Every finding on record at Kirby Pines Manor

Based on policy review, review of the facility's Infection Control Program documents, and interview, the facility failed to establish and implement a program to identify, report, investigate and control infections and communicable diseases when the Infection Preventionist (IP)/Director of Nursing (DON) failed to track organisms being treated in the facility and monitor for outbreaks and cross contamination. This had the potential to affect 7 of 7 residents in the facility. The findings include: 1. Review of the facility policy titled, Surveillance for Infections, dated 9/2017, revealed, .The Infection Preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions .The purpose of the surveillance of infections is to identify both individual case and trends of epidemiologically significant organisms and Healthcare-Associated Infections, to guide appropriate interventions, and to prevent future infections .For residents with infections that meet the criteria for definition of infection for surveillance, collect the following data .resident's name .room number .unit .date of onset of infection .Infection site .Pathogens . Review of the facility policy titled, Infection Control, dated 10/2018, revealed .This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections .The objectives of our infection control policies and practices are to .Prevent, detect, investigate, and control infections in the facility . Review of the facility policy titled, Infection Prevention and Control Program, dated 10/2018, revealed .An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections .The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection .Surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, detecting unusual pathogens with infection control implications .Culture reports, sensitivity date, and antibiotic usage reviews are included in surveillance activities . 2. Review of the INFECTION CONTROL PROGRAM, monitoring documents dated 1/2025, 2/2025, 3/2025, and 4/2025, revealed .Infections by Unit .UTI [urinary tract infection] by Unit .URI [upper respiratory infection] by Unit .Wounds/Skin by Unit .GI [gastrointestinal infection] by Unit .Other Categories .ANALYSIS OF ANTIBIOTIC USAGE BASED ON INFECTION TYPE . There was no documentation listed in the INFECTION CONTROL PROGRAM, that named the organism that was being tracked. 3.During an interview on 6/3/2025 at 3:03 PM, IP/DON confirmed that she does not track the organisms in the INFECTION CONTROL PROGRAM. IP/DON was unable to provide documentation that infection organisms were being tracked.

Based on policy review, medical record review, and interview, the facility failed to follow physician orders for the care and services of a dialysis fistula (a plastic device inserted into a vein or artery to deliver treatment for kidney failure), failed to provide documentation between the facility and the dialysis center, and failed to revise the care plan related to the care of a dialysis fistula for 1 of 1 (Resident #4) residents reviewed for dialysis. The findings include: 1.Review of the facility policy titled, End-Stage Renal Disease, Care of a Resident with, dated October 2010, revealed .Staff caring for resident with ESRD (End Stage Renal Disease) including residents receiving dialysis care outside facility, shall be trained in the care and special needs of these residents .The care of grafts and fistula [plastic devices inserted into the an extremity to deliver treatment for kidney disease] .The resident's comprehensive care plan will reflect the resident ' s needs related to ESRD/dialysis care . Review of the facility policy titled, Hemodialysis Access Care, dated October 2010, revealed .Hemodialysis .Care involves the primary goal of preventing infection and maintaining patency of the catheter (preventing clots) .Keep site clean at all times .Check for signs of infection (warmth, redness, tenderness or edema) at the access site when performing routine care and at regular intervals .Check the patency of the site at regular intervals. Palpate (touch) the site to feel the thrill, or use a stethoscope to hear the whoosh of bruit [whooshing sound produced by blood flow through the fistula] of blood flow through the access .The general medical nurse should document in the resident ' s medical record every shift as follows .location of catheter .condition of dressing (interventions as needed) .If dialysis was done during shift .any part of report from dialysis nurse post [after]-dialysis being given .observations post [after] dialysis . 2.Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses including, End Stage Renal Disease, Dependance on Renal Dialysis, Chronic Kidney Disease, and Hypertension. Review of the admission Minimal Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #4 was cognitively intact. Resident #4 received Hemodialysis. Review of the Physician Order dated 5/1/2025 revealed .Dialysis on TThSat [Tuesday, Thursday, Saturday] @ [at] [named facility]- 3 Times per week on TThSat with pick-up @ 11[11:00] am For END STAGE RENAL DISEASE [ESRD] . Review of the Physician Order dated 5/6/2025 revealed .check LUE [left Upper Extremity] Fistula [a connection between an artery and a vein, surgically created for dialysis] for thrill [a palpable vibration or buzz felt when touching the fistula, indicating the flow of blood through it. A thrill is a key sign that the fistula is functioning correctly] qday [every day] . Review of the Physician Order dated 5/7/2025 revealed .dialysis on MWF [Monday, Wednesday, Friday] @ [named facility] .3 times per week on MWF @ 11[11:00] am w [with]/pick-up at 10:15am with [named facility] to transport. For (ESRD) . Review of the Care Plan dated 5/9/2025 revealed .chronic kidney disease and receives dialysis on Monday, Wednesday, and Friday .Monitor Fistula for Thrill and bruit every shift and PRN [as needed] .Notify MD [Medical Doctor] of problems . Review of Interdisciplinary Notes revealed the facility was able to provide documentation that the fistula was monitored for thrill on 5/10/2025, 5/16/2025, 5/19/2025, 5/26/2025, and 5/27/2025. No other documentation could be provided for 28 days out of 33 days since admission. Review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for May and June 2025, revealed no documentation that the thrill was monitored per physician order for Resident #4. 3.During an interview on 6/3/2025 at 9:35 AM, LPN A was asked how the facility communicated with the dialysis center. LPN A stated . We send a dialysis cover sheet with him which includes his vital signs, weight, and the address he ' s going to . LPN A was asked if she could provide the communication sheets. LPN A was unable to provide a record of the communication between the facility and the dialysis center. LPN A was asked if she checked the thrill as was stated in Resident #4 ' s care plan. LPN A stated, .no I don ' t check the thrill . During an interview on 6/3/25 at 5:16 PM, the Director of Nursing (DON) confirmed the care plan should be updated immediately and should reflect the Physician current order. The DON was unable to provide record of communication between facility and dialysis. The facility failed to provide communication between the dialysis center and the facility, the facility failed to follow physicians order related to dialysis, the facility failed to revise the care plan to reflect the Physician order and staff failed to monitor the thrill every day as ordered.

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by dark black and brown build-up on skillets, baking pans, convection ovens, deep fat fryers, and that chicken was thawed properly. The facility had a census of 23 residents with 23 of those residents receiving a tray from the kitchen. The findings include: 1. The facility's Sanitation policy revised (MONTH) 2008 documented, .The food service area shall be maintained in a clean and sanitary manner .All kitchens, kitchen areas .shall be kept clean .All equipment .shall be washed to remove or completely loosen soils . The facility's Food Preparation and Service policy revised (MONTH) 2019 documented, .Thawing Frozen Food .Thawing procedures include .Completely submerging the item in cold running water .that is running fast enough to agitate and remove loose ice particles . 2. Observations in the kitchen beginning on 7/1/19 at 9:32 AM, revealed the following: a. 8 skillets with a scratched coating and dark build-up b. 7 baking pans with black and brown build-up on the top and the bottom c. chicken breasts in both sides of a 2 compartment sink, submerged under water, without water running over them on 1 side of the sink, and only a slight drip of water on the other side of the sink Observations in the kitchen beginning on 7/2/19 at 8:50 AM, revealed the following: a. 2 convection ovens with food particles and a black and brown build-up inside b. 3 deep fat fryers with loose particles on the top sides and a thick brown build-up around the sides Interview with the Culinary Director on 7/3/19 at 10:03 AM, in the Harmony Room, the Culinary Director was asked should skillets have a scratched coating and a black and brown build-up. The Culinary Director stated, That's not a standard of practice. The Culinary Director was asked should chicken breasts be thawing in the sink submerged under water without water running over them. The Culinary Director stated, That's not our standard of practice . The Culinary Director was asked should the convection ovens be dirty with food particles and black and brown build-up inside. The Culinary Director stated, That is not a standard of practice. The Culinary Director was asked should the deep fat fryers have crumbs and a thick brown build-up around the side. The Culinary Director stated, That is not the standard of practice.

Based on review of MED-PASS DIABETES: Injectable Medications provided by the American Society of Consultant Pharmacist, policy review, medical record review, observation, and interview, the facility failed to ensure residents were free of significant medication errors when 2 of 2 (Licensed Practical Nurse (LPN) #1 and #5) nurses failed to administer insulin correctly in correlation with meals. LPN #1 and #5 failed to administer insulin within the proper time frame related to food intake for Resident #4 and #10, which resulted in significant medication errors. The findings include: 1. The MED-PASS DIABETES: Injectable Medications provided by the American Society of Consultant Pharmacist for typical dosing administration of insulin related to meals documented, .Humalog .Onset (In hours, unless noted) .15 min (minutes) TYPICAL ADMINISTRATION/COMMENTS .5 minutes prior to meals or immediately after eating . 2. The facility's Insulin Administration policy revised (MONTH) 2014 documented, .To provide guidelines for the safe administration of insulin to residents with diabetes .Type .Rapid-acting .Onset .10-(to)15 min . 3. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Humalog .100 units/ml (milliliters) subcutaneous .Four Times a Day For TYPE 2 DM (Diabetes Mellitus) .201-250=(equal)4 units . Observations in Resident #4's room on 7/1/19 at 11:45 AM, revealed LPN #1 administered 4 units of Humalog to Resident #4. At 12:12 PM, the resident received her lunch tray, 27 minutes after receiving the insulin. The failure of the nurse to provide a meal or substantial snack within 15 minutes of administration of the Humalog resulted in a significant medication error. 4. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's telephone orders dated 6/9/19 documented, .Humalog SSI (sliding scale insulin) .201-250=4 units . Observations in Resident #10's room on 7/3/19 at 5:32 AM, revealed LPN #5 administered 4 units of Humalog to Resident #10. At 7:37 AM, the resident received her breakfast tray, 2 hours and 5 minutes after receiving the insulin. The failure of the nurse to provide a meal or substantial snack within 15 minutes of administration of the Humalog resulted in a significant medication error. Interview with LPN #5 on 7/3/19 at 7:37 AM, at the Nurses' Station, LPN #5 was asked when should a resident receive a snack or meal after receiving Humalog insulin. LPN #5 stated, Within 30 minutes. Interview with the Certified Pharmacy Technician on 7/3/19 at 8:32 AM, in the Senior Staffing Lounge, the Certified Pharmacy Technician was asked how soon should a resident receive a snack or meal after receiving Humalog insulin. The Certified Pharmacy Technician stated, .Within 15 minutes .

Based on policy review, observation, and interview, 5 of 6 (Wound Care Nurse, Licensed Practical Nurse (LPN #1, #3, #4, and #5) nurses failed to ensure the practices to prevent the potential spread of infection were followed during wound care and medication administration observations. The findings include: 1. The facility's HANDWASHING/HAND HYGIENE policy revised on (MONTH) (YEAR), documented, .This facility considers hand hygiene the primary means to prevent the spread of infections .Use an alcohol-based hand rub containing at least 62% alcohol; or, alternately, soap (antimicrobial or non-antimicrobial) with water for the following situations .Before handling clean or soiled dressings, gauze pads .Before moving from a contaminated body site to a clean body site during resident care .After removing gloves .turn off faucets with a clean, dry paper towel . 2. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #5's room on 7/2/19 at 10:47 AM, revealed the Wound Care Nurse washed his hands then turned off the faucet with his bare hands. Interview with the Wound Care Nurse on 7/3/19 at 7:43 AM, in the Senior Staff Lounge, the Wound Care Nurse was asked how should the faucet be turned off after washing hands. The Wound Care Nurse stated, With a clean paper towel. Medical record review revealed Resident #117 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #117's room on 7/2/19 at 3:01 PM, revealed the Wound Care Nurse gathered the wound care supplies, turned the resident to the right side, removed the old dressing, removed his gloves, applied new gloves, and did not perform hand hygiene. The Wound Care Nurse helped Resident #117 turn to the right side and then measured and cleaned the wound with the same gloves on. He assisted the resident to her back and placed a pillow behind her. He then removed the gloves and did not perform hand hygiene. Interview with the Director of Nursing (DON) on 7/3/19 at 10:33 AM, in the DON Office, the DON was asked what would she expect staff to do after they remove gloves and before they don new gloves. The DON stated, .wash hands before and after . The DON was asked after performing wound care, would she expect staff to keep the same gloves on and have contact with the resident. The DON stated, No, should have taken off their gloves and washed hands before contact .that's our practice . 3. Observations on 7/1/19 at 11:31 AM, in Resident #4's bathroom, revealed LPN #1 washed her hands and turned off the faucet with the same wet paper towel. Observations on 7/1/19 at 3:58 PM, in Resident #68's room, revealed LPN #3 entered the room to administer medications. LPN #3 dropped the [MEDICATION NAME] capsule between the folds of Resident #68's blanket, picked up the capsule, and placed it in the resident's mouth. Observations on 7/1/19 at 4:24 PM, in Resident #4's bathroom, revealed LPN #4 washed her hands and used the same wet paper towel to turn off the faucet. Observations on 7/2/19 at 11:57 AM, in Resident #11's bathroom, revealed LPN #1 washed her hands and used the same wet paper towel to turn off the faucet. Observations on 7/3/19 at 5:07 AM, in Resident #10's bathroom, revealed LPN #5 washed her hands and used the same wet paper towel to turn off the faucet. LPN #5 then used the same wet paper towel to wipe around the sink. Interview with LPN #5 on 7/03/19 at 5:48 AM, at the Nurses' Station, LPN #5 was asked how should the faucet be turned off after washing hands. LPN #5 stated, With a dry paper towel. Interview with the Director of Nursing (DON) on 7/3/19 at 9:37 AM, in the Administrator Office, the DON was asked how should the staff members turn off the faucet after hand washing. The DON stated, With a clean paper towel. The DON was asked should the nursing staff turn off the faucet with their bare hands. The DON stated, No. The DON was asked should the nurse have picked up the pill from the resident's blanket and then gave the medication to the resident. The DON stated, No, she should not have done that .

Based on review of MED-PASS DIABETES: Injectable Medications provided by the American Society of Consultant Pharmacist, policy review, medical record review, observation, and interview, the facility failed to ensure 4 of 5 (Licensed Practical Nurse (LPN) #1 #3, #4, and #5) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 4 errors were observed out of 27 opportunities, resulting in an error rate of 14.81%. The findings include: 1. The MED-PASS DIABETES: Injectable Medications provided by the American Society of Consultant Pharmacist for typical dosing administration of insulin related to meals documented, .Humalog .Onset (In hours, unless noted) .15 min (minutes) TYPICAL ADMINISTRATION/COMMENTS .5 minutes prior to meals or immediately after eating . 2. The facility's Insulin Administration policy revised (MONTH) 2014 documented, .To provide guidelines for the safe administration of insulin to residents with diabetes .Type .Rapid-acting .Onset .10-(to)15 min . The facility's Administering Medications policy revised (MONTH) 2012 documented, .Medications must be administered in accordance with the orders, including any required time frame .Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified . 3. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Humalog .100 units/ml (milliliters) subcutaneous .Four Times a Day For TYPE 2 DM (Diabetes Mellitus) .201-250=(equal) 4 units . Observations in Resident #4's room on 7/1/19 at 11:45 AM, revealed LPN #1 administered 4 units of Humalog to Resident #4. At 12:12 PM, the resident received her lunch tray, 27 minutes after receiving the insulin. The failure of the nurse to provide a meal or substantial snack within 15 minutes of administration of the Humalog resulted in medication error #1. 4. Medical record review revealed Resident #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Calcium [MEDICATION NAME] 600 mg .1 tablet By Mouth Twice a Day . Observations in Resident #68's room on 7/1/19 at 3:58 PM, during medication administration, LPN #3 removed medications one by one from the medication cup with her gloved hand and administered medications to Resident #68. The plastic medication cup was noted to have a large amount of white creamy substance remaining. LPN #3 was asked what the white substance was. LPN #3 stated, I must have spilled water into the medication cup .that was the calcium pill that dissolved in the cup . LPN #3 tossed the medication cup containing the dissolved calcium pill into the trash can. LPN #3 did not administer the calcium as ordered, which resulted in medication error #2. 5. Medical record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] 325 mg (milligrams) 2 tablets By Mouth Four Times a Day For PAIN . Observations at medication cart #1 on 7/2/19 at 4:33 PM, LPN #4 stated the [MEDICATION NAME] (Tylenol) tablets were on hold. LPN #4 left the tablets on top of her computer and entered Resident #14's room and completed her medication administration. LPN #4 returned to the medication cart and placed the Tylenol tablets in the top drawer of the medication cart. LPN #4 did not administer the Tylenol as ordered, which resulted in medication error #3. 6. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's telephone orders dated 6/9/19 documented, .Humalog SSI (sliding scale insulin) .201-250=4 units . Observations in Resident #10's room on 7/3/19 at 5:32 AM, revealed LPN #5 administered 4 units of Humalog to Resident #10. At 7:37 AM, the resident received her breakfast tray, 2 hours and 5 minutes after receiving the insulin. The failure of the nurse to provide a meal or substantial snack within 15 minutes of administration of the Humalog resulted in medication error #4. Interview with the Unit Manager on 7/3/19 at 6:19 AM, at the Nurses' Station, the Unit Manager was asked should the nurse have given Resident #14's Tylenol. The Unit Manager stated, Yes, she should have . The Unit Manager was asked if a calcium pill dissolved in the medication cup during medication administration, should the nurse have ensured that Resident #68 received the correct dose of calcium. The Unit Manager stated, Yes, he should get the right dose. Interview with the Certified Pharmacy Technician on 7/3/19 at 8:32 AM, in the Senior Staffing Lounge, the Certified Pharmacy Technician was asked how soon should a resident receive a snack or meal after receiving Humalog insulin. The Certified Pharmacy Technician stated, .Within 15 minutes . Interview with the Director of Nursing (DON) on 7/3/19 at 9:37 AM, in the Administrator Office, the DON was asked should Resident #14 have received the Tylenol as ordered. The DON stated, Yes. The DON was asked should the nursing staff make sure the residents are getting their entire dose of medications as ordered. The DON stated, Yes.

Based on policy review, observation, and interview, the facility failed to ensure medications were stored properly and safely in 1 of 5 (Medication Cart #1) medication storage areas and failed to ensure medications were stored securely when 1 of 5 (Licensed Practical Nurse (LPN) #4) nurses left medications unattended. The findings include: 1. The facility's Storage of Medications policy revised (MONTH) 2007 documented, .Drugs for external use, as well as poisons, shall be clearly marked as such, and shall be stored separately from other medication . The facility's Administering of Medications policy revised (MONTH) 2012 documented, .No medications are kept on top of the cart .The cart must be clearly visible to the personnel administering medications . 2. Observations in Medication Cart #1's drawer on 7/1/19 at 9:54 AM, revealed the following: a. 1 pack of Adult wipes b. 4 bottles of Polyethylenene [MEDICATION NAME] c. 1 bottle of [MEDICATION NAME] Syrup d. 1 bottle of Mucus & Chest Congestion e. 1 bottle of Pro Stat sugar free f. 1 bottle of [MEDICATION NAME] g. 1 bottle of Sore Throat spray h. 1 bottle of Acid Gas Relief tablets i. 1 box of Anti-Diarrheal tablets Interview with LPN #2 on 7/1/19 at 9:57 AM, at Medication Cart #1, LPN #2 was asked should adult wipes be stored in the same compartment with medications on the medication cart. LPN #2 stated, No, ma'am. Observations on 7/1/19 at 4:09 PM, outside of Residents #4's room, revealed LPN #4 placed a vial of [MEDICATION NAME] and a vial of Humalog on top of the medication cart. LPN #4 entered Resident #4's room, closed the door, and left the 2 vials of insulin on top of the medication cart unattended and out of sight. LPN #4 returned to the medication cart and drew up the insulin. LPN #4 returned to Resident #4's room, administered the insulin, and left the vials of insulin on the medication cart unattended and out sight of the nurse. Observations on 7/2/19 at 4:38 PM, outside of Resident #14's room, revealed LPN #4 placed 2 packaged Tylenol capsules on the medication cart and stated the Tylenol were on hold. LPN #4 left the Tylenol in their package on top of her computer key board, out of sight and unattended. LPN #4 entered Resident #14's room, closed the door, and completed her medication administration. Interview with LPN #4 on 7/2/19 at 4:48 PM, outside of Resident #14's room, LPN #4 was asked should medications be on top of the medication cart unattended and out of sight. LPN #4 stated, No. Interview with the Unit Manager on 7/3/19 at 6:19 AM, at the Nurses' Station, the Unit Manager was asked should the nursing staff leave medications on top of the medication cart unattended and out of sight. The Unit Manager stated, No. The Unit Manager was asked should the medication carts have internals and externals in the same compartment on the medication cart. The Unit Manager stated, No.

Based on policy review, medical record review, observation, and interview, the facility failed to follow the physician orders for oxygen and a breathing treatment for 3 of 3 (Resident #12, 15, and 19) sampled residents reviewed for respiratory services. The findings included: 1. The facility's Oxygen Administration policy dated (MONTH) 2010 documented, .Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration .Steps in the Procedure .10. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered .Documentation .3. The rate of oxygen flow, route, and rationale . 2. Medical record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Plan dated 8/19/18 documented, .at risk for complications related to [MEDICAL CONDITIONS] on continuous O2 (oxygen) .Provide oxygen as ordered . The physician's order dated 9/17/18 documented, .Oxygen - 2L (liters) Nasal Continuous . Observations in Residents #12's room on 9/16/18 at 11:05 AM and in the Rehab Dining room on 9/17/18 at 8:27 AM and 9:44 AM, revealed Resident #12 was receiving oxygen via nasal cannula at a flow rate of 3 liters/minute. Interview with Registered Nurse (RN) #1 on 9/17/18 at 10:16 AM, in the Rehab Nurses' station, RN #1 was asked if Resident #12 had an order for [REDACTED].#1 was asked to confirm Resident #12's oxygen rate. RN#1 confirmed the oxygen was on 3 liters and turned the oxygen down to 2 liters. RN #1 was asked if the flow rate of the oxygen was correct. RN #1 stated, No it was incorrect. Interview with the Director of Nursing (DON) on 9/17/18 at 1:55 PM in the Senior Staff lounge, the DON was asked if it acceptable for a resident to be on 3 liters of oxygen if the order was for 2 liters. The DON stated, No, it should have been on 2 liters . 3. Medical record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The STANDING ORDERS (YEAR) documented,DYSPNEA OR SHORTNESS OF BREATH .OXYGEN AT 2L BNC (binasal cannula) . The Interdisciplinary Notes dated 9/8/18 documented, .O2 @ (at) 3L BNC in use . Observations in Resident #15's room on 9/16/18 at 11:00 AM, revealed Resident #15 was lying in the bed with O2 on at 3L by nasal cannula. Interview with the DON on 9/17/18 at 10:30 AM, in the Senior Staff lounge, the DON confirmed the standing orders documented O2 to be at 2L BNC. 4. Medical record review revealed Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The PHYSICIAN TELEPHONE ORDER dated 9/12/18 documented, .[MEDICATION NAME] (a breathing treatment) BID (twice a day) indefinitely . Review of the (MONTH) (YEAR) Medication Record revealed no documentation that the [MEDICATION NAME] had been given twice a day as ordered. Observations in the Rehab lounge area on 9/16/18 at 11:19 AM, revealed Resident #43 was seated in a wheelchair with audible wheezing. Interview with RN #1 on 9/17/18 at 11:03 AM, in the Rehab (Rehabilitation) Nurses' station, RN #1 was asked if Resident #19 had been receiving [MEDICATION NAME] twice a day as ordered. RN #1 stated, It does not appear she has .didn't transcribe the order correctly . RN #1 was asked since 9/12/18 the number of [MEDICATION NAME] treatments Resident #19 had received . RN #1 stated, .none on the 12th, 13th, 14th, 15th .the order said continuously . Interview with the DON on 9/18/18 at 8:00 AM, in the Rehab Nurses' station, the DON was asked if the breathing treatments should have been on the medication record. The DON stated, .should have been transcribed on the MAR (Medication Administration Record) .

Based on policy review, medical record review, observation, and interview, the facility failed to ensure appropriate infection control practices were followed when signage for isolation was not posted for 1 of 1 (Resident #226) sampled residents observed in isolation and when 1 of 3 (Licensed Practical Nurse (LPN ) #1) nurses did not perform hand hygiene between glove use during medication administration observations. The findings included: 1. The facility's Isolation - Categories of Transmission-Based Precautions policy revised (MONTH) 2012 documented, .Contact Precautions 1. In addition to Standard Precautions, Implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with resident or indirect contact with environmental surfaces or resident-care items in the resident's environment .8. Signs - The facility will implement a system to alert staff to the type of precaution resident requires . Medical record review revealed Resident #226 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. The Interdisciplinary Notes dated 9/14/18 documented, .Today noted to have several loose slimy stools every attends change/4-5x (times). Medical Team alerted; will place on Contact isolation . Observations in Resident #226's room on 9/16/18 at 10:30 AM, 3:01 PM, 9/17/18 at 7:57 AM, 10:16 AM, 1:55 PM, and 9/18/18 at 8:08 AM, revealed a cart with personal protective equipment. There was no sign on the door indicating the resident was in isolation. Interview with LPN #1 on 9/17/18 at 1:45 PM at the Rehab Nurses' station, LPN #1 was asked if a resident was in contact isolation should there be a sign to be on the door to alert staff and visitors. LPN #1 stated, Yes. 2. The facility's Personal Protective Equipment (PPE) - Using Gloves policy revised (MONTH) 2010 documented, .Purpose To guide the use of gloves .Objectives 1. To prevent the spread of infection .3. To protect hands from potentially infectious material .Miscellaneous .5. Wash hands after removing gloves. (Note: Gloves do not replace handwashing.) . The facility's Handwashing/Hand Hygiene policy revised (MONTH) (YEAR) documented, .Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation .7 .m. After removing gloves .9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections . Observations in front of the Rehab Nurses' station on 9/17/18 at 9:50 AM revealed LPN #1 washed her hands, applied gloves, prepared the medications for Resident #226, removed the gloves, entered Resident #226's room, applied PPE and gloves without performing hand hygiene, and administered eye drops to this resident. LPN #1 removed her gloves and applied new gloves without performing hand hygiene, checked gastrostomy tube placement, and administered medications through the gastrostomy tube. LPN #1 then removed the PPE and gloves and washed her hands. LPN #1 went to the medication cart, applied gloves, cleaned the bag containing the eye drops with a bleach wipe, removed her gloves, and obtained the next set of eye drops to administer to the resident. LPN #1 entered Resident #226's room, applied PPE and gloves without performing hand hygiene, and administered eye drops to the resident. Interview with the Director of Nursing (DON) on 9/18/18 at 10:35 AM, in the Senior Staff lounge, the DON was asked what nurses should be do after the removal of gloves and application of new gloves. The DON stated, Wash hands.

Based on policy review, observation and interview, the facility failed to ensure food was stored, prepared and served in a sanitary manner when 3 bins were wet nested in the kitchen which could potentially affect 28 of the 30 residents in the facility who receive a meal tray, desserts were uncovered on trays in a hallway on 1 of 2 dining observations, and 1 of 15 (Certified Nursing Assistant (CNA) #2) staff members did not perform hand hygiene between touching objects and feeding a resident. The findings included: 1. The facility's Food Preparation and Service Policy documented, .Food preparation equipment and utensils that are manually washed will be allowed to air dry . Observations in the kitchen on on 6/26/16 beginning at 9:55 AM, revealed 3 large bins wet nested on a rack. Interview with the Dietary Director (DD) on 6/26/16 at 10:00 AM, in the kitchen, the DD was asked if the bins should be stacked up while wet. The DD stated, They should not be. 2. Observations on the C hall on 6/26/16 at 12:20 PM, revealed 3 trays of uncovered individual desserts on a rolling cart being pushed down the hallway. Interview with the Director of Nursing (DON) on 6/28/16 at 2:50 PM, in the Harmony Room, the DON was asked if food should be uncovered on a cart being pushed down the hall. The DON stated, No. 3. Observations in the Rehabilitation Unit dining room on 6/26/16 at 12:30 PM, revealed CNA #2 grabbed a chair and pulled it up to the table, touched the back of the wheelchair, touched the back of the resident, then sat down and began to feed the resident. CNA #2 did not perform hand hygiene after touching the objects and before feeding the resident. Interview with the DON on 6/29/16 at 9:00 PM, in the Harmony Room, the DON was asked if a CNA should touch objects and then feed a resident without performing hand hygiene. The DON stated, .if they touch things in the environment .would expect them to wash their hands . 4. Observations at the nurses station on 6/27/16 at 6:15 PM, revealed LPN #6 dropped a can of Ensure on the floor in the nourishment room. LPN #6 then picked up the can off of the floor and placed it in the nourishment room refrigerator beside other food products. Interview with the DON on 6/29/16 at 6:10 PM, in the Harmony Room, the DON was asked if it was acceptable to place a can of Ensure that had fallen on the floor in the nourishment refrigerator. The DON stated, I would wipe it down .

Based on medical record review and interview the facility failed to follow care plan interventions related to nutritional supplements for 1 of 17 (Resident #49) sampled residents of the 30 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician orders [REDACTED].Ensure BID (twice daily) c (with) meals Prostat 30 ml (milliters) po (per mouth) q (every) day . The Medication Record for the month of May and June 2016 did not document Resident #49 received Ensure from 6/1/2016 to 6/28/16 and the Prostat from 5/10/16 to 6/28/16. The care plan dated 5/27/16 documented, .At risk for weight loss related to new admit to skilled nursing .provide supplements as ordered: .ensure . Interview with the Director of Nursing (DON) on 6/28/16 at 2:00 PM, in the Harmony room, the DON was asked if Ensure should be documented as ordered. The DON stated, Yes. The DON was asked if she would expect a resident with an order for [REDACTED]. Interview with LPN #2 on 6/28/16 at 2:40 PM, at the nurses station, LPN #2 was asked if Resident #49 received Prostat as ordered. LPN #2 stated, No, ma'am LPN #2 was asked if Resident #49 received Ensure as ordered. LPN #2 stated, No, ma'am .

Based on policy review, observation, and interview, the facility failed to ensure that all medications and biologicals were stored properly when left unattended by 1 of 5 (Licensed Practical Nurse (LPN) #4) nurses and an expired medication was observed in 1 of 3 (C hall medication room) storage areas. The findings included: 1. The facility's Storage of Medications policy documented, .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Observations outside of Resident #68's room on [DATE] at 4:22 PM, revealed LPN #4 placed the resident's insulin pen on the medication cart, unattended. Interview with LPN #4 on [DATE] at 4:25 PM, outside of Resident #68's room, LPN #4 was asked if the insulin pen should have been left unattended. LPN #4 stated, No. 2. The facility's Storage of Medication policy documented that .The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals . Observations in the C hall medication room on [DATE] at 2:14 PM, revealed a box of Heparin lock syringes with a (former resident's) name on it, with a receive date of [DATE] and an expiration date of [DATE]. Interview with LPN #2 on [DATE] at 3:02 PM, in the C hall medication room, LPN #2 was asked if the Heparin syringes were out of date. LPN #2 stated, Yes, they expired 01 of 2016.

Based on policy review, medical record, and interview, the facility failed to ensure documentation of wound care for 1 of 3 (Resident #49) sampled residents reviewed of the 3 residents with a pressure ulcer. The findings included: Review of the facility's Wound Care policy documented, .Documentation .The type of wound care given .The date and time the wound care was given .The name and title of the individual performing the wound care .The signature and title of the person recording the data . Medical record review revealed Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Skin Assessment Form dated 5/6/16 documented .unstageable pressure wound (L) (left) lateral heel . The Medication Record documented, .clean unstageable pressure wound (L) (left) lateral heel c (with) NS (Normal Saline) Pat dry, Apply [MEDICATION NAME] Cream to wound edges, Santyl/ointment to wound bed, cover c Abd (abdominal) pad and wrap c kerlix q (every) day & (and) PRN (as needed) until resolved . The Medication Record had no documentation wound care was provided on 5/11/16 and 5/22/16. Interview with the Wound Care nurse (WC) on 6/28/16 at 10:15 AM, in the hallway outside Resident #49's room, the WC nurse was asked if wound care was performed on 5/11/16 and 5/22/16. The WC nurse stated, .I would think had not . Interview with the Director of Nursing (DON) on 6/28/16 at 12:35 PM, in the dining room, the DON was asked would you expect wound care be documented. The DON stated, .Yes .

Based on medical record review, and interview, the facility failed to provide residents their choice of bathing for 1 of 27 (Residents #51) sampled residents reviewed regarding choices in the Stage 1 Review. The findings included: Review of the facility's Certified Nursing Assistant (CNA) Assignment Sheet 3-11 Shift documented, .(Resident #51) was scheduled to receive a shower on Tuesday, Thursday and Saturday . Medical record review revealed Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented that Resident #51 needed extensive assistance with personal hygiene and physical assistance with bathing. Review of the facility's SHOWER SHEETS revealed that Resident #51 did not receive a shower. There was no documentation that she refused a shower for the following dates: 6/9/16, 6/11/16, 6/14/16, 6/16/16, 6/18/16, 6/21/16 and 6/23/16. Interview with Resident #51 on 6/26/16 beginning at 4:58 PM, in Resident #51's room, Resident #51 stated .has only had two maybe three showers since she was admitted . Interview with CNA #1 on 6/28/16 at 10:02 AM, in the Rehabilitation Unit Dining Room, CNA #1 stated, .last Saturday Resident #51 said she had not been getting a shower . I spoke with the nurse and told her about the resident stating she had not been getting her showers on 3-11 shift . Interview with Registered Nurse (RN) #1 on 6/28/16 at 9:02 AM, in the Sun Room, RN #1 stated, .heard about the resident not receiving her showers in the stand up meeting .and found the showers were not done according to schedule .if a resident refused her shower it should be documented on the shower sheet and care planned. RN #1 was asked if the refusals were documented on the shower sheets, RN #1 stated, No. Interview with the Director of Nursing (DON) on 6/29/16 at 9:18 AM, in the Harmony Room, the DON was asked what the minimum number of showers per week should be. The DON stated, Three a week. The DON was asked to provide the shower sheets for Resident #51. The DON could not provide shower sheets for the following dates: 6/9/16, 6/11/16, 6/14/16, 6/16/16, 6/18/16, 6/21/16 and 6/23/16. The DON was asked what should the staff do if a resident refuses or does not receive a shower. The DON stated, I would expect the staff to write refused on the shower sheet and report it to the nurse .

Based on policy review, resident rights review, medical record review, and interview, the facility failed to notify the resident or their family of a new roommate assigned to her room before the new roommate arrived for 1 of 11 (Resident #8) residents reviewed of the 27 sampled residents in the stage 1 review. The findings included: The facility's Transfer, Room to Room policy documented, .A roommate will be informed of any new transfer into his/her room . The facility's RESIDENT RIGHTS policy documented, .The facility must also promptly notify the resident and, if known, the resident's legal representative or interested family member when there is- (A) A change in room or roommate assignment as specified in §483.15(e)(2) . Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with Resident #8 on 6/26/16 at 4:43 PM, in her room, Resident #8 was asked if she was notified when there was a roommate change. Resident #8 stated, A roommate was just moved in night before last. They just moved her in. Interview with Licensed Practical Nurse (LPN) #1 on 6/28/16 at 9:35 AM, in the admission nurse office, LPN #1 was asked if a resident is notified when they are assigned to get a new roommate. LPN #1 stated, .Usually . LPN #1 was asked if the family was notified about new roommates. LPN #1 stated, .There is not a reason . LPN #1 was asked if there any documentation that either the resident or the family is notified. LPN #1 stated, . I don't think so. LPN #1 was then asked if there was any documentation that Resident #8 was notified that she was getting a new roommate. After reviewing the chart, LPN #1 stated, I don't see anything documented.

Based on policy review, medical record review, and interview, the facility failed to ensure that residents received the correct medication for 1 of 30 (Resident #72) sampled residents in the stage 2 review. The findings included: 1. The facility's Reconciliation of Medications on Admission policy documented .Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer/process. Medical record review revealed Resident #72 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's POST ACUTE admission orders [REDACTED].Q Day(every day) . The current physician orders did not have Duloxetine listed. Interview with the Unit Manager, Registered Nurse (RN) #1 on 6/28/16 at 3:50 PM, at the C hall nurses station, RN #1 was asked if Resident #72 was getting medication for depression. RN #1 stated, Not at this time. RN #1 was asked if she had been receiving the medication. RN #1 stated that Resident #72 had been receiving Duloxetine in the hospital prior to admission. RN #1 provided the Post-acute orders from the hospital signed and dated 6/8/16 by the physician. RN #1 then asked LPN #3 about the order for Duloxetine. LPN #3 was asked if the order was in the computer. LPN #3 stated, No. LPN #3 was asked if the resident had received the medication since she had been in the facility. LPN #3 stated, Nope.

Based on medical record review and interview, the facility failed to provide nutritional supplements as ordered for 2 of 30 (Resident #49 and 126) sampled residents included in the stage 2 review. The findings included: 1. Medical record review revealed Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].Ensure BID (twice a day) with meals .Prostat 30 mL (milliliters) po (by mouth) q (every) day . Review of the facility's June 2016 Medication Record for Resident #49 revealed no documentation that the Ensure was given as ordered from June 1 to June 28. Review of the facility's May 2016 Medication Record for Resident #49 revealed no documentation that the Prostat was given as ordered from 5/10/16 to 6/28/16. Interview with the Director of Nursing (DON) on 6/28/16 at 2:30 PM, in the Harmony Room, the DON was asked if she expected Ensure to be given to a resident as ordered. The DON stated, .Yes . The DON was asked if she expected Prostat to be given to a resident as ordered. The DON stated, .Yes . Interview with Licensed Practical Nurse (LPN) #2 on 6/28/16 at 2:40 PM, at the C hall nurses station, LPN #2 was asked if Resident #49 received Prostat as ordered. LPN #2 stated, No, ma'am. LPN #2 was asked if Resident #49 received Ensure as ordered. LPN #2 stated, No, ma'am . 2. Medical record review revealed Resident #126 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].Ensure (one) can BID (twice a day) . Review of the facility's MEDICATION RECORD FOR 06/2016 for Resident #126 revealed no documentation that the supplement was given as ordered. Interview with LPN #2 on 6/28/16 at 11:42 AM, at the C hall nurses station, LPN #2 was asked if Resident #126 had received the Ensure as ordered. LPN #2 looked at the medication record for June and stated, .it's not on here .it wasn't put on the MAR (medication administration record) .no. Interview with the DON on 6/28/16 at 11:40 AM, in the Harmony Room, the DON was asked should supplement orders be on the MAR indicated [REDACTED]. The DON stated, Yes.

Based on facility policy, medical record review, and interview, the facility failed to notify the resident's family when a medication was changed for 1 of 30 (Resident #72) sampled residents in the stage 2 review. The findings included: 1. The facility's RESIDENT RIGHTS policy documented, .A need to alter treatment significantly (i.e. (that is), a need to discontinue an existing form of treatment . Medical record review revealed Resident #72 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's POST ACUTE admission orders [REDACTED].Q Day(every day) . The current physician orders did not have Duloxetine listed. Interview with the Unit Manager, Registered Nurse (RN) #1 on 6/28/16 at 3:50 PM, at the C hall nurses station, RN #1 was asked if Resident #72 was getting medication for depression. RN #1 stated, Not at this time. RN #1 was asked if she had been receiving the medication. RN #1 stated that Resident #72 had been receiving Duloxetine in the hospital prior to admission. RN #1 provided the Post-acute orders from the hospital signed and dated 6/8/16 by the physician. RN #1 then asked LPN #3 about the order for Duloxetine. LPN #3 was asked if the order was in the computer. LPN #3 stated, No. LPN #3 was asked if the resident had received the medication since she had been in the facility. LPN #3 stated, Nope. Interview with the Unit Manager, Registered Nurse (RN #1) on 6/28/16 at 3:50 PM, at the C hall nurses station, RN #1 was asked what should be done now that resident had not been receiving the medication. RN #1 stated, We need to call the doctor and notify the family

Based on medical record review, observation, and interview the facility failed to ensure medical records contained complete and accurate documentation of resident medications related to pain medication administration for 1 of 17 (Resident #3) sampled residents of the 30 included in the stage 2 review. The findings included : Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME]-APAP ([MEDICATION NAME]) 5-325 MG (milligram) TAB (tablet) TAKE 1 TABLET BY MOUTH EVERY 4 HOURS AS . Observations on 6/28/16 at 8:45 AM, revealed LPN #2 gave Resident #3 a [MEDICATION NAME] APAP 5-325 mg. LPN # 2 did not document the medication was given in the narcotic book. Interview with LPN #2 on 6/28/16 at 9:05 AM, at the nurses station, LPN #2 was asked if all medications given had been signed (documented) out. LPN #2 stated, Yes, ma'am LPN #2 was asked if the [MEDICATION NAME] had been signed out in the blue book (narcotic book). LPN #2 stated, No and went and documented the [MEDICATION NAME]-APAP 5-325 on the narcotic record. Interview with the Director of Nursing (DON) on 6/29/16 at 6:10 PM, in the Harmony room, the DON was asked when would you expect a [MEDICATION NAME] to be documented in the blue book. The DON stated, At the time of administration .

Based on policy review, observations, and interview, the facility failed to ensure practices to prevent the potential spread of infection were followed by 3 of 5 (Licensed Practical Nurses (LPN # 4, 2, and 5) nurses during medication administration. The findings included: 1. Review of the facility's Handwashing/Hand Hygiene policy documented, .Employees must wash their hands .using antimicrobial or non-antimicrobial soap and water under the following conditions .Before and after performing any invasive procedures .finger stick blood sampling . Observations in Resident #68's room on 6/27/16 beginning at 4:15 PM, revealed LPN #4 performed an accu check (blood glucose monitoring) test and did not wash or sanitize her hands before or after performing the test. Interview in Resident #68's room on 6/27/16 at 4:22 PM, revealed LPN #4 was entering the room and stated, I should have washed my hands before and after that accu check . Interview with the Director of Nursing (DON) on 6/29/16 at 6:10 PM, in the Harmony room, the DON was asked if hands should be washed before or after performing an accu check. The DON stated, Definitely before, wash or sanitize . 2. Review of the facility's Administering Topical Medications policy documented, .Trans-dermal patches .Clean and dry a selected area that is approved for application of the patch . Observations in Resident #3's room on 6/28/16 at 8:50 A M, revealed LPN #2 removed a Rivastigmine [MEDICATION NAME] and placed a new Rivastigimine [MEDICATION NAME] without cleaning the skin after the removal of the patch and before applying the new patch. Interview with the DON on 6/29/16 at 6:10 PM, in the Harmony room, the DON was asked if you would expect the skin to be cleaned before and after applying a Rivastigimine [MEDICATION NAME]. The DON stated, Expect it to be applied to clean skin . 3. Observations in Resident #116's room on 6/28/16 beginning at 9:10 AM, revealed LPN #5 took [MEDICATION NAME] nasal spray out of her pocket in a plastic bag and administered the nasal spray after lying the plastic bag on the bedside table. The [MEDICATION NAME] was placed back in the plastic bag and then LPN #5 placed the [MEDICATION NAME] back in the medication cart without any type of sanitation. Interview with the DON on 6/29/16 at 6:10 PM, in the Harmony room, the DON was asked would you expect nasal spray to be taken into a resident's room in her uniform pocket and then returned to the medication cart without any type of sanitation. The DON stated, Probably not .