply a gown and gloves before entering R4's room. CNA1 removed R4's meal tray from the room and placed the meal tray in the food cart with other dirty meal trays. CNA1 did not wash her hands before leaving R4's room or after placing the dirty meal tray on the food cart.During an observation on 06/11/26 at 10:00 AM, during a facility tour revealed, personal protective equipment (PPE) carts with various items in and on the cart, such as a deck of playing cards, a stethoscope, a blood pressure cuff, body wash, lotion, briefs, a neck pillow and a leg brace.During an interview on 06/11/26 at 12:05 PM, CNA1 confirmed that she had not applied gloves or a gown before entering R4's room. She also confirmed that she did not wash her hands with soap and water before entering and prior to exiting R4's room. CNA1 also confirmed that she did not wash her hands after placing R4's meal tray on the food cart with other dirty meal trays. CNA1 stated, I just went in for just a quick second, to get her tray and came out. I get hot. I have hot flashes, so I do not always put that stuff on. Is that a problem? CNA1 was directed to the enteric precautions sign located on R4's door.During an interview on 06/11/26 at approximately 5:55 PM, Registered Nurse (RN)1 who was covering for the Infection Preventionist revealed, I monitor compliance by observing staff while I am doing my daily nursing duties. I do not do audits. When I catch staff doing something wrong, I talk with them and reeducate. The resident with C-Diff on the 500 hall does not like her room door all the way shut. She is claustrophobic. Environmental control makes sure the resident has wash away bags for her laundry and her clothes are washed separately from other resident's laundry. It is not standard practice for the facility to use disposable meal trays. If there is an outbreak, we use disposable meal trays. RN1 revealed that the isolation carts are an ongoing battle and stated, What you saw is what you saw. We tell staff over and over. Nothing helps.During an interview on 06/11/26 at 7:10 PM, the Staff Development Coordinator revealed, I cover handwashing, personal protective equipment donning and doffing, all transmission-based precaution signage and N95 testing and training on the first day of orientation.During an interview on 06/11/26 at 7:00 PM, the Director of Nursing revealed, I expect staff to dress out exactly like the sign says. Nothing but personal protective equipment should be on those carts.

Based on review of facility policy, observation, record review, and interview, the facility failed to maintain dignity for Resident (R)3. Specifically, R3's foley catheter bag was not covered, for 1 of 1 resident reviewed. Findings include:Review of the facility policy titled, Points To Remember In Respecting Dignity issued 08/16 revealed, . 20. Respect a resident's personal privacy, which includes the following: a. Own physical body b. His/her personal space/private space (i.e., room, bathroom) c. His/her personal care d. His/her personal belongings (i.e., room furnishings, photos, letters).Review of the facility policy titled, Protecting A Resident's Dignity reviewed 02/18 revealed, The facility must promote care for residents in a manner and environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Dignity Means that while interacting with residents, staff carries out activities that assist the resident to maintain and enhance his/her self-esteem and self-worth.Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date of 03/25/26 revealed, the facility admitted R3 on 03/19/26, with diagnoses including, but not limited to, diabetes mellitus type 2, stroke, neurogenic bladder and vascular dementia.Review of the Report of Consultation revealed that R3 was seen by the Nephrologist on 06/08/26 for simple cystolitholapaxy, fulguration of multiple inflammatory lesions of bladder, fulguration of lesions along the trigone bladder neck, clot evacuation and simple cystometrogram.During an observation on 06/11/26 at 10:00 AM, revealed R3 was in the [NAME] day room. R3 had a foley catheter that did not have a privacy bag. The foley bag was halfway full of yellow color urine. During a second observation on 06/11/26 at 10:28 AM, R3 was observed in the [NAME] day room. R3 had a foley catheter that did not have a privacy bag. The foley bag was halfway full of yellow color urine. During an interview on 06/11/26 at 5:45 PM, a request was made to review the facility policy on providing a privacy covering for a foley catheter bag. The Director of Nursing ( DON) stated that there was no policy for providing a privacy covering for a foley catheter bag. During an interview with the Unit Manager on 06/11/26 at 6:55 PM, revealed that another nurse changed R3s foley catheter bag from the bag without a privacy cover to a fig leaf bag with a privacy cover about an hour ago.During an interview with the Director of Nursing (DON) at approximately 7:00 PM, the DON stated, We have to watch if the resident sees the nephrologist. The nephrology office does not use the covered foley bags. The resident comes back to the facility from the nephrology appointment; the nurses have to change the foley bag to the fig leaf bag. The fig leaf bags are all we order. When the resident returns back to the facility from a nephrology appointment, the nurses should assess the resident's foley bag timely and replace the bag with the fig leaf bag if needed.During an interview with the Staff Development Coordinator at approximately 7:10 PM revealed, I teach the staff about the fig leaf catheter bags for residents as well as positioning the catheter bag on the side of the bed that is not visible if the resident's room door is open.

Based on observation, interview, and review of facility policy, the facility failed to properly store medications and remove expired medications from 3 of 7 medication carts reviewed for medication storage and labeling.Findings include: Review of the facility policy titled Medication Storage in the Facility dated 09/21/22, revealed, Policy: Medications are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier . Procedure: 9. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction, and reordered from the pharmacy, if a current order exists. During an observation of the 400 Hall medication cart on 09/11/25 at 10:21 AM, revealed Hydroxyzine HCI 12.5 milligram tablets, 4 count with Lot #18030A, were expired on 07/31/2025. The expired medication was confirmed by Licensed Practical Nurse (LPN)1 and removed from storage with other medications in use for residents. During an observation of the medication cart on the 600 Hall on 09/11/25 at 9:54 AM, one bottle of Fluticasone Propionate Suspension nasal inhalation in the original box with the box lid flipped up and no cap on the bottle. During an observation of the medication cart on the 300 Hall on 09/11/25 at approximately 12:00 PM, one bottle of Fluticasone Propionate Suspension nasal inhalation in the original box with the box lid flipped up and no cap on the bottle. During an interview with Registered Nurse (RN)1 on 09/11/25 at 9:54 AM, she confirmed the absence of the cap over the nasal nozzle on the Fluticasone Propionate Suspension nasal inhalation on the 600 Hall medication cart. RN1 stated they clean the nozzle with alcohol before giving it to the resident. When asked if she was concerned about the medication being exposed due to no cap over the opening, she stated, The other nurses are always losing the caps. They are hard to keep track of. RN1 proceeded to put the medicine back in the box and cart. During an interview with Licensed Practical Nurse (LPN)2 on 09/11/25 at approximately 12:00 PM, she confirmed the absence of the cap over the nasal nozzle on the Fluticasone Propionate Suspension nasal inhalation on the 300 Hall medication cart. LPN2 stated, I will throw this away. I will order a new one. During an interview with the Director of Nursing (DON) on 09/11/25 at approximately 1:00 PM, the DON revealed, If a nasal spray does not have a cap, I would expect the nurse to throw away the medication and order a replacement. During an interview with the Pharmacist on 09/11/25 at approximately 1:00 PM, the Pharmacist stated, If a nurse finds a nose spray without a cap, I would want her to try and replace it. The problem is we can't get just a cap to replace the lost cap. Although, if it is in the box it came in, I'm not as concerned about it. During an interview with the Administrator on 09/11/25 at approximately 1:00 PM, the Administrator revealed, The nurse needs to throw away the medication. We will just have to eat the cost of replacing it. Our pharmacist checks the carts monthly, and in fact, he just went through them yesterday.

Based on review of facility policies, resident records, and staff interviews, the facility failed to ensure that Resident (R)1 was protected from a significant medication error. Specifically, R1 received multiple medications not prescribed to her: Metoprolol, Amiodarone, Digoxin, Eliquis, Fenofibrate, Furosemide, Loratadine and Potassium. This medication administration error resulted in R1 requiring hospitalization for further evaluation and monitoring. On 07/21/25 at 4:13 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations could cause serious injury, serious harm, serious impairment, or death.On 07/21/25 at 4:20 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 06/28/25. The IJ was related to 42 CFR 483.25 - Pharmacy Services.On 07/21/25 the facility provided an acceptable IJ Removal Plan. On 07/21/25 the survey team, validated the facility's corrective actions and determined the facility put forth due diligence in addressing the noncompliance. The IJ is considered at Past Non-Compliance as of 06/29/25.An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F760, constituting substandard quality of care.Review of the facility policy titled Oral Medication Administration Procedure dated January 14, 2020, revealed, that the purpose of the policy is To administer oral medication in an organized and safe manner. Log into clinical software system (or use appropriate paper record) and find the appropriate resident and note the first medication to administer. Read label three times prior to removing medication. Identify resident before administering the medication. a. checks the arm band or photograph, call the resident by name, or check with other staff members if necessary. Administer medication and remain with resident while medication is swallowed.Review of R1's Face Sheet revealed R1 was re-admitted to the facility on [DATE] with diagnoses including but not limited to: hypertension, atrial fibrillation, atherosclerotic heart disease of native coronary artery without angina pectoris, and hyperparathyroidism.Review of R1's Orders, revealed that R1 did not have orders for the following: Digoxin 125 (micrograms)mcg, Fenofibrate 160 (milligrams)mg, Amiodarone 200mg, Eliquis 5mg, Vitamin D3 50mcg, Klor-Con (Potassium) 10(milliequivalent)MEQ, Folic Acid 1mg, Loratadine 10mg, Metoprolol 25mg, Pantoprazole 20mg and Vitamin B12 100mcg.Review of R2's Face Sheet revealed R2 was admitted to the facility on [DATE] with diagnoses including but not limited to: hypokalemia, primary hypertension, chronic atrial fibrillation, and vitamin d deficiency.Record review of R2's Order Summary Report revealed resident had an order for: Digoxin 125mcg, Fenofibrate 160mg, Amiodarone 200mg, Eliquis 5mg, Vitamin D3 50mcg, Klor-Con (Potassium) 10MEQ, Folic Acid 1mg, Loratadine 10mg, Metoprolol 25mg, Pantoprazole 20mg and Vitamin B12 100mcg.Review of a progress note dated, 06/28/25 at 2:58 PM documented by the Assistant Director of Nursing (ADON) revealed, MD [Medical Director] notified related to medication. [vital signs]VS: 112/47, 60 [heart rate]HR, 97.5 oral, O2 99% on [room air] RA. Orders to send to [emergency room] ER. RR [resident representative] notified.Review of an Emergency Department (ED) progress note dated 06/28/25 documented by the Doctor of Osteopathy (DO), revealed: HPI [R1] is a [AGE] year-old white female presents the ED today for evaluation after being inadvertently given another patient's medications. Patient received 25 mg metoprolol, 200 mg of amiodarone, 125 mcg of digoxin, 5 mg of Eliquis, fenofibrate, folic acid, 20 mg of furosemide, 20 mg of loratadine, 10 mill equivalents of potassium, vitamin B12 and D3, 20 mg of Protonix as well as some probiotics. Patient unfortunately has advanced dementia and is unable to provide any history. Apparently prior to receiving the medications patient's heart rate was already in the 50s however upon arrival to the ED heart rate in the upper 40s. Pressure acceptable. Here for evaluation given inadvertent administration of another residents medications.Record review of a, Hospitalist Discharge summary dated [DATE] documented by Hospitalist Medical Doctor (HMD), revealed: Brief HPI. Patient is a [AGE] year-old female that is a long-term care resident at a nursing home facility coming into the emergency department due to her getting medications for different patient. It seems that the patient got 25 mg of metoprolol, 200 mg of amiodarone, 125 mcg of digoxin, Eliquis, 20 mg furosemide, vitamins. Patient has advanced dementia and is unable to provide any history. Patient is admitted for observation Hospital Course Patient is a [AGE] year-old female that came into the emergency department due to wrongful medication being administered at the nursing home facility. She received metoprolol, amiodarone, digoxin, Eliquis and Lasix among other medication. Patient was observed in the hospital on telemetry. It seemed that her heart rate was low, seem to be in the 20s, patient received a dose of atropine 1 time. Cardiology was consulted, after reviewing the telemetry strips, cardiology noted that likely a error in read and the actual heart rate was around 40s to 50s at that time. Patient is being discharged back to her nursing home facility. Intensive care specialist recommended a root cause analysis for the incident. We are also recommending holding Nebivolol at the moment due to her bradycardia until she sees her primary.Review of a document titled, ECF/SNF Provider Progress Note dated 06/30/25, revealed, 98 [year old] yo resident sent to the ER because she was given another person(s) medication. She received metoprolol, amiodarone, digoxin, Eliquis and Lasix among other medications. She was placed in the hospital on telemetry. Heart rate was on the low 20's. Patient received atropine. During an interview on 07/21/25 at 1:32 PM, with Licensed Practical Nurse (LPN1) regarding a medication administration error involving R1. LPN1 explained that her usual process for administering medications includes identifying the correct resident, checking the orders in the electronic health record, and verifying the medication pack. The medication pack includes the name of the medication, route, frequency, resident's full name, room number, and any special instructions such as whether the medication should be crushed. After this verification process, she proceeds with administering the medication. On the morning of the incident, a cook who was familiar with residents' diets called out of work. This led to Certified Nursing Assistants (CNAs) frequently approaching the nurse station to ask questions about residents' dietary needs. While LPN1 was preparing medications for R2, a CNA asked about R1's specific diet. As a result of this interruption, LPN1 had R1 in mind while preparing R2's medications and accidentally administered R2's medications to R1. Immediately after administering the medications, as she walked back to the medication cart, LPN1 realized that R1 had received the wrong medications. She immediately notified the (Registered Nurse) RN Supervisor, who advised her to contact the MD. While LPN1 was on the phone with the supervisor, a CNA collected a set of vital signs for R1. LPN1 reported that the vital signs were within R1's normal range, noting that the resident typically trends with a lower heart rate and blood pressure. LPN1 documented the list of medications incorrectly administered to R1 and reported the incident to the Medical Director. The MD gave an order to send R1 to the emergency room for evaluation and monitoring. LPN1 contacted Emergency Medical Services, gathered all relevant paperwork including the resident's current medication list and the list of medications given in error, and provided a report to the receiving Emergency Department. The resident's representative was then notified of R1's hospital transfer.During an interview on 07/21/25 at 2:02 PM, the ADON outlined the facility's expectations and standard procedure for safe medication administration. The process includes reviewing the resident's Medication Administration Record (MAR) and assessing medication safety parameters prior to administration. The nurse then pulls the corresponding medication packet, which includes the medication name, route, frequency, the resident's full name, and room number. Once the MAR is verified against the medication packet, the next step is to confirm the identity of the resident using their identification band, MAR photograph, and by asking for the resident's name and date of birth when the resident is alert and oriented. The nurse is also expected to lock the computer screen, ensure no sharps are exposed on the cart, secure the medication cart, enter the resident's room, administer the medication, and document whether the medication was taken. During the incident in question, LPN1 contacted the ADON regarding a medication error. Since it occurred on a Saturday morning, the ADON was not on-site but responded promptly upon being notified. LPN1 explained that she had been distracted throughout the morning by multiple staff inquiries related to residents' dietary needs, following the absence of the scheduled cook. While preparing medication for R2, LPN1 was interrupted by a staff member asking about R1's dietary restrictions. As a result, with R1 on her mind, LPN1 mistakenly administered R2's medication to R1. According to the ADON, LPN1 immediately recognized the error after administration and promptly notified the ADON, the RN Supervisor, and the MD. The MD gave the order to send R1 to the emergency department for evaluation and monitoring, which was carried out without delay. The ADON confirmed that LPN1 did not follow the facility's required medication administration protocol, specifically by failing to verify the resident's identity prior to administering the medication. This constituted a failure to meet the facility's expectations for a safe medication pass. During an interview on 07/21/25 at 2:42 PM, the MD reported that he received a call early Saturday morning notifying him that LPN1 had administered R2's medication to R1. Based on the information provided to him at the time, the MD understood that the error occurred due to the nurse being distracted during medication pass, related to staffing issues in the dietary department. The MD was informed of the specific medications that were incorrectly administered to R1, as well as her vital signs at the time. He noted that R1 had a low heart rate, but clarified that this was typical for her, as she had a history of chronically low heart rate. However, given the nature of the medications involved-specifically cardiac medications such as digoxin, amiodarone, and metoprolol-the MD determined that R1 should be sent to the hospital for closer observation and continuous cardiac monitoring The MD stated that R1 was later readmitted to the facility, and, to date, he has had no further concerns regarding her condition. He emphasized that his expectation for safe medication administration includes verifying that the medication order matches the resident for whom it is intended for and ensuring that proper identity checks are performed prior to administration. In his opinion, the nurse involved did not meet those expectations during the incident. He further emphasized that nurses are expected to remain focused during medication passes and to minimize or eliminate distractions to ensure resident safety.During an interview with the Director of Nursing (DON) and Nursing Home Administrator (LNHA) on 07/21/25 at 3:36PM the DON stated, to practice safe medication administration, it is important for nurses to follow the 5 Rights, right patient, right med, right route, right dose and right time and to do 3 verification checks. Verification checks are done through resident arm bands, resident picture on the electronic chart, and name DOB. To prevent this from happening in the future, leadership team came in on 06/28/25 and re-educated and did a med pass observation with all nurses in the facility during that day. The pharmacy team was then consulted to help with completing med pass observation as part of their monthly review. LPN 1 was checked off by ADON, Pharmacist, and the Pharmacy Nursing Consultant and completed med pass in accordance with safe medication practices. The facility also verified that all residents have legible names and DOBs on arm bands and verified that each residents had pictures on their medication record. After conclusion of facility investigation, all safety systems were in check and revealed that the error was one that isolated.On 7/21/25 at approximately 5:30PM, the facility provided an acceptable IJ Removal Plan, which included the following:1. Immediate Corrective Action for Residents Affected: Resident #1 was given medications that were not prescribed to her, but to Resident #2. Upon returning to the med cart and recognizing the error, the nurse immediately notified the physician to inform him of the error and obtained new orders, which included sending the resident to the ER for evaluation Vital signs were checked of Resident #1 and were within normal ranges for this resident The Resident Representative was notified of the error and the orders to send to ER for evaluation The ADON arrived onsite and immediately began an investigation, which included providing education to the nurse and medication administration observation A medication error report was completed on 6/28/2025 A root cause analysis was initiated on 6/28/20252. Identification of Other Residents Affected or Likely to be Affected: An audit was completed to identify if there were any significant medication errors and there were none noted the last 6 months3. Actions to Prevent Occurrence/Recurrence: Facility administration reviewed policies and procedures on medication administration All nurses were given signs to hang on medication carts that say do not disturb unless emergency to help minimize distractions during medication pass All nurses are encouraged to place medication carts outside of the room of the resident they are working with to help avoid distractions and errors Immediate education of all licensed nurses was initiated by ADON on medication administration. This education began on 6/28/2025. All nurses will be educated by July 1 or prior to their next working day Any new hires will receive education on medication administration during their orientation and complete competency prior to completing their orientation period. This will be completed by the SOC or her designee The [NAME] Oak Pharmacy staff will continue to complete medication administration observations monthly There will be at least 3 observations of licensed nurses performing medication pass completed weekly X4 and then monthly X3 on random shifts completed by the DON, ADON, SOC, Unit Managers, or designated staff4. How the Corrective Action Will be Monitored to Ensure It Will not Recur: The DON will review all findings from medication pass observations and report them to the QAA Committee. The committee will review the findings and make recommendations for changes to policies and procedures, forms used, additional education needed, and/or the need for disciplinary action, if necessaryDate Facility Asserts Likelihood for Serious Harm No Longer Exists: 6/29/2025

Based on interview, record review, review of Centers for Disease Control and Prevention (CDC) guidance, and review of facility policy, the facility failed to maintain a functional Antibiotic Stewardship Program that ensured criteria was met for the use of antibiotics for 1 of 2 residents reviewed for antibiotics in a sample of 29 residents (Resident (R)119). Findings include: Review of the undated facility policy titled Antibiotic Stewardship Program revealed, . Frequency of meetings . monthly . Medical Director . sets standards for antibiotic prescribing practices for all healthcare providers prescribing antibiotics in the facility . Director of Nursing . Oversees established standards for nursing staff to assess, monitor, and communicates changes in a resident's condition that could impact the need for antibiotics . Infection Preventionist . Oversees facility infection control and Antibiotic Stewardship Programs . Tracks infections control data and reports to . Antibiotic Stewardship Committee . Review of an undated, untitled CDC [Centers for Disease Control and Prevention] document located at http://uprevent.[NAME].com/2855wp/wp-content/uploads/2018/01/nh-hac_mcgreercriteriarevcomp_2012-1.pdf; revealed The Core Elements of Antibiotic Stewardship for Nursing Homes indicated . Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority . Antibiotic stewardship refers to a set of commitments and actions designed to 'optimize the treatment of infections while reducing the adverse events associated with antibiotic use' . CDC also recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use . Nursing homes monitor both antibiotic use practices and outcomes related to antibiotics in order to guide practice changes and track the impact of new interventions. Below are examples of antibiotic use and outcome measures . Process measures: Tracking how and why antibiotics are prescribed . Antibiotic use measures . Tracking how often and how many antibiotics are prescribed . Antibiotic outcome measures . Tracking the adverse outcomes . Review of R119's undated Face Sheet, located under the Face Sheet tab of the electronic medical record (EMR), revealed R119 was admitted to the facility on [DATE] with diagnoses including but not limited to: pneumonia, and acute respiratory failure with hypoxia. Review of R119's Physician Orders revealed an order, dated 07/05/24, for one tablet of Levaquin 500 milligram (mg) daily for ten days for pneumonia. Review of the monthly Antibiotic Stewardship Tracking logs dated July 2023 through April 2024, revealed the logs consisted of name, type of infection, symptom onset, pathogen, if antibiotic used, disposition and status. There was no documentation on the logs which stated the type of antibiotic used, duration of therapy and if the criteria were met for antibiotic usage. Review of the Antibiotic Stewardship Monthly Meeting reports revealed reports for the months of September 2023, November 2023, December 2023, and April 2024. These reports contained residents who were started on antibiotics prior to receiving urinalysis and culture and sensitivity results. Review of the July 2024 Antibiotic Stewardship Monthly Tracking log revealed R77 was listed on the document but did not indicate whether the criteria for antibiotic use was met or not met, which antibiotic was used, and for how long. During an interview on 07/19/24 at 4:00 PM, the Administrator and Director of Nursing (DON) were notified of the above documented findings regarding the antibiotic stewardship tracking, trending, and ordering of antibiotic for R119's pneumonia. The DON stated, We use the McGeer's criteria, and we have areas that can be improved upon. The Infection Preventionist was not available for interview concerning the failure to ensure criteria were met as was indicated on the review the Antibiotic Stewardship logs.

Based on observation, record review, interview and review of facility policy, the facility failed to follow infection control guidelines for Enhanced Barrier Precautions for 2 of 2 residents (Resident (R)237 and R57) and failed to follow infection control guidelines for 1 of 1 resident out of 29 sampled residents (R72) during a dressing change. Findings include: 1. Review of the facility's policy titled Novel or Targeted MDROs [Multi-Drug Resistant Organisms] dated 10/19 revealed, .Implement Enhanced Barrier Precautions (EBP) for all residents residing on the same neighborhood who have a central line, urinary catheter, feeding tube, tracheostomy, or open wound. Wear gloves and a gown for the following high-contact resident care activities: Dressing - Changing linens, Bathing/showering - Providing hygiene, Transferring - Changing briefs or Assisting with toileting, and Device care or use: central line, urinary catheter, feeding tube, tracheostomy, wound care (any skin opening requiring a dressing) . Review of R237's undated Face Sheet located under the Face Sheet tab in the electronic medical record revealed R237 was admitted to the facility on [DATE] with diagnoses including but not limited to: hypertensive chronic kidney disease, Alzheimer's Disease, and sepsis. Review of R237's Admission Note located under the Progress Note tab in the EMR revealed an entry dated 07/15/24 at 3:59 PM, which stated, .She [R237] is demented and unable to answer question appropriately . Review of R237's Admission Minimum Data Set (MDS) revealed the MDS had not been completed at the time of this review. Review of R237's Baseline Care Plan dated 07/15/24, revealed, Foley placed for urinary retention with interventions to encourage fluids, Foley catheter care and output noted. During observations made on 07/17/24 at 3:00 PM and 07/18/24 at 8:30 AM, R237 had a Foley catheter in place with a privacy bag covering the drainage bag. Observations also revealed there was no signage on the door indicating the resident was on Enhanced Barrier Precautions (EBP). During an interview on 07/18/24 at 1:16 PM, Licensed Practical Nurse (LPN)5 confirmed R237 had a Foley catheter in place. When asked if R237 should be on EBP due to having a Foley catheter, LPN5 stated, No, she [R237] doesn't have to be. LPN5 was asked when is a resident placed on Enhanced Barrier Precautions and she stated, When they have ESBL [Extended-spectrum beta-lactamase] or other organisms in the urine. During an interview on 07/18/24 at 1:18 PM, the Unit Manager (UM)1 was asked when is a resident placed on EBP and UM1 stated, When they have something like ESBL in their urine, we put them on precautions. During an interview on 07/18/24 at 1:45 PM, the Assistant Director of Nursing (ADON) was asked when a resident is placed on Enhanced Barrier Precautions and the ADON stated, Residents are placed on this if they have wounds, Foley catheters, history of any infectious organisms. This is our way of protecting our staff and residents from passing on infections during direct patient care. During an interview on 07/18/24 at 1:48 PM, the Director of Nursing (DON) confirmed that residents are placed on Enhanced Barrier Precautions when they have wounds or indwelling medical devices such as peg tubes or Foley catheters. When asked if R237 should be on Enhanced Barrier Precautions, the DON stated, Yes, she has a Foley catheter. Review of R57's Face Sheet located in the Face Sheet tab of the physical chart revealed R57 was admitted to the facility 10/01/20 with diagnoses including but not limited to: chronic kidney disease stage 3, Bacteremia and calculus of kidney. Review of R57's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/14/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated the resident was not cognitively intact. Review of R57's Physician Orders dated July 2024 revealed an order for Enhanced Barrier Precautions (Foley) with start date 07/17/24. During an observation on 07/17/24 at 1:23 PM, revealed R57 had an enhanced barrier precaution sign noted beside the door. The sign was visible and detailed Enhanced Barrier Precaution protocol and directions. Certified Nursing Assistant (CNA)2 was observed going into the room with Hoyer lift and transferring R57 to the bed with just gloves on. CNA2 proceeded to provide incontinence care for R2 with just gloves on. During an interview on 07/17/24 at 3:01 PM, CNA2 stated they were trained on enhanced barrier precautions a few months ago. CNA2 stated they were instructed that they only have to use the directions placed on the resident's door if the resident had an active infection. CNA2 stated R57 did not have an active infection so gloves would suffice for care. During a follow-up interview on 07/18/24 at 2:31 PM, CNA2 stated they were wrong previously, and they were supposed to wear Personal Protective Equipment (PPE) for any resident that had an enhanced barrier precautions sign when providing hands on care. 2. Review of the facility's policy titled Dressing - Non-Sterile dated 08/04, provided by the facility, stated, . Open sterile dressings. Pour prescribed cleaning solutions over needed number of clean (for wound cleaning) and sterile (for wound dressing) gauze pads . Put on non-sterile gloves. Clean wound gently but thoroughly with prepared gauze pads. Clean from top to bottom and from the center outward. Use a separate gauze pad for each stroke. Discard soiled gloves, wash hands, and apply clean gloves . Review of R72's undated Face Sheet located under the Face Sheet tab in the EMR revealed R72 was admitted to the facility on [DATE] with diagnoses including but not limited to: dementia, and stage four pressure ulcer to the sacral region. Review of R72's Quarterly MDS with an ARD of 06/18/24, coded the resident as having a stage four pressure ulcer which was present on admission to the facility. Review of R72's Physician Orders located under the Orders tab in the EMR revealed an order, dated 06/25/24, which stated, sacrum: clean with wound cleanser, skin prep to surrounding tissue, apply calcium alginate to bed and pack wound edges, cover with gauze, then apply blue sorbex dressing, ABD, then tape 2 ties (cover all of ABD with tape). This treatment was to be performed every shift every day. Review of R72's Care Plan dated 10/02/23, revealed R72 was at risk for impaired skin integrity related to incontinent of bowel and bladder, immobility, and pressure ulcer present on admission. The interventions in place were to provide incontinence care for episodes of incontinence, ensure proper body alignment, weekly body audit, offer fluids as tolerated, evaluate nutritional status as needed, report changes to medical doctor and obtain treatment orders as indicated, and air mattress to bed. During a wound care observation on 07/19/24 at 11:35 AM, with Licensed Practical Nurse (LPN)3 the following observations were made: 1. LPN3 cleaned the overbed table with a Santi Cloth bleach wipe but did not wait the dry time of four minutes before placing barrier on top of it. 2. LPN3 brought scissors from their personal bag into R72's room and cleaned the scissors with an alcohol prep before using them to cut the gauze and packed the gauze in the wound. 3. LPN3 sprayed wound cleanser into the wound and then wiped around the outer edges of the wound with a 4x4. 4. After LPN3 cleaned the wound, he did not discard his dirty gloves and apply clean gloves before cutting the calcium alginate with scissors and begun to dress the wound. During an interview on 07/19/24 at 2:00 PM, LPN3 stated, I thought the dry time of the wipes was two to three minutes. I didn't realize my scissors could not be cleaned with the alcohol preps and I thought I had changed my gloves after I cleaned the wound. When asked how a wound is to be cleaned when performing wound care, LPN3 stated, I did not want to wipe the center of the wound so that I didn't disturb the granulation tissue. During an interview on 07/19/24 at 3:00 PM, the ADON was notified of the observation made of the wound care performed by LPN3 on R72. The ADON stated, You clean the wound from the center to the outer of the wound. The nurse is to clean the scissors with the bleach wipe and not the alcohol wipe and the nurse should have changed his gloves after cleaning the wound, washed his hands and applied cleaned gloves before redressing the wound. During an interview on 07/19/24 at 3:30 PM, Registered Nurse (RN)1 stated, The dry time for the bleach wipes is four minutes. During an interview on 07/19/24 at 3:40 PM, the DON stated her expectation for a nurse that is performing a dressing change is for the nurse to follow the physician orders for the wound care as well as follow infection control guidelines during wound care. 38517

Amended 10/04/23 Based on interviews, record review, and review of the facility policy, the facility failed to ensure significant medication errors did not occur for 1 of 1 residents reviewed for medication administration. Specifically, Resident (R)1 received medications intended for another resident. As a result of this failure, R1's blood pressure started trending downward. R1 reported a headache and became increasingly lethargic. R1 was sent to the emergency room for evaluation and stabilization. On 09/25/23 at 2:20 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 09/25/23 at 2:25 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 09/13/23. The IJ was related to 42 CFR 483.45 - Pharmacy Services. On 09/25/23 at 2:25 PM, the Administrator was notified that the failure to ensure a resident received the correct medications per physician orders constituted IJ at F760. On 09/25/23 at 6:42 PM, the facility provided an acceptable IJ Removal Plan. The survey team, validated the facility's corrective actions and determined the facility put forth good faith attempts to address the non-compliance. The IJ is considered at past non-compliance with an Allegation of Compliance date of 09/19/23. An extended survey was completed in conjunction with the Complaint Survey for noncompliance at F760, constituting substandard quality of care. Findings include: Review of the undated facility policy titled, Oral Medication Administration Procedure, states, Administer oral medications in an organized and safe manner . #7. Only one resident's medication at a time should be prepared and taken into a resident's room. #8. Identify resident before administering medication. Check arms band or photograph, call resident by name, or check with other staff members if necessary. #9. Explain to resident the type of medication to be administered, the resident has the right to be informed of all medications that are administered . #12. Administer medication and remain with resident while medication is swallowed. Review of R1's medical record revealed R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to dementia, legally blind, hearing loss and chronic congestive heart failure. R1 was admitted to the facility for therapy due to a left femur fracture. Review of R1's ordered medications included: Magnesium Oxide 400 mgs daily, Sertraline 25mgs daily, Eliquis 2.5 mgs, Doxcycline 100 mgs 2 times daily with food, Hydrocodone 5 mgs - 325 mgs every eight hours as needed for pain, Acidophilus 175 mgs 2 times daily, Sucralfate 1 gram 2 times daily, Vitamin D 3, Vitamin B-12, Atorvastatin 10 mgs, Memantine 5 mgs and Ondansetrol HCL 4 mgs every 6 hours as needed for nausea and vomiting. Further review of R1's orders revealed no blood pressure medications or heart medications. Review of R1's hospital stay starting on 09/13/23 revealed after blood pressure dropped to 68/55 with a heart rate of 46, R1 received the following medications at the facility, Eliquis 2.5 mgs, Flecainide 100 mgs, Senna 8.6 mgs, Trelogy, Diltiazem 360 mgs, Losartan 100 mgs, Polythylene 17 grams, Vitamin C 500 mgs, Vitamin D 125 mcgs, Integra 125 mgs and Toprol XL 25 mgs. (All of these medications were intended for another resident and given to R1). Per chart review patient was not supposed to be on any of these blood pressure medications, was given antiarrhythmic, calcium channel blocker and a beta blocker. Patient endorses fatigue and weakness. Blood pressure has continued to drop where she was required a PICC (Peripherally inserted central catheter) line and Epinepherine intravenously. In an interview on 09/25/23 at 9:15 AM, the Administrator stated, It was an honest mistake, the nurse feels really bad about it. The entire staff of nurses have been in-serviced. Pharmacy comes and watches med pass periodically. The nurse was so upset. She is a really good nurse. In an interview on 09/25/23 at 9:45 AM, R1 stated she did not know what was wrong with her or why she was in the hospital. In an interview on 09/25/23 at 10:00 AM, Registered Nurse (RN)1 stated, I was passing medications to 7 residents. Got to the end of the hallway, I pulled all the medications for the resident in the room next to [R1] and had them in a cup on the medication cart. I was distracted by therapy asking about the resident in the next room. They wanted to know if she had her pain medication and was ready for therapy. I looked on the computer for pain medication for [R1] and informed them that the resident had pain medication earlier from the 3rd shift nurse. I informed therapy that [R1] had Tylenol ordered, so I pulled the 650 mgs of Tylenol and put them in a cup and sat them beside the pills for the resident in the room next to [R1]. I took both cups of pills to R1. I realized immediately that I had given the wrong resident the wrong medications. I went to the day shift nurse and told her what had happened and I stayed with the resident and started taking vital signs immediately. The other RN on the hall stepped away to go get the charge nurse. The charge nurse was in a room with the Physician's Assistant (PA), and the RN came back and said to monitor the vital signs for five hours. So every hour on the hour I check the vital signs. The resident was stable until about noon and her blood pressure dropped to 72/51. I went to the nurse that had ICU (Intensive Care Unit) experience and asked about the half life of the medications I had given to the wrong resident and told her I was concerned about the Cardizem 360 mgs extended release and the Metoprolol Succinate 25 mgs extended release. With the Losartan 100 mgs I knew that 4 hours was most likely the half life and I had given the medications around 8:30 AM. As I was taking her vitals her heart rate got down to 46 and the blood pressure down to 68/55. Her O2 sats (saturation) never went down they stayed in the 90's. I had been giving her water and she received about 500 milliliters between 11:30 AM and 1:30 PM. The Director of Nursing (DON), Charge Nurse and myself were at the bedside, and the resident would not take anymore fluids. [R1] was in the bedside chair and had a large bowel movement on herself so between 1:00 PM and 1:30 PM we asked the PA if we could give IV fluids or send her to the ER and the physician gave the order to send her out to the emergency room (ER) for stabilization. RN1 further stated R1 went from the ER to ICU and she was there a few days before coming back to the facility. In an interview on 09/25/23 at 3:30 PM, the Medical Director (MD) stated, The nurse made a mistake and she let them know she did. My Nurse Practitioner (NP) was there and assessed the resident, I told them to watch the blood pressure every 30 minutes. I feel like they took action, it was a medication error. The resident is ok and the family is ok. I have checked on the resident since she came back from the hospital and she is doing ok. Of course you would expect there to be no med errors, but none of us are perfect. On 09/25/23 at 6:42 PM, the facility presented the following removal plan: Resident #1 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Resident #1's diagnoses, include, but not limited to, displaced intertrochanteric fracture of left femur, difficulty walking, muscle weakness, and dementia. On 09/13/23, Resident #1 received Resident #2's medication by mistake, when Registered Nurse #1 was going to administer Resident #2's medication, and became distracted when Physical Therapy was asking about pain medication for Resident #1. Pain medication and Resident #2's medication were administered to Resident #1. Registered Nurse #1 realized the error and immediately began monitoring Resident #1's blood pressure and heart rate every hour for 5 hours. Resident #1's vitals were monitored on 09/13/2023 as the following: at 8:30 AM - T97.5, P56, R16, B/P 130/79; 9:35 AM - T97.6, P58, R20, BP 98/68; at 10:49 AM - T97, P64, R16, B/P 92/58 and 109/60 ; at 11:49 AM - P 60, R16 BP 78/51; at 12:49 PM - P60, R20, B/P 68/55; 1:49 PM - P96, R20, BP 68/55 and 78/52; and prior to leaving with EMS - B/P 82/65. Resident #1 was sent to the hospital when she reported a headache and became increasingly lethargic. Resident #1's representative was notified of the medication error, change in condition and transfer to the hospital. The Director of Nursing immediately started an in-service on accurately administering medications. Other facility residents can potentially be at risk if given medications intended for another resident. Facility will ensure significant medication errors do not occur for residents. Action: An audit of current residents were completed by the Director of Nursing on 09/13/2023, and revealed no other significant medication errors had occurred for any other resident. The Director of Nursing and Corporate Pharmacy Consultant completed the in-service of accurately administering medications to all current Licensed Nursing staff. Newly hired Licensed Nursing staff will receive this education during their job specific orientation by Staff Development Coordinator. The facility Nursing Administration or Corporate Pharmacy Consultant will monitor by observing 3 Licensed Nurses administering medications weekly for 12 weeks. Identified trends or issues from the monitoring will be discussed during the morning QI meetings, weekly for 12 weeks, and then discussions with the Quality Assurance Committee meetings for further recommendations as needed. The Director of Nursing is responsible for the ongoing compliance of F760. Compliance date is 09/19/2023.

Based on observations, interview, record review, and review of facility policies Standards of Care, and Oral Medication Administration Procedure, the facility failed to administer oral medications in an organized and professional manner for 1 of 1 reviewed. Resident #52 was given medication by Registered Nurse (RN) #1 in a medication cup and then RN #1 walked away to get additional medication when resident was observed taking medication unsupervised by the nurse. The findings included: During an interview with Registered Nurse (RN) #1 on 11/4/20 at approximately 10:00 AM, h/she stated Resident #52 wanted [MEDICATION NAME] to go along with morning medications and I went to get the [MEDICATION NAME]. Medications were left on a paper towel as that is how Resident #52 likes them with water. Asked RN #1 if Resident #52 started taking any medications prior to being left unattended in the room with medications, and RN # 1 replied, I think h/she started taking them, not sure, may have taken 1 or 2 pills before I left the room to look at the computer to get the [MEDICATION NAME]. I was out of the room [ROOM NUMBER] or 2 minutes. RN # 1 was asked if the remaining un-taken medications were with RN #1 when h/she left the room, RN # replied no. Informed RN # 1 that medications should be taken with them when h/she is not in the room and RN # 1 stated, I know. Review of the facility policy Standard of Care section P revealed that no medications are at the resident's bedside without being determined safe to self-administer by the RPOC team, successful return demonstration, and a physician order. Other medications found to be at bedside will be removed until such time that the RPOC team can make the appropriate determination and physician notified. Review of the facility policy titled Oral Medication Administration Procedure revealed under Procedure # 12: Administer medication and remain with resident while medication swallowed. A) Never leave a medication in a resident's room without orders for self-administration. B) If resident is in bed, head of bed should be elevated prior to administration of medication. Record review of Resident #52 physician order's revealed no order to be left alone to self-administer medications. An observation on 11/03/20 at approximately 8:50 AM revealed Resident #52 with medications lying loosely on a napkin on his/her bedside table. The Resident's medications had been taken out of the medication administration cup and were spread out on the bedside table that was positioned in front of him/her. The Resident was taking his/her pills one at the time. RN #1 was not present when Resident #52 was in their room taking the medications. On 11/03/20 at approximately 8:52 AM Resident #52 was observed in his/her room with multiple pills laying on a paper towel with no nurse present. Resident #52 appeared to be having some difficulty swallowing the medication as he/she took one pill at a time. On 11/03/20 at approximately 8:53 AM RN #1 was interviewed and asked if he/she was allowed to leave residents with medications unattended? RN #1 stated that he/she was not allowed to leave residents with medication unattended. RN#1 confirmed he/she left the Resident #52 with multiple pills laying on paper towel.

Based on observations, interviews, record review, and review of the facility's policies and procedures, the facility failed to ensure proper infection prevention and control procedures were followed for cleaning therapy equipment used with one of five sampled residents (Resident #1) who was on transmission-based precautions and two of five residents (Resident #2 and Resident #3) who were on standard precautions. On 06/10/2020, a Certified Occupational Therapy Assistant (COTA) was observed exiting Resident #1's room with equipment used to provide therapy services. The COTA was observed cleaning the equipment prior to taking off the disposable gloves s/he wore while providing care to Resident #1. This failure had the potential to negatively affect eight other residents receiving therapy services provided by the COTA on 06/10/2020. Findings include: On 06/10/2020 from 10:32 AM- 11:01AM, the COTA was observed in Resident #1's room providing therapy services while wearing Personal Protective Equipment (PPE), that included a disposable gown, disposable gloves, a facemask, and a face shield. At 11:02 AM, the COTA was observed exiting Resident #1's room with a bedside table used to transport therapy equipment. The therapy equipment included two Therap-E bars, one pedal machine, three hand grips, a timer, and two barbells. The COTA was observed cleaning the therapy equipment with a CaviWipe (a hard surface, disinfectant wipe) prior to taking off the disposable gloves she wore while providing care to Resident #1. After cleaning the therapy equipment found on the bedside table, the COTA took off her/his disposable gown and disposable gloves, performed hand hygiene, then removed her/his face shield and cleaned the face shield with a CaviWipe and placed it on the bedside table. During a interview on 06/10/2020 at 11:03 AM, the COTA stated s/he used the therapy equipment on the bedside table to provide services to multiple residents in the facility and only cleaned the equipment after using the equipment with each resident. In addition, COTA did not know the dry time for the CaviWipes used to clean the equipment. A review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] and was placed in a private room for 14 days of isolation. Further review of Resident #1's physicians orders in the medical record revealed the resident had an order to be placed on Tier 2 transmission-based precautions, to include contact and droplet precautions. These precautions require facility staff to wear a gown, gloves, and face mask while providing care to the resident. On 06/10/2020 at 12:48 PM, the Director of Therapy Services (DTS) stated s/he expected therapy services staff members to clean and sanitize equipment before and after the equipment is used to provide services to residents in the facility. In addition, the DTS stated all therapy services staff members have been trained on proper use of PPE and the COTA should have changed her disposable gloves prior to cleaning the equipment. The DTS further indicated the COTA had eight residents on her caseload for 06/10/2020. However, the DTS could not confirm if any of the other residents receiving services from the COTA were potentially exposed to the therapy equipment prior to the equipment being properly disinfected or replaced. On 06/10/ 0 at 1:37 PM, the COTA was observed in Resident #2's room performing bedside therapy with the same therapy equipment on a bedside table. At 1:51 PM, the COTA was observed cleaning the equipment with the CaviWipes. At 1:55 PM, the COTA was observed entering Resident #3's room with the table tray and therapy equipment without cleaning it prior to entering the room to provide therapy services to Resident #3. The observation also revealed one hand grip with broken plastic coating and one dumbbell with broken plastic coating, creating an uncleanable surface on the equipment. Review of Resident #2's medical record revealed Resident #2 was admitted to the facility on [DATE] for therapy after a femur fracture. Further review revealed Resident #2 was not on isolation precautions and did not have any signs and/or symptoms of infection. Review of Resident #3's medical record revealed Resident #3 was admitted to the facility on [DATE] for therapy related to the repair of a right [MEDICAL CONDITION]. In addition, the review revealed the resident was not on any isolation precautions and had no signs and/or symptoms of any infection. On 06/10/2020 at 1:45 PM, the Infection Control Nurse (ICN) stated equipment used to provide care to residents should be cleaned before and after use. In addition, the ICN stated the COTA should have changed her/his gloves prior to cleaning the equipment and any equipment with broken plastic coatings should be replaced to ensure equipment does not have uncleanable surfaces. On 06/10/2020 at 2:00PM, the Director of Nursing (DON). stated s/he expected all facility staff to follow proper infection control practices and acknowledged the COTA should have changed her/his gloves prior to cleaning the therapy equipment used to provide services to Resident #1. On 06/10/2020 at 2:20 PM, the Administrator stated all staff have been trained on the proper use of PPE and the infection control practices of the facility. The Administrator further stated the facility would replace the therapy equipment with uncleanable surfaces and acknowledged the COTA should have used clean gloves to clean equipment used to provide care to residents at the facility. Review of the facility policy's titled, Infection Control, dated revised 11/30/2017, stated, Change gloves between tasks and procedures on the same resident. In addition, the policy required, Used equipment will be cleaned/disinfected after use when a resident is in isolation precautions. In addition, the facility's policy stated the appropriate device handling patient care equipment included staff should ensure that reusable equipment is not used for the care of another patient until it has been appropriately cleaned.

Based on observation, interview, and review of facility policies titled Sanitation and Infection Control, Production, Purchasing, and Storage Area and Equipment Cleaning Frequency/Schedules, Ice Machine Maintenance and Cleaning and Hair Restraints, the facility failed to prepare, distribute, and serve food under sanitary conditions for 1 of 1 kitchen reviewed and had the potential to affect residents receiving a physician ordered diet as evidenced by failing to do the following: date and label opened items, remove food which had spoiled or expired, wear facial hair restraint, maintain adequate sanitizing solution in cleaning buckets, clean equipment (can opener) after use, and remove mop from standing water in bucket. In addition, the ice machine located on the second floor had several small gray areas on the inside of the lid. The findings included: On [DATE] at approximately 11:10 AM, during an observation of the main kitchen with the Registered Dietician (RD)/Certified Dietary Manager (CDM) revealed: 1) The can opener with residue on the blade; 2) (1) box of cream of wheat not opened, not wrapped/dated and (1) box of potato pearls opened and not dated; 3) (1) partial ,[DATE] gallon of buttermilk with expiration date of ,[DATE]; 4) (1) container of blueberries with a blueberry with a whitish, gray substance; 5) (1) male employee with beard with no beard restraint. During the initial tour the RD/CDM stated the can opener had been used to prepare the upcoming meal. Upon observing the unwrapped and/or undated boxes of cream of wheat and potato pearls, expired buttermilk and blueberries, the RD/CDM discarded the items. On [DATE] at approximately 11:30 AM, (1) red bucket did not have sufficient sanitization (50 parts per million) and a mop was observed to be stored in standing water. The RD/CDM confirmed the above observations of the red bucket and mop at the time of discovery. During the temping of the lunch meal on [DATE] at approximately 11:30 AM, two male staff members were observed with beard restraints which were not pulled up over the mustache. One male staff member was serving on the line. At the time of the observation, the RD/CDM confirmed these findings. During observation of the second floor kitchenette on [DATE], several small gray areas were observed on the inside panel of the icemaker lid. During the observation, a staff member from environmental services confirmed the areas. Review of the cleaning schedule for the icemaker revealed the last time the icemaker had been cleaned was [DATE]. During an interview with the Nurse Consultant on [DATE] at 5:58 PM, s/he stated the areas had been noticed and could not be removed from the lid of the icemaker. Observation of the icemaker on [DATE] at 5:45 PM revealed the gray areas were no longer present. Review of the facility policy titled Sanitizing Food Contact Surfaces revealed under the Red Bucket section to replace sanitizer solution in buckets every 2 hours or more frequently and under the policy section the sanitizer solution must be at 200 ppm - 400 ppm for Oasis 146 Multi-Quat sanitizer. Review of the facility policy titled Food Production, Service, Storage, and Distribution Standards revealed the following: Food stored refrigerated should be kept no longer than expiration date. Any opened or prepared products should be labeled and dated using the HHS Culinary approved label. Review of the facility policy titled Area and Equipment Cleaning Frequency/Schedules revealed the following: Can opener should be cleaned after each use. Review of the facility policy titled Hair Restraints revealed the following: Team members will wear hair restraints regardless of length of hair or beard at all times in the kitchen. Review of the facility policy titled Ice Machine Maintenance and Cleaning revealed the following: Each department is responsible for cleaning ice machines in their area on a daily basis and nutrition/food service and Environmental Service will perform on weekly basis.

Based on record review and interview, the facility failed to provide written notice of transfer to the Resident and/or Resident Representative for 1 of 3 sampled residents reviewed for hospitalization (Resident #88). The findings included: The facility admitted Resident #88 with [DIAGNOSES REDACTED]. Record review on 05/24/19 at approximately 10:42 AM revealed a physician's orders [REDACTED].#88 to the hospital for evaluation and treatment. No documentation of the facility providing written notice of transfer to the resident and/or resident representative was located in the medical record. In an interview on 05/23/19 at approximately 5:43 PM, the Social Worker confirmed no written Notice of Transfer was provided to the family and/or Resident Representative.

Based on observation and interview, the facility failed to protect and ensure dignity for 1 of 1 sampled residents reviewed for dignity (Resident #26). The findings include: The facility admitted Resident #26 with [DIAGNOSES REDACTED]. During random observations by several surveyors during the days of the survey, the catheter discharge bag for Resident #26 was uncovered with contents visible from the doorway and when entering the room to visit both Resident #26 and his/her roommate. An observation on 05/23/19 at approximately 3:27 PM revealed Resident #26 visiting with family members with the catheter bag attached to the foot of the bed at the door side with a large amount of urine observed in the bag. On 05/24/19 at approximately 12:00 PM, Resident #26 was observed in the room with the catheter bag with urine hanging on the rail near the foot of the bed, which was visible from the doorway. In an interview on 05/24/19 at approximately 12:00 PM Licensed Practical Nurse (LPN) #1 confirmed the bag was uncovered with the contents visible from the doorway. LPN #1 stated the cover was only used when the resident left the room. In a subsequent interview on 05/24/19 at approximately 12:13 PM, the Director of Nursing stated it was his/her expectation that the bag should be covered.

Based on record review, interview and review of the facility policy titled, Bed Hold, the facility failed to ensure residents and/or their personal representative received a copy of the Bed Hold policy upon transfer/discharge to the hospital for 1 of 3 residents reviewed for hospitalization (Resident #46). The findings included: The facility admitted Resident #46 on 2/26/2009 with [DIAGNOSES REDACTED]. Review on 5/21/2019 at approximately 1:56 PM of the medical record for Resident #46 revealed a hospital stay from 3/24/2019 through 4/1/2019. No documentation could be found in the medical record for Resident #46 to ensure the resident and/or his/her personal representative had received a copy of the bed hold policy upon transfer/discharge to the hospital An interview on 5/24/2019 at approximately 3:59 PM with the Social Worker confirmed that Resident #46 and/or his/her personal representative had not received a copy of the Bed Hold policy upon transfer/discharge to the hospital. Review on 5/24/2019 at approximately 4:30 PM of the facility policy titled, Bed Hold, states, At the time you are admitted , transferred to an acute care facility (hospital), or on a leave of absence, you or your personal representative will be provided written information that specifies Bed Hold Policies and readmission procedures.

Based on observation and interview, the facility failed to maintain equipment in a safe operating condition for 2 of 2 double deck convection ovens reviewed. Double deck convection ovens had a large build-up of grease and dust in the main kitchen. The findings included: On 4-3-18 at 9:30 AM, an observation of the main kitchen with the Kitchen Supervisor revealed (2) double deck convection ovens back to back with a large multi-outlet electrical outlet and pipes in between. The backs of the ovens had vents and motors that were covered with a heavy build-up of grease and dust, along with the pipes, wiring and electrical outlet box. Following the observation, in an interview with the Kitchen Supervisor, s/he verified the heavy build-up of grease and dust and was asked if the ovens were on a cleaning schedule, and s/he stated No. On 4-4-18 at 11:45 AM, another observation of the main kitchen with the Nutrition Food Service Director revealed the same (2) double deck convection ovens mentioned above, back to back with a large multi-outlet electrical outlet and pipes in between. The backs of the ovens vents and motors continues to have a heavy build-up of grease and dust, along with the pipes, wiring and electrical outlet box. Following the observation, in an interview with the Nutrition Food Service Director, s/he verified the heavy build-up of grease and dust on the ovens and indicated the kitchen had a licensure inspection recently that referenced the same build-up of grease and dust. On 4-4-18 at 4:00 PM, a review of the DHEC Bureau of Health Facilities Licensing report notice dated 12-29-17 revealed, Excessive accumulation of grease build up observed on the vent hood filters above the main line and on pipes behind the cook line equipment.

Based on observation, interview, and review of the facility policies, the facility failed to prepare, distribute, and serve food under sanitary conditions for 1 of 1 kitchen reviewed and has the potential to affect 84 of 85 residents with ordered diets as evidenced by failing to do the following: Air dry pans, maintain adequate sanitizing solution in cleaning buckets, wear facial hair restraint, clean (floor, fans, vents, coolers, ovens), and temp foods to avoid cross contamination. The findings included: On 04/03/18 at 9:30 AM, during the initial tour of the main kitchen with the Kitchen Manager revealed: 1.) Vents and ceiling above the cooking area had a large build-up of grease and dust. 2.) Double deck convection ovens exhaust vents, motors, and pipes behind ovens had a large build-up of grease and dust. 3.) (2) Red Buckets did not have a chemical solution to sanitize. 4.) Produce cooler and Caterer cooler fan had a large build-up of a white substance that was blowing onto prepared uncovered food, also a white substance was growing on all the racks inside both coolers, furthermore a package of strawberries had a white substance growing on the berries. 5.) Food, grease, and debris build-up were on the floor along the walls near the dry clean utensil racks and behind stove, fryer and ovens. 6.) (12) 1/3 pans were stacked wet below the food preparation area. 7.) Exhaust vent in dishwashing area had a large build-up of dust. Following the above (7) observations the Kitchen Manager verified the large build-up of grease/dust, lack of sanitizer in buckets, and the pans were stacked wet. On 04/04/18 at 11:30 AM, during an observation of the main kitchen lunch line temping, the Dietary Supervisor used the same sanitizing wipe to clean the food temperature probe between food items pork, broccoli, and sweet potato. Following the observation the Dietary Supervisor verified s/he used the same sanitary wipe between food items. On 04/04/18 at 11:45 AM, during an observation of the main kitchen with the Nutrition Food Service Director revealed: 1.) Vents and ceiling above the cooking area had a large build-up of grease and dust. 2.) Double deck convection ovens exhaust vents, motors, and pipes behind ovens had a large build-up of grease and dust. 3.) Produce cooler and Caterer cooler fan had a large build-up of a white substance that was blowing onto prepared uncovered food, also a white substance was growing on all the racks inside both coolers, furthermore a package of strawberries had a white substance growing on the berries. 4.) Food and debris build-up were on the floor along the walls near the dry clean utensil racks and be-hind stove, fryer and ovens. 5.) (8) 1/3 pans were stacked wet below the food preparation area. 6.) (1) man with mustache and beard not restrained at the food serving line. 7.) Exhaust vent in dishwashing area had a large build-up of dust. Following the above (7) observations the Director of Nutrition Food Service verified the large build-up of grease/dust, pans were stacked wet, white substance growing in the coolers, and the man not wearing a facial hair restraint. On 4-4-18 at 4:00 PM, a review of the Licensing report notice dated 12-29-17 revealed, Excessive accumulation of grease build up observed on the vent hood filters above the main line and on pipes behind the cook line equipment. Review of the facility policy, Cross Contamination Precautions, states under procedure, (5.) Use red buckets sanitizing solution for clean rags. Also, policy Uniform Dress Code states,longuards are to be worn by all employees with facial hair, the guard is to be pulled up over the nose to cover all beard and mustache hair. Furthermore, policy Kitchen Sanitization states under procedures, (4.) All surfaces of the dish room are cleaned and sanitized after each meal. Walls and ceiling are checked weekly, the exhaust fan is cleaned per need. (5.) Ceiling tiles are checked and replaced as needed. (12.) The ovens are cleaned weekly after daily use is completed. (13.) Walk in refrigerators and freezers are cleaned by staff on a weekly schedule.

Based on record review and interview the facility failed to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs for Resident's #38, # 58, # 65, #25, #34, #69, #63, #82, #47, #48, #51, #54, #81 and #72. The findings included: Resident # 38 was admitted to the facility 11/20/2017 with [DIAGNOSES REDACTED]. Record review on 04/05/2018, the Care Plan Conference sheet was reviewed with no Certified Nursing Assistant attendance or signature. During an interview on 04/05/2018 at 11:48 am the facility Consultant confirmed that the care plan meeting was not attended by the Certified Nursing Assistant. Resident # 58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review on 04/05/2018, the Care Plan Conference sheet was reviewed with no Certified Nursing Assistant attendance or signature. During an interview on 04/05/2018 at 11:00 am the facility Consultant confirmed that the care plan meeting was not attended by the Certified Nursing Assistant that cared for the resident. Resident # 72 was admitted : 10/27/13 with diagnoses, including but not limited to, [MEDICAL CONDITION] Arthritis, [MEDICAL CONDITION], pleurisy, unspecified Hydro[DIAGNOSES REDACTED], Heart Failure, [MEDICAL CONDITION], neuromuscular dysfunction of bladder, long term use of anticoagulant, muscle weakness, [MEDICAL CONDITION], history of chronic Urinary Tract Infections, other discord of bone density, unspecified [MEDICAL CONDITION] Fibrillation, [MEDICAL CONDITION], Lumbar Disc disease and history of [MEDICAL CONDITION]. Record review on 04/03/2018, the Care Plan Conference sheet was reviewed with no Certified Nursing Assistant attendance or signature. During an interview on 04/03/2018 at 04:15 pm the facility Consultant confirmed that the care plan meeting was not attended by the Certified Nursing Assistant. Resident #65 was admitted [DATE] with [DIAGNOSES REDACTED]. Vein [MEDICAL CONDITIONS] bladder secondary to [MEDICAL CONDITION] requiring in and out catheter, status [REDACTED]. Record review on 04/03/2018, the Care Plan Conference sheet was reviewed with no Certified Nursing Assistant attendance or signature. During an interview on 04/03/2018 at 04:15 pm the facility Consultant confirmed that the care plan meeting was not attended by the Certified Nursing Assistant. Resident #25 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review on 04/06/18 at approximately 9:00 a.m. revealed multiple care plan conference forms that did not include the required participation of the interdisciplinary team. On 02/22/18, a meeting was held and the staff present included the Minimum Data Set (MDS) nurse, the hospice nurse, the facility social worker, the hospice social worker and the hospice chaplain. On 12/20/17, a meeting was held and the staff present included the MDS nurse, the dietician and the facility social worker. On 09/20/17, a meeting was held and the staff present included the nurse, the social worker, the dietician and the activities coordinator. Resident # 34 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review on 04/06/18 at approximately 9:00 a.m. revealed multiple care conference forms that did not include the required participation of the interdisciplinary team. On 02/14/18, a meeting was held and the documented staff present included the MDS nurse and the social worker. On 11/17/17, a meeting was held and documented staff included the MDS nurse, the dietician, the activities coordinator and the social worker. On 08/23/17, a meeting was held and staff present included the MDS nurse, the dietician, the social worker and the activities coordinator. Resident #69 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A care plan meeting was held on 03/02/18. Staff present included the social worker, the activities coordinator, physical and occupational therapist and the MDS nurse. At approximately 10:09 a.m. on 04/06/18, the forms for Residents #65, 25, and 34 were reviewed with the Director of Nursing who reviewed and confirmed the staff titles, as indicated on the conference form. The provided policy entitled Comprehensive Team Care Planning was reviewed on 04/05/18 at 12:53 p.m. and indicated on line item 1 B. of the Procedure, The planning for each resident must be interdisciplinary and involve at least one staff member from Social Services, Activities, Nursing, Dietary and other disciplines as indicated. The facility admitted Resident #63 on 2-10-18 with [DIAGNOSES REDACTED]. Review of Resident 63's weight record on 4-5-18 at 8:32 AM revealed a 14.6 pound (#) weight loss (8.8%) from 2-10-18 (165.9#) to 3-5-18 (151.3#) and an additional 5 pounds by 3-26-18 (146.3#). By 4-2-18 (144.4#), in less than 2 months, Resident #63 had lost a total of 21.5# or 12.95% of his/her body weight. Review of Nurses Notes at 9:44 AM on 4-5-18 revealed an entry on 2-21-18 that a Care Plan meeting had been held with the resident and family member, There was no evidence of participation by nutrition services or a Certified Nursing Assistant (CNA). Review of the 2-21-18 and 4-3-18 LTC Care Plan Conference forms also revealed no evidence of participation by the physician, nutrition services, or a CNA. During an interview at 1:48 PM on 4-5-18, the Director of Nurses (DON) reviewed the medical record and stated, I don't see where they participated. Record review on 4-5-18 at 9:47 AM revealed that the Care Plan included a potential for weight loss as a problem, but it had not been updated with the actual weight loss on 3-8-18 and any subsequent interventions. During an interview at 1:49 PM on 4-5-18, the DON and Corporate Representative verified that the Care Plan had not been updated with the weight loss. The facility admitted Resident #82 on 2-25-18 with [DIAGNOSES REDACTED]. Review of Progress Notes at 3:26 PM on 4-5-18 and Incident Reports on 4-5-18 at 4:09 PM revealed that Resident #82 sustained two falls in the facility, one self-reported on 3-23-18 at approximately 3 AM and one on 3-26-18 at 6:45 AM. Record review at 12:24 PM on 4-5-18 a 3-31-18 physician's orders [REDACTED]. (patient) safety. Multiple observations over 2 shifts on 4-5-18 (11:35 AM, 2:45 PM, 4:55 PM) revealed that Resident #82 was seated in a bedside chair with no alarm in place. During an interview on 4-5-18 at 4:55 PM, when asked how s/he knew about special care items that were required to be in place, Certified Nursing Assistant (CNA) #1 (assigned to the resident's care) stated they did not have a CNA care plan to go by. S/he stated they got a verbal report of changes and went by an assignment sheet. CNA #1 produced the assignment sheet and confirmed that it did not include alarms. Review of the Interdisciplinary Care Plan at 5:08 PM on 4-5-18 revealed that it had been updated with the 3-23-18 self-reported fall but there there were no noted changes in interventions to prevent recurrence. The Interdisciplinary Care Plan had not been updated with the 3-26-18 fall or the 3-31-18 physician-ordered alarms. During an interview at 10:52 AM on 4-6-18, the MDS (Minimum Data Set) Coordinator verified that there were no changes in interventions following the 3-23-18 fall and that the care plan had not been updated following the 3-26-18 fall. Review of the 3-12-18 LTC (long term care) Care Plan Conference form revealed no nutrition services or CNA participation. This was verified during an interview on 4-6-18 at 11:16 AM by the MDS Coordinator. Review of the facility's undated Comprehensive Team Care Planning Policy and Procedure revealed it had not been updated with the 11-28-16 requirements for required care plan participation. It states: The services are implemented and updated on the care plan . The planning for each resident must be interdisciplinary and involve at least one staff member from Social Services, Activities, Nursing, Dietary, and other disciplines as indicated . The facility admitted Resident #47 on 3/6/16 with [DIAGNOSES REDACTED]. Review of the medical record revealed the care plan conference attendance sheets contained space for signatures of staff participating in the meeting. Review of the attendance sheet dated 3/22/18 revealed no signature of a Certified Nurses Aide (CNA) or Dietary staff member. The attendance sheets dated 12/20/17 and 9/20/17 contained no CNA signature. During a review of the attendance forms on 4/6/18 at approximately 9:15 AM, the MDS Coordinator confirmed these findings. The facility admitted Resident #48 on 1/29/18 with [DIAGNOSES REDACTED]. Review of the medical record revealed the care plan attendance sheet dated 2/14/18 contained no signature of a CNA or Dietary staff member. This finding was confirmed by the MDS Coordinator on 4/6/18 at approximately 9:15 AM. The facility admitted Resident #51 on 11/15/95 with [DIAGNOSES REDACTED]. Review of the care plan attendance sheets dated 3/7/18, 12/13/17, and 9/13/17 revealed no signature of a CNA to indicate participation in the meeting. The MDS Coordinator confirmed this finding on 4/6/18 at approximately 9:15 AM. The facility admitted Resident #54 on 5/26/17 with [DIAGNOSES REDACTED]. Review of the medical record revealed the care plan attendance sheets dated 2/28/18, 12/6/17, and 9/13/17 contained no CNA signature to indicate participation in the meeting. The MDS Coordinator confirmed this finding on 4/6/18 at approximately 9:15 AM. The facility admitted Resident #81 on 1/16/14 with [DIAGNOSES REDACTED]. Review of the medical record revealed the care plan attendance forms dated 3/29/18, 1/11/18, and 10/17/17 contained no CNA signature to indicate participation in the meeting. The MDS Coordinator confirmed this finding on 4/6/18 at approximately 9:15 AM.

Based on observation, record review, interviews, and review of the facility policy, the facility failed to ensure that medications were stored in 1 of 2 medication room refrigerators at temperatures specified by FDA (Food and Drug Administration) approved package inserts, manufacturer package labeling and the Facility's policy. Medication was stored in the unit 2 medication storage room refrigerator below manufacture specifications. The findings included: On 4/3/18 at 11:19 AM, an observation of the unit 2 medication storage room refrigerator with Licensed Practical Nurse (LPN) #1 revealed the temperature of the refrigerator was 30 degrees of Fahrenheit (F). The medication in the refrigerator was: 1.) (1) 10 ml. vial of [MEDICATION NAME] R insulin 2.) (1) 10 ml. vial of [MEDICATION NAME] mix 70/30 insulin 3.) (1) 10 ml. vial of [MEDICATION NAME] 70/30 insulin 4.) (1) 3 ml. vial of Humalog insulin 5.) (1) 10 ml. vial [MEDICATION NAME] 6.) (1) 10 ml. vial of Levamir insulin 7.) (1) 10 ml. vial of [MEDICATION NAME] N insulin 8.) (8) 2gm./ml. vials of Lorazapam 9.) (2) .5 ml. vial of Pnuemovax 23 10.) (1) 5TU/0.1 ml. vial of [MEDICATION NAME] Purified Protein Derivative (PPD) On 4/3/18 at 11:20 AM, LPN #1 verified the temperature in the refrigerator was 30 degrees of (F.), and the above (10) medications in the refrigerator, and further indicated s/he did not know the correct temperature for insulin storage. On 4/4/18 at 7:45 AM, a review of the (MONTH) (YEAR) unit 2 Refrigerator Temperature Chart revealed that on (14) days the temperature was recorded at 33 degrees (F.), (4) days at 34 degrees (F.), and (9) days had no temperature recorded. On 4/4/18 at 9:30 AM, a review of the pharmacy technicians Med Room/Station Inspection, dated 3/20/18 revealed under Refrigerator/Freezer, the mark X and 32 degrees was identified next to #44 which stated, Temperature (Refrigerator: 35 degrees to 46 degrees F or 2 to 8 Celsius), indicating the temperature was 32 degrees. On 4/4/18 at 1:56 PM, a review of the facility policy entitled, Medication Storage In The Facility, states under procedure (7) Medications requiring refrigeration or temperatures between 36 degrees F and 46 degrees F are kept in a refrigerator with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label. Review of the manufacture specifications for [MEDICATION NAME] Purified Protein Derivative, (Mantoux) (PPD) ([MEDICATION NAME]) states under section Storage, Store at 2 degrees to 8 degrees of Celsius (35 to 46 degrees of Fahrenheit). Do not freeze. Discard product if exposed to freezing. Review of the FDA approved manufacturer package inserts and manufacturer package labeling revealed that the Insulin, Pnuemovax 23, and Lorazapam should be stored 36-46 degrees F.

Based on record review and interview, the facility failed to conduct an assessment to determine the underlying cause of falls and attempt alternate interventions prior to the implementation of alarms for one of two sampled residents reviewed for restraints (Resident #82). Resident #82 had no restraint assessment completed prior to implementation of alarms. The findings included: The facility admitted Resident #82 on 2-25-18 with [DIAGNOSES REDACTED]. Review of Progress Notes at 3:26 PM on 4-5-18 and Incident Reports on 4-5-18 at 4:09 PM revealed that Resident #82 sustained two falls in the facility, one self-reported on 3-23-18 at approximately 3 AM (witnessed by roommate) and one on 3-26-18 at 6:45 AM. Record review at 12:24 PM on 4-5-18 revealed that no changes in interventions were implemented to prevent further falls until a 3-31-18 physician's orders [REDACTED]. (patient) safety. Further review revealed no investigations to determine the underlying causes of the accidents. No restraint assessment could be located in the medical record. During an interview on 4-6-18 at 11:16 AM, the Minimum Data Set (MDS) Coordinator stated the facility did have a form they used for restraint assessment. S/he reviewed the medical record and verified it was not in the chart. There was no evidence of assessments following the 3-23-18 or 3-26-18 falls to determine the underlying cause(s) so individualized interventions could be attempted prior to alarm use. During an interview at 10:52 AM on 4-6-18, the MDS Coordinator verified that there were no changes in interventions following the 3-23-18 fall.

Based on record reviews and interviews, the facility failed to ensure each resident remained free from physical restraints imposed for purposes of convenience, and not required to treat the resident's medical symptoms. Resident #1 was noted to be physically restrained by a Certified Nursing Assistant when s/he wrapped a gait belt around Resident #1s lower legs to restrict his/her movement. 1 of 4 residents reviewed for abuse/neglect. A review of the facility's abuse reporting and investigation documentation on 6/28/17 revealed there was an allegation that a Licensed Practical Nurse (LPN) observed a gait belt tied around Resident #1s legs just below the knees on while the resident was in bed on 4/11/17 at approximately 4:30 PM. The documentation further indicated a Certified Nursing Assistant (CNA) stated s/he tied the gait belt around the resident's legs. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #1 could not be interviewed due to severe cognitive impairments. Further review of the medical record on 6/28/17 at 5:40 AM revealed a History and Physical dated 3/07/17 that indicated Resident #1 was unable to provide information due to Dementia. Nurses note dated 3/21/17 at 10 PM indicated Resident #1 was up and wandering all shifts in wheelchair. Nurses note dated 3/22/17 indicated the resident was up the entire night. Nurses note dated 4/06/17 indicated Resident #1 was up all evening wheeling self in wheelchair. Further review of nurses' notes dated 3/09/17 to present did not indicate Resident #1 being physically aggressive towards facility staff. A review of the facility's care plan dated 3/14/17 and updated on 6/12/17 revealed Resident #1 required extensive total assist for all activities of daily living and the gait belt to be used with resident for transfer. The care plan did not indicate that Resident #1 was physically aggressive/combative with staff. During a face to face interview on 6/28/17 at approximately 6:15 AM with LPN #1 revealed s/he observed the gait belt wrapped around Resident #1s legs below the knees when s/he checked him/her for incontinent care. Reportedly CNA #1 was in the room seated by the resident in bed near the window. LPN #1 stated CNA #1 admitted to putting the gait belt around Resident #1s legs to keep him/her from squirming and trying to get up. LPN #1 stated s/he removed the gait belt from Resident #1s legs right away. LPN #1 further reviewed her/his written statement and confirmed s/he wrote the statement that CNA #1 acknowledged s/he placed the gait belt around Resident #1s legs to keep him/her from moving. During a face to face interview on 6/28/17 at approximately 7:30 AM with the Director of Nursing (DON) revealed CNA #1 refused to write a statement related to placing the gait belt around Resident #1s legs. The DON stated that CNA #1 admitted to placing the gait belt around Resident #1s legs to keep him/her from moving and hitting his/her legs. The DON further reviewed and confirmed her/his written statement related to the allegations of abuse. During a telephone interview on 7/05/17 at approximately 9:58 AM with the Administrator revealed CNA #1 admitted to placing the gait belt around Resident #1s legs because s/he would not keep still. The Administrator further acknowledged her/his written statement and confirmed the incident occurred in April 2017 related to the allegations of abuse.