Every finding on record at Lake Prince Woods, Inc

Based on observation and staff interviews, the facility's staff failed to maintain dignity during mealtime for 2 of 26 residents (Resident #7 and Resident #30) in the survey sample.The findings included:1.The facility staff failed to maintain dignity during mealtime by feeding two residents at the same time. Resident #7 was originally admitted to the facility on [DATE] and re-admitted on [DATE] after an acute care hospital stay. The current diagnoses included; Vascular Dementia. The admission, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/29/25 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long-term and short-term memory problems, as well as moderately impaired for daily decision making. The person-centered care plan dated 10/02/25 read that Resident #7 is at risk for impaired nutritional status related to vascular dementia. The Goal for the resident was that the resident would eat 50% of her meal. The interventions are: Assist x 1 with eating and provide a mechanical soft diet with thin liquids.In sectionG(Physical functioning) the resident was coded as requiring assistance with eating, bathing, dressing, and using the toilet.On 11/25/25 at approximately 12:00 pm, a dining observation was made in the dining room. Certified Nursing Assistant (CNA) was observed sitting at a dining room table between two residents, Resident #7, who was observed sitting in a [NAME] chair to the left of CNA #1, was being fed, and Resident #30 was observed sitting in a [NAME] chair to the right of CNA #1, asleep. CNA #1 was observed trying to arouse Resident #30 in between feeding Resident #7, oftentimes attempting to feed both residents simultaneously without washing her hands. 2.The facility staff failed to maintain dignity during mealtime by feeding two residents at the same time. Resident #30 was originally admitted to the facility 6/05/25 after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; Cognitive Communication Deficit. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/05/25 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long-term and short-term memory problems, as well as severe impairment for daily decision making. In sectionG(Physical functioning) the resident was coded as requiring assistance with eating, bathing, dressing, and using the toilet. The person-centered care plan dated 6/05/25 read that Resident #30 is at risk for impaired nutrition related to an end-of-life process, senile degeneration of the brain, with anxiety. The goal for Resident #30 was to have the resident consume 50% of his meals. The interventions were: Resident to be fed by staff or companion aid, and provide a regular diet with thin liquids. On 11/25/25 at approximately 12:00 pm, a dining observation was made in the dining room. Certified Nursing Assistant (CNA) was observed sitting at a dining room table between two residents, Resident #7, who was observed sitting in a [NAME] chair to the left of CNA #1, was being fed, and Resident #30 was observed sitting in a [NAME] chair to the right of CNA #1, asleep. CNA #1 was observed trying to arouse Resident #30 in between feeding Resident #7, oftentimes attempting to feed both residents simultaneously without washing her hands. On 11/25/25 an interview was conducted at approximately 3:10 pm, with Certified Nursing Assistant (CNA) concerning Resident #7 and Resident #30. CNA #1 mentioned that she was the only person in the dining room so she had to feed both residents at the same time, but she should have fed one resident at a time and washed her hands in between residents. On 11/25/25 at approximately 4:00 pm., an interview was conducted with Licensed Practical Nurse (LPN) #3 concerning feeding residents. LPN #3 said that when feeding residents, only one resident should be fed at a time, and hand hygiene should be performed. On 11/25/25 at approximately 4:00 p.m., during the end-of-day meeting, the above findings were shared with the Administrator, Director of Nursing (DON), and the Assistant Administrator. The DON said that hand hygiene should have been completed. An opportunity was offered to the facility's staff to present additional information, but no further information was provided.

Based on resident interview, staff interview, clinical record review, and review of facility documents, the facility staff failed to explain the binding arbitration agreement to the resident in a form and manner that the resident understands for 1 of 26 residents (Resident #2), in the survey sample. The findings included: Resident #2 was originally admitted to the facility 11/5/25. The current diagnoses included spinal stenosis, urinary tract infection, type 2 diabetes mellitus without complications, and anemia. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/10/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #2's cognitive abilities for daily decision making were intact.On 11/25/25 at 11:50 AM an interview was conducted with Resident #2. Resident #2 stated that she does not remember signing a document in the admission paperwork that was an arbitration agreement. Resident #2 also stated that the Resident and Facility Arbitration Agreement was not explained in a manner that she understood. Resident #2 further stated, If I signed any paperwork, the staff should not have had me do that. I was in too much pain in the beginning of my stay here and I would not have been in the right frame of mind to sign important documents or even been able to remember important details regarding signing admission or arbitration documents, due to my pain at the time.A review of the Appendix B - Resident and Facility Arbitration Agreement dated and signed by Resident #2 on 11/5/25 read that Resident #2 signed her signature in the Resident Signature location. The document also read: The Parties understand and agree that by entering into this arbitration agreement, they are giving up and waiving their constitutional right to have claims decided in a court of law before a judge and jury. On 11/25/25 at 1:20 PM an interview was conducted with the Director of Transitional Services. The Director of Transitional Services stated that the admission paperwork and the arbitration agreement has to be signed by the resident or resident representative within 24 hours of admission. The Director of Transitional Services also stated that she remembers meeting with Resident #2 and completing the signing of the admission paperwork and arbitration agreement. The Director of Transitional Services further stated that she remembers meeting with Resident #2 due to the resident being in a lot of pain during the paperwork signing process. On 11/26/25 at approximately 2:20 p.m., a final interview was conducted with the Executive Director, Director of Nursing, and the Administrator of Home Health and Hospice. An opportunity was offered to the facility's staff to present additional information. They had no further comments and voiced no concerns regarding the above information.

Based on observations and staff interviews, the facility's staff failed to follow infection control measures during mealtime for 2 of 26 residents in the survey sample (Resident #7 and Resident #30).The findings included:1.The facility staff failed to ensure infection control measures were followed during mealtime by feeding two residents at the same time without maintaining proper hand hygiene. Resident #7 was originally admitted to the facility on [DATE] and re-admitted on [DATE] after an acute care hospital stay. The current diagnoses included; Vascular Dementia. The admission, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/29/25 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as moderately impaired for daily decision making. The person-centered care plan dated 10/02/25 read that Resident #7 is at risk for impaired nutritional status related to vascular dementia. The Goal for the resident was that the resident would eat 50% of her meal. The interventions are: Assist x 1 with eating and provide a mechanical soft diet with thin liquids.In sectionG(Physical functioning) the resident was coded as requiring assistance with eating, bathing, dressing, and using the toilet.On 11/25/25 at approximately 12:00 pm, a dining observation was made in the dining room. Certified Nursing Assistant (CNA) was observed sitting at a dining room table between two residents, Resident #7, who was observed sitting in a [NAME] chair to the left of CNA #1, was being fed, and Resident #30 was observed sitting in a [NAME] chair to the right of CNA #1, asleep. CNA #1 was observed trying to arouse Resident #30 in between feeding Resident #7, oftentimes attempting to feed both residents simultaneously without washing her hands. 2.The facility staff failed to ensure infection control measures were followed during mealtime without maintaining proper hygiene. Resident #30 was originally admitted to the facility on [DATE] after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included: Cognitive Communication Deficit. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/05/25 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long-term and short-term memory problems, as well as severe impairment for daily decision making. In sectionG(Physical functioning) the resident was coded as requiring assistance with eating, bathing, dressing, and using the toilet.The person-centered care plan dated 6/05/25 read that Resident #30 is at risk for impaired nutrition related to an end-of-life process, senile degeneration of the brain with anxiety. The goal for Resident #30 was to have resident consumed 50% of his meals. The interventions were: Resident to be fed by staff or companion aid and provide regular diet with thin liquids. On 11/25/25 at approximately 12:00 pm, a dining observation was made in the dining room. A Certified Nursing Assistant (CNA) was observed sitting at a dining room table between two residents. Resident #7, who was observed sitting in a [NAME] chair to the left of CNA #1, was being fed, and Resident #30 was observed sitting in a [NAME] chair to the right of CNA #1, asleep. CNA #1 was observed trying to arouse Resident #30 in between feeding Resident #7, oftentimes attempting to feed both residents simultaneously without washing her hands. CNA #1 was observed at approximately 12:30 pm., feeding both residents, going from Resident #7 to Resident #30. CNA #1 was also observed getting up and assisting other residents in the dining room by pushing them in their wheelchairs to the doorway to exit the dining room, returning to the table to feed Residents #7 and #30 without providing hand hygiene. On 11/25/25, an interview was conducted at approximately 3:10 pm, with a Certified Nursing Assistant (CNA) concerning Residents #7 and #30. CNA #1 mentioned that she was the only person in the dining room, so she had to feed both residents at once, but she should have fed each resident at a time.On 11/25/25 at approximately 4:00 pm., an interview was conducted with Licensed Practical Nurse (LPN) #3 concerning feeding residents. LPN #3 said that when feeding residents, only one resident should be fed at a time, and hand hygiene should be performed. On 11/25/25 at approximately 4:00 p.m., during the end-of-day meeting, the above findings were shared with the Administrator, Director of Nursing (DON), and the Assistant Administrator. The DON said that hand hygiene should have been completed. An opportunity was offered to the facility's staff to present additional information, but none was provided.

Based on observation, staff interviews and clinical record review the facility staff failed to provide the accommodation needed for 1 of 19 residents (Resident #2) in the survey sample. The findings included: The facility staff to ensure Resident #2's call bell remained within reach. Resident #2 was admitted to the nursing facility on 08/29/16. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The current Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/19/21 coded Resident #2 Brief Interview for Mental Status (BIMS) scored a 99 indicating short and long term memory problems and with severe cognitive impairment - never/rarely made decisions. The MDS coded Resident #2 total dependence of two with transfer, toilet use, personal hygiene and bathing, total dependence of one with dressing and extensive assistance of one with eating with Activities of Daily Living (ADL) care. Resident #2's comprehensive care plan documented Resident #2 at risk for falls related to impaired mobility, dementia, [CONDITION(S)] and occasion pain from arthritis. The goal set for the resident by the staff will have interventions in place to minimize the risk of a serious injury. Some of the approaches to manage goal is to keep the call light within reach and to encourage the resident to use call bell or call out for assistance. On 02/02/22 at approximately 10:00 a.m., Resident was observed sitting up in the wheel chair with the call bell back behind the resident's bed. On the same day at approximately 3:09 p.m., Resident #2 was observed lying in bed; call bell remain in the same place (back behind the resident bed). License Practical Nurse (LPN) #1 went into Resident #2's room along with this surveyor. The LPN removed Resident #2's call light from back behind the resident's bed and attached it to the resident's covering. When asked, What is the purpose for keeping Resident #2's call light within her reach, The LPN stated, The call bell should be within reach so the resident can call for assistance. She said Resident #2 cannot use the call be all the time but at times she will put the call light when she needs help. An interview was conducted with the Director of Nursing on 02/03/22 at approximately 12:50 p.m. The DON said the resident's call bell should be within reach at all times. She said the call light should be attached/clipped to their shirt or blanket and for best practice to inform the staff of their needs and to help prevent falls. A pre-exit conference was conducted with the Administrator and Director of Nursing on 02/03/22 at approximately 3:30 p.m. The Administration team were informed of the above findings; no further information was provided prior to exit. The facility titled: Call Light board of approval date of 10/25/02. Policy statement: The purpose of this procedure is to respond to the resident's requests and needs. Key Procedural Points read in part: 5. When the resident is in bed or confined to a chair, be sure the call light is within reach of the resident.

Based on information gleamed during the antibiotic stewardship task, observation, staff interview, and clinical record review the facility staff failed to ensure a Resident who is prescribed an antibiotic has appropriate indication for use and receives the antibiotic timely for 1 of 19 residents (Resident #21), in the survey sample. The findings included: Resident #21 was originally admitted to the facility 1/24/20 and had not been discharged from the facility. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/11/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 10 out of a possible 15. This indicated Resident #21's cognitive abilities for daily decision making were moderately impaired. In section G (Physical functioning) the resident was coded as requiring supervision after set-up with bed mobility, transfers, and locomotion, limited assistance of one person personal hygiene, dressing, and toileting and physical help of one person in part of his bathing activity. In section H (Bladder and Bowel) the resident was coded for use of an indwelling catheter. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The current care plan included a problem dated 1/24/20 read; (name of the resident) has a history of urinary tract infection with an indwelling urinary catheter and remains at risk for recurrent urinary tract infections. The goal read; (name of the resident) will have interventions in place to minimize the risk of urinary tract infections through next review, 5/5/21. The interventions included; Keep fluids next to the resident at all times. Provide cues/assist the resident to drink fluids with medications and between meals. Monitor the resident for burning/painful urination. Record Intake and Output. Monitor for bladder distention. On 2/2/22, the resident was observed in the activity area, an indwelling catheter bag was attached to his chair and bright yellow urine was observed in the catheter tubing. Resident #21 was identified as one of the residents requiring use of an antibiotic on the antibiotic stewardship report for December 2021. The Director of Nursing stated documentation revealed the resident presented with a new onset of confusion, acute meatus tenderness, purulent drainage and hematuria, therefore an assessment by the Nurse Practitioner (NP) was requested. Review of the clinical record revealed; a progress note dated 11/29/21 at 20:56 which read; Resident alert and oriented times three. Skin warm and dry to touch. Denies pain or discomfort. Indwelling catheter patent and draining yellow urine with bloody sediment. Resident had paper towels stuffed in his brief with yellowish color stain. He also had thrown a stained paper towel on the floor. Educated resident on use of trash can, not putting paper towels in brief and notifying staff of need to change brief. Resident noted to have redness noted to scrotum and groin. Peri care provided and [MEDICATION(S)] applied. Resident resting comfortably in bed with call bell in reach. On 11/30/21 the NP visited Resident #21 secondary to the above observations indicating a possible urinary tract infection. The NP ordered a Urine, Culture & Sensitivity to be collected One Time Daily for One Day (Starting 11/30/2021 Ending 11/30/2021 Anytime) Another progress note dated 12/1/21 at 6:17 read; Per Provider orders removed 16 French (Fr) catheter with 20 cubic centimeter (cm) balloon without issues. Inserted 16 Fr catheter with 30 cc balloon without issues with yellow color urine return. Used [MEDICATION(S)] 2% Jelly Urojet for comfort. Resident tolerated the procedure without difficulty. There is some jelly bloody like substance leaking around the catheter, which is from the jelly which was injected into the penis prior to insertion of catheter. Will report to oncoming shift to continue to monitor. A note dated 12/2/21 read; Seen by NP order for new Foley to be placed. Order for [MEDICATION(S)] with applicator to be applied before insertion, and a lab order to obtain a Urinalysis/Culture and Sensitivity (UA/CS) to be sent after placement of the new Foley catheter. A progress note dated 12/7/21 at 11:09 read; Resident seen by NP for results of the UA/CS. An order was obtained to start [MEDICATION(S)] on 12/08/21. [MEDICATION(S)] is an antibiotic used to treat bladder infections (acute [MEDICATION(S)]). It works by stopping the growth of bacteria. This antibiotic treats only bacterial infections. On 2/2/22 at 12:30 p.m., review of the laboratory report revealed the urine specimen was received by the laboratory on 12/1/21, the results were received from the laboratory by the nursing facility 12/6/21 which revealed the urine specimen contained 100,000 colonies of [CONDITION(S)] oxytoca and was susceptible to the antibiotic [MEDICATION(S)]. The results were reported to the Practitioner on 12/7/21. The NP ordered [MEDICATION(S)] 100 milligrams by mouth every 12 hours for 7 days for urinary retention. The laboratory report revealed the resident had a urinary tract infection and the bacterias were susceptible to an antibiotic not to administer an antibiotic for urinary retention. The antibiotic [MEDICATION(S)] was first administered to Resident #21 on 12/8/21, therefore from the observation of Resident #21's onset of confusion, acute meatus tenderness, purulent drainage and hematuria it took eight since the changes were An interview was conducted with the Director of Nursing/Infection Preventionist on 2/3/22 at approximately 1:30 p.m. The Director of Nursing stated the delay in processing the specimen is related to the backup in the lab secondary to COVID-19 test; that information was confirmed by lab technician at the local laboratory. The DON further stated there was no reason for the delay in initiating the antibiotic for the medication was available in their in house supply. The Director of Nursing further stated when the nurse obtained the order a starting dose should have been administered and all other doses scheduled thereafter. On 2/3/22 at approximately 3:15 p.m., the above findings were shared with the Administrator and Director of Nursing. An opportunity was offered to the facility's staff to present additional information but no additional information was provided and no concerns were voiced.

Based on staff interview and clinical record review, the facility staff failed to ensure that a 1 of 15 residents in the survey sample was free from administration of an unnecessary [MEDICAL CONDITION] medication. (Resident #16) The findings included: The facility staff failed to have a 14 day stop date on the use of [MEDICATION NAME] that was ordered by the physician for Resident #16. Resident #16 was readmitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the admission, MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/1/19 coded the resident as having a BIMS (Brief Interview for Mental Status) score of 14 out of a possible score of 15. Resident #16 was also coded as requiring extensive assistance of 1 staff member for dressing, personal hygiene and bathing. During the clinical record review on 8/29/19 by the surveyor, it was noted that the physician ordered [MEDICATION NAME] 2 mg/ml (milligram/milliliter) 0.25 ml as needed every four hours for anxiety. This ordered was written on 7/29/19. There was not a stop date provided for the medication to be given for 14 days and then be re-evaluated by the physician to assess if the resident would need continued need of this medication or if this needed to be discontinued. The surveyor notified the DON (Director of Nursing) of the above documented findings on 8/29/19 at 11:13 am. The DON stated that the order for the [MEDICATION NAME] was received when the resident was admitted to hospice services and the thinking of not having a stop date for the [MEDICATION NAME] was OK because the resident was in Hospice. No further information was provided to the surveyor prior to the exit conference on 8/29/19.

Based on observations, and staff interviews the facility staff failed to store and prepare food with professional standards for food service safety. The findings included: During the initial kitchen tour on 11/14/17 at 12: 18 P.M. An uncovered bowl of cake mix, with blender blades which had cake mix on them were observed on a cart. In the ice cream freezer two of four five gallon ice cream containers had lids inside the ice cream containers touching the ice cream There was one un-covered bowel of Cole slaw observed sitting on the serving line. There were four uncovered bowls of berry's observed sitting on the serving line. One bag of puree turkey sausage was observed sitting on top of a tray of bacon on a food cart in the middle of the floor leading into the refrigerator. A review of the menu for November 14, 2017 indicated: Cole slaw was to be served during the lunch meal and a mixed berry salad was to be served during the dinner meal A Dietary Food Storage Policy indicated: Food storage areas shall be maintained in a clean, safe and sanitary manner. 3. Cold foods shall be maintained at temperatures of 40 degrees or below. 5. All foods stored in walk-in refrigerators and freezers shall be stored in the kitchen area or in storerooms for food or food preparation. The Dietary Manager stated during the tour on 11/14/17 at 12: 24 P.M. that new ice cream container tops were on order. A dietary aide stated, The cake mix was to be discarded.

Based on observations, and staff interviews, the facility staff failed to provide a safe, sanitary and comfortable environment. The findings included: During the General Observations of the environment on 11/16/17 at 11:14 A.M. the following areas were noted: In the shower room an old battery charger was observed on the floor the shower. The shower room floor drain was observed to have trash and debris. In the Electrical Room that also housed the copier and fax machine was observed paper. trash and debris on the floor. In the Mechanical Room mold and mildew like substance was observed on the vent cover of an air duct. The Maintenance Director stated, the air goes all over the residential area. In the Soiled Utility Room a 2 x 3 foot board was observed sitting on top of a small refrigerator used for storing laboratory samples. In the Medication storage room dead bugs and cob webs were observed on the counter where the Stat Medication box was stored. The light bulbs in the Laundry chemical storage room were not functioning. The outside Bi-Hazard Room was observed to have trash and debris. There were two old container tops used to cover laundry carts stored in the room. Two five gallon containers of sand with cigarette butts were observed in the room along with an old cigarette snuffer. During an interview with the Maintenance Director he stated, some areas are to be cleaned on a routine bases and others on a monthly schedule. The facility staff failed to provide a safe, sanitary and comfortable environment.

Based on observation, resident interview, staff interview, facility documentation review, clinical record review the facility staff failed to: 1. The facility staff failed to ensure non-pharmacological interventions were attempted prior to the administration of [MEDICATION NAME] for 1 Resident (Resident #4) of 14 residents in the survey sample. 2. The facility staff failed to ensure non-pharmacological interventions were attempted prior to the administration of [MEDICATION NAME] for 1 Resident (Resident #8) of 14 residents in the survey sample. 3. The facility staff failed to follow physician orders [REDACTED]. 4. The facility staff failed to ensure non-pharmacological interventions were attempted prior the administration of prn (as needed) pain medication *Tylenol for Resident #1 of 14 residents in the survey sample. The findings included: 1. Resident #4 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED].* (1). Resident #4's Quarterly Minimum Data Set (MDS - an assessment protocol) with an Assessment Reference Date of 9/25/17 coded Resident #4 with a BIMS (Brief Interview for Mental Status) of 13 of 15 indicating no cognitive impairment. In addition, the Quarterly MDS coded Resident #4 as requiring extensive assistance with one staff person assistance for hygiene and bathing. Resident #4 was coded as requiring supervision with one staff person assistance for transfers, eating and toileting. Resident #4's Active/Current 1/10/17 to Present Care Plan documented the following problem: Problem: Requires pain management monitoring secondary to prior TKR (Total Knee Replacement), arthropathy/arthritis joint pain and back pain. Interventions included but were not limited to: Implement the following nonpharmacological* (2) pain management program, specifically: distraction, massage, imagery, relaxation, aromatherapy, and application of heat or cold. Resident #4's Physician orders [REDACTED]. 1/4/17 [MEDICATION NAME] 500 mg (milligrams) (1 tab) Tablet Oral as needed three times a day Resident #4's Clinical Record MAR (Medication Administration Record) for November 2017 documented the following administration times for [MEDICATION NAME] 500 mg (1) Tablet Oral as needed three times a day: Medline Plus documented: [MEDICATION NAME] is used to relieve mild to moderate pain 11/5/17 administered 9:58 a.m. 11/5/17 administered 16:27 (4:27 p.m.) 11/5/17 administered 21:19 (9:19 p.m.) 11/8/17 administered 10:00 a.m. 11/9/17 administered 17:25 (5:25 p.m.) 11/12/17 administered 8:27 a.m. All of the above administered doses were documented as being effective for Resident #4. On 11/16/17 at approximately 10:00 a.m., the Facility was requested to provide any documentation showing use of non-pharmacological interventions were completed prior to the use of the [MEDICATION NAME]. The facility did not provide any documentation. The Director of Nursing (DON) on 11/16/17 at approximately 3:00 p.m. stated there was no documentation for non pharmacological measures prior to the administration of [MEDICATION NAME]. The Facility did not present a Policy for use of non pharmacological measures prior to the administration of pain medications. The facility administration was informed of the findings during a briefing on 11/14/17 at approximately 2:26 p.m. The facility did not present any further information about the findings. 2. Resident #8 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #8's Admission Minimum Data Set (MDS - an assessment protocol) with an Assessment Reference Date of 8/29/17 coded Resident #8 a BIMS (Brief Interview for Mental Status) of 01 of 15 indicating a severe cognitive impairment. In addition, the Admission MDS coded Resident #8 as requiring extensive assistance with one staff person assistance for transfers, bed mobility, dressing, toilet use, hygiene and bathing. Resident #8's current/active Care Plan did not include a problem for pain. Resident #8's Physician orders [REDACTED]. 8/22/17 [MEDICATION NAME] -[MEDICATION NAME] 5 mg - 325 mg tablet; 1 tab as needed every four hours Medline Plus documented: [MEDICATION NAME] is used to relieve moderate to severe pain Resident #8's October 2017 MAR (Medication Administration Record) documented the following [MEDICATION NAME] -[MEDICATION NAME] 5 mg - 325 mg tablet administration times: 10/5/17 administered 16:35 (4:35 p.m.) 10/25/17 administered 18:04 (6:04 p.m.) All of the above administered doses were documented as being effective for Resident #4. On 11/16/17 at approximately 10:00 a.m., the Facility was requested to provide any documentation showing use of non-pharmacological interventions were completed prior to the use of the [MEDICATION NAME]. The facility did not provide any documentation. The Director of Nursing (DON) on 11/16/17 at approximately 3:00 p.m. stated there was no documentation for non pharmacological measures prior to the administration of [MEDICATION NAME]. The Facility did not present a Policy for use of non pharmacological measures prior to the administration of pain medications. The facility administration was informed of the findings during a briefing on 11/14/17 at approximately 2:26 p.m. The facility did not present any further information about the findings. Definitions: 1. Rhabdomyolysis: (rab-doe-my-OL-ih-sis) Mayoclinic.org documented: a rare condition that causes muscle cells to break down. The most common signs and symptoms of rhabdomyolysis include: Severe muscle aching throughout the entire body . 2. Non-Pharmacological: Non medicine measures such as relaxation, aromatherapy, massage: the National Institute of Health documented: The guidelines recommend that practitioners consider these non-pharmacologic interventions as appropriate options when treating patients whose low-back pain does not improve with more conservative self-care. 3. Non-Alzheimer's Dementia: Medline Plus documented: Dementia is the name for a group of symptoms caused by disorders that affect the brain. It is not a specific disease. People with dementia may not be able to think well enough to do normal activities, such as getting dressed or eating. They may lose their ability to solve problems or control their emotions. Their personalities may change. They may become agitated or see things that are not there. A type of dementia not associated with [MEDICAL CONDITION]. The findings included: 3. Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED].*End Stage [MEDICAL CONDITIONS] and Right *femur fracture. The current Minimum Data Set (MDS) a 30-day assessment with an Assessment Reference Date (ARD) of 09/15/17 coded the resident with a 08 of a total possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. In addition, the MDS coded Resident #1 requiring total dependence of one with bathing, extensive assistance of two with transfers and mobility, extensive assistance of one with dressing, hygiene and toilet use, and limited assistance of one with eating. Resident #1 was coded frequently incontinent of bowel and bladder. *Phoslo is used to prevent high blood [MEDICATION NAME] levels in patients who are on [MEDICAL TREATMENT] due to severe kidney disease (www. com). *[MEDICAL CONDITION] is the last stage of [MEDICAL CONDITION]. This is when your kidneys can no longer support your body's needs (https://medlineplus.gov/ency/article/ 0.htm). *[MEDICAL CONDITION] is a [MEDICAL CONDITION] is a break in the upper part of the thigh bone (femur) where the thigh bone joins the pelvis to form the hip joint (www.webmd.com/[MEDICAL CONDITION]/hip-fracture). Review of Resident #1's Physician orders [REDACTED]. 1). Phoslo 667 mg capsule -oral three times daily scheduled to be administered at 8 a.m., 11:30 a.m., and 5:00 p.m. for [MEDICAL CONDITION]. During the review of Resident #1's Medication Administration Audit Record for September, October and November 2017 revealed the following medication were not administered due to resident out of facility at [MEDICAL TREATMENT]: 1). Phoslo 667 was document as not being administered at 11:30 a.m., in September 2017 on the following days: 9/4, 9/6, 9/8, 9/11, 9/13/ 9/15, 9/18, 9/20, 9/22, 9/25, 9/27/2017. 2). Phoslo 667 was document as not being administered at 11:30 a.m., in October 2017 on the following days: 10/2, 10/4, 10/6, 10/9, 10/11, 10/16, 10/20, 10/23, 10/25, 10/27 and 10/30/17. 3). Phoslo 667 was document as not being administered at 11:30 a.m., in November 2017 on the following days: 11/1, 11/3, 11/6, 11/8 and 11/13/17. The facility administration was informed of the finding during a briefing on 11/17/17 at approximately 2:30 p.m. The facility did not present any further information about the findings. 4. Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED].*Femur Fracture. The current Minimum Data Set (MDS) a 30-day assessment with an Assessment Reference Date (ARD) of 09/15/17 coded the resident with a 08 of a total possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. In addition, the MDS coded Resident #1 requiring total dependence of one with bathing, extensive assistance of two with transfers and mobility, extensive assistance of one with dressing, hygiene and toilet use, and limited assistance of one with eating. Resident #1 was coded frequently incontinent of bowel and bladder. **[MEDICAL CONDITION] is a [MEDICAL CONDITION] is a break in the upper part of the thigh bone (femur) where the thigh bone joins the pelvis to form the hip joint (www.webmd.com/[MEDICAL CONDITION]/hip-fracture). Resident #1 received an order for [REDACTED]. *Tylenol is used to relieve mild to moderate pain and to reduce fever (https://medlineplus/gov/drugingfo/meds/a 4.html). Review of the Medication Administration Record [REDACTED] Tylenol Extra Strength 500 mg tablet (2 tabs) on the following days without any non-pharmacological intervention prior to the administration of as needed pain medication: In September 2017: 5th, 8th, 9th, 11th, 12th, 13th, 14th, 16th, 16th, 17th, 18th, 19th, 20th, 21st, 22nd, 26th, 27th, 28th and 30th. In October 2017: 5th, 13th, 25th, 29th and 30th. In November 2017: 4th,5th, 7th, 11th, 12th,13th and 14th. An interview was conducted with Director of Nursing (DON) on 11/16/17 at 1:15 p.m., who stated she expect for the nurses to assess residents for their pain level but to try non-pharmacological interventions prior to the administration of prn pain medications; if non-pharmacological interventions are not effective then give prn pain mediation but to document the pain level and the effectiveness of the pain medication after being administered. The DON reviewed Resident #1's clinical record for documentation that non-pharmacological interventions were tried prior to the administration of prn Tylenol then replied, I was unable to locate non-pharmacological intervention prior to the administration of Resident #1's prn Tylenol. The facility administration was informed of the finding during a briefing on 11/17/17 at approximately 2:30 p.m. The facility did not present any further information about the findings.

Based on observation, staff interviews, clinical recorded review and facility documentation, the facility staff failed to follow physician orders [REDACTED].#1) in the survey sample. The facility staff failed to notify the physician that the following medications were not administered as ordered: *Phoslo 667 capsule for Resident #1. The findings included: Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED].*End Stage [MEDICAL CONDITIONS] and Right *Femur Fracture. The current Minimum Data Set (MDS) a 30-day assessment with an Assessment Reference Date (ARD) of 09/15/17 coded the resident with a 08 of a total possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. In addition, the MDS coded Resident #1 requiring total dependence of one with bathing, extensive assistance of two with transfers and mobility, extensive assistance of one with dressing, hygiene and toilet use, and limited assistance of one with eating. Resident #1 was coded frequently incontinent of bowel and bladder. *Phoslo is used to prevent high blood [MEDICATION NAME] levels in patients who are on [MEDICAL TREATMENT] due to severe kidney disease (www.webmd.com). *End Stage [MEDICAL CONDITION] is the last stage of [MEDICAL CONDITION]. This is when your kidneys can no longer support your body's needs(https://medlineplus.gov/ency/article/ 0.htm). *[MEDICAL CONDITION] is a [MEDICAL CONDITION] is a break in the upper part of the thigh bone(femur) where the thighbone joins the pelvis to form the hip joint (www.webmd.com/[MEDICAL CONDITION]/hip-fracture). Review of Resident #1's Physician orders [REDACTED]. 1). Phoslo 667 mg capsule - oral three times daily scheduled to be administered at 8 a.m., 11:30 a.m., and 5:00 p.m. for [MEDICAL CONDITION]. During the review of Resident #1's Medication Administration Audit Record for September, October and November 2017 revealed the following medication were not administered due to resident out of facility at [MEDICAL TREATMENT]: 1). Phoslo 667 was document as not being administered at 11:30 a.m., in September 2017 on the following days: 9/4, 9/8, 9/11, 9/13/ 9/15, 9/18, 9/20, 9/22, 9/25, 9/27 and 9/29/2017. 2). Phoslo 667 was document as not being administered at 11:30 a.m., in October 2017 on the following days: 10/2, 10/4, 10/6, 10/9, 10/11, 10/16, 10/20, 10/23, 10/25 and 10/27/17. 3). Phoslo 667 was document as not being administered at 11:30 a.m., in November 2017 on the following days: 11/1, 11/3, 11/6 and 11/13/17. The review of Resident #1's clinical record did not indicate that the physican was notified that the resident missed multiple doses of Phoslo due to resident being out to [MEDICAL TREATMENT]. On 11/16/17 at appropriately 1:40 p.m., and interview was conducted with the NP who stated, Resident #1 was under another provider until October 20, 2017 but the nurses should have contacted the physician to have his medication times adjusted; the times should have been adjusted. The surveyor asked, why is Phoslo given to [MEDICAL TREATMENT] patients, the NP stated, Phoslo is a supplement that helps to prevent high [MEDICATION NAME] levels with [MEDICAL TREATMENT] patients, their kidneys don't work so the Phoslo helps to maintain that low [MEDICATION NAME] level. The NP proceeded to say, I do have concerns that Resident #1's medication wasn't administered because he was out to [MEDICAL TREATMENT], the medication should to be administered appropriately; they should have contacted someone to have his medications adjusted to fit his [MEDICAL TREATMENT] days. The facility administration was informed of the finding during a briefing on 11/17/17 at approximately 2:30 p.m. The facility did not present any further information about the findings.

Based on observation, resident interview, staff interview, facility documentation review, clinical record review, the facility staff failed to: 1. The facility staff failed to ensure that documentation dates were included in section V of the MDS for 1 Resident (Resident #6) of 14 Residents in the survey sample. The findings included: 1. Resident #6 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED].* (1). Resident #6's Annual Minimum Data Set (MDS - an assessment protocol) with an Assessment Reference Date of 5/8/17 coded Resident #6 with a BIMS (Brief Interview for Mental Status) score of 12 of 15, indicating a moderate cognitive impairment. Section V of the Annual MDS coded Resident #6 with the following CAA (Care Area Assessment) trigger areas: Cognition Urinary Incontinence ADL (Activity of Daily Living) functioning Continence Falls Dental Care Pressure Ulcer Section V of the Annual MDS (Minimum Data Set) did not include a notation of date and location for documentation related to the decision making process for the triggered areas listed above. The Facility provided a copy of pages (4-6 to 4-7) taken from the CMS's RAI (Resident Assessment Instrument) Version 3.0 Manual Chapter 4 that documented the following guidance: CAA documentation. CAA documentation helps to explain the basis for the care plan by showing how the IDT (Interdisciplinary Team) determined that the underlying causes, contributing factors, and risk factors were related to the care area condition for a specific resident: for example, the documentation should indicate the basis for these decisions, why the finding(s) require(s) an intervention, and the rational(s) for selecting specific interventions. Based on the review of the comprehensive assessment, the IDT and the resident and/or the resident's representative determine the areas that require care plan intervention(s) and develop, revise, or continue the individualized care plan. Relevant documentation for each triggered CAA describes: causes and contributing factors; The nature of the issue or condition (may include presence or lack of objective data and subjective complaints). In other words, what exactly is the issue/problem for this resident and why it is a problem; Complications affecting or caused by the care area for this resident; Risk factors related to the presence of the condition that affects the staff's decision to proceed to care planning; Factors that must be considered in developing individualized care plan interventions, including the decision to care plan or not to care plan various findings for the individual resident; The need for additional evaluation by the attending physician and other health professionals, as appropriate; The resource(s), or assessment tool(s) used for decision-making, and conclusions that arose from performing the CAA; Use the Location and Date of CAA Documentation column on the CAA Summary (Section V of the MDS 3.0) to note where the CAA information and decision making documentation can be found in the resident's record. Also indicate in the column Care Planning Decision whether the triggered care area is addressed in the care plan. The Acting MDS Coordinator on 11/15/17 at approximately 2:30 p.m., stated: Yes, there should be a date. when asked if there should be a corresponding note and date for Section V of the Annual MDS with ARD of 5/8/17 The facility administration was informed of the findings during a briefing on 11/14/17 at approximately 2:26 p.m. The facility did not present any further information about the findings.

Based on observation, clinical record review, staff interviews and review of the facility documentations, the facility failed ensure the necessary treatment was provided to prevent infection and promote healing for 1 of 16 Residents (Resident #1) in the survey sample. The facility staff failed to ensure infection control practice were followed during a sacral wound *stage 2 *pressure ulcer dressing for Resident #1. The findings included: Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED].*femur fracture and *[MEDICAL CONDITION]. The current Minimum Data Set (MDS) a 30-day assessment with an Assessment Reference Date (ARD) of 09/15/17 coded the resident with a 08 of a total possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. In addition, the MDS coded Resident #1 requiring total dependence of one with bathing, extensive assistance of two with transfers and mobility, extensive assistance of one with dressing, hygiene and toilet use, and limited assistance of one with eating. Resident #1 was coded frequently incontinent of bowel and bladder. In section M (Skin Conditions) of MDS 09/15/17 coded Resident #1 at risk for developing pressure ulcers, having a stage 1 or higher. Resident #1 was also coded 0 if resident have one or more unhealed pressure ulcer(s) at Stage 1 or higher. *Pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/). *Pressure Injury - Stage 2 (Partial-thickness skin loss with exposed dermis_ Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ *Right femur fracture is a [MEDICAL CONDITION] is a break in the upper part of the thigh bone(femur) where the thighbone joins the pelvis to form the hip joint (www.webmd.com/[MEDICAL CONDITION]/hip-fracture). *[MEDICAL CONDITION] is condition when blood does not carry enough oxygen to the rest of your body (Source: NIH U.S. National Library of Medicine: Medline Plus). Resident #1's care plan documented Resident #1 at risk for impaired skin integrity related to impaired mobility, incontinence and poor tissue perfusion. The goals: the resident will remain free of skin breakdown over the next 90 days. Some of the interventions include but not limited to: Pressure reducing mattress, check skin for redness, skin tears, swelling, or pressure areas. Report and signs of skin breakdown. The current treatment as of 11/10/17 is to cleanse sacrum with normal saline, apply barrier ointment, apply *[MEDICATION NAME] foam pad, cover with [MEDICATION NAME] dressing, off load area when every possible and change daily until resolved. *[MEDICATION NAME] is a foam dressing suitable for a wide range of wounds like venous leg ulcers, pressure ulcers or diabetic ulcers (www.molnlycke.us/advanced-wound-care-products/foam-dressings/[MEDICATION NAME]/). On 11/15/17 at approximately 10:00 a.m., the resident was observed lying in bed on a specialty mattress; in a supine position. LPN #2 performed wound care with the assistance of LPN #3. Both LPN's washed her hands then donned a pair of gloves prior to starting sacral wound care dressing change, LPN #2 removed the dressing from the sacral wound, placed the soiled dressing inside a clear plastic bag, removed her gloves then went into the bathroom, got a pair of clean gloves from the glove holder on the bathroom wall, donned the new gloves, returned to the bedside, proceeded to clean the wound with normal saline, applied barrier cream to the wound followed with [MEDICATION NAME] the covered with a foam dressing. On 11/15/17 at approximately 2:35 p.m., and interview was conducted with LPN #2 who stated, I should have removed my gloves after I removed the soiled dressing, washed my hands then put on another pair of gloves, cleaned the wound, remove my gloves, finish wound care then wash may hands again. An interview was conducted with the Director of Nursing (DON) on 11/16/17 at approximately 11:20 a.m., who stated, The nurse should have washed her hands before starting wound care, after removing the soiled dressing, remove gloves, wash hands, donned a new pair of gloves, clean the wound, remove gloves, wash hands again then put on another pair of gloves. The facility administration was informed of the finding during a briefing on 11/16/17 at approximately 2:30 p.m. The facility did not present any further information about the findings. The facility's policy: Skin Care - Wound Care (Revised 10/22/14) Policy Statement: -The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Policy Interpretation and Implementation -This procedure may involve potential and/or direct exposure to blood, body fluids, infectious diseases, air contaminants, and hazardous chemicals. Steps in the Procedure include but not limited to: -Wash your hands thoroughly before beginning the procedure. -Tape plastic bag to bedside table for waste. Clean bedside table with chemical wipe. -Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. Wash hands or use hand sanitizer. -Use new, clean gloves. Loosen tape and remove dressing. -Pull glove over dressing and discard both into appropriate receptacle. Wash hands or use hand sanitizer. -Use new, clean gloves. -Pour liquid solutions directly on gauze sponges on their papers. -Use new, clean gloves for holding gauze to catch irrigation solutions that are poured directly over the wound. -Clean wound as ordered. Discard gloves. Wash hands or use sanitizer. -Use new, clean gloves. Apply treatment as indicated. -Dress wound as ordered. -Place barrier cloth and soiled items into designated container. Remove gloves and discard into designated container. Wash your hands. -Use new, clean gloves. Clean over bed table with chemical wipe. -Wash your hands.

Based on observation, staff interviews and facility documentation review the facility staff failed to ensure one treatment cart was stored in a secured location, accessible to designated staff only. The facility staff failed to ensure treatment cart containing medication in the hallway was locked when not in direct site of the nurse. The findings include: On 11/15/17 at approximately 9:55 a.m., LPN #2 removed wound care supplies from the back hall treatment cart located in the hallway; then went into room 538B to perform wound care on Resident #1. At approximately 10:15 a.m., the surveyor came out of the room and noticed the treatment cart was left unlocked. The nurse came out of room 538, walked pass the unlocked treatment cart over to the medication cart. The surveyor informed the LPN that she had left her treatment cart unlocked after she had removed wound supplies. The surveyor asked, Should your medication cart have been locked with not in direct site, the LPN stated, My cart should have locked my cart. An interview was conducted with the Director of Nursing (DON) on 11/15/17 at approximately 11:25 a.m., who stated, I expect for all nurses to lock their treatment and medication cart when not in direct view of the nurse. The facility administration was informed of the finding during a briefing on 11/17/17 at approximately 2:30 p.m. The facility did not present any further information about the findings. The facility's policy: Medications - Storage of Medications (Revised 09/18/15). Policy Statement: The purpose of this procedure is to ensure that medications are stored in a safe, secure, and orderly manner.

Based on observation, resident interview, staff interview, facility documentation review, clinical record review,the facility staff failed to: 1. The facility staff failed to ensure infection control measures of hand hygiene and allowing santi wipe to dry for a full 2 minutes were followed during a glucometer check to prevent potential infections for 1 Resident (Resident #14) in the survey sample of 14 Residents. 2. The facility staff failed to implement appropriate hand hygiene during a sacral wound care dressing change in addition to disinfect the over bed table after being used for wound care for Resident #1 in the survey sample of 14 Residents. The findings included: 1. Resident #14 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED].*(1). Resident #'s Initial Minimum Data Set (MDS - an assessment protocol) had not been completed. Resident #14 was observed on 11/15/17 at approximately 5:00 p.m. to require the assistance of one staff member for transfers. Resident #14 was alert and oriented to name only at this time. Resident #14's 11/8/17 to present active/current Care Plan documented the following: Problem: Risk for unstable blood glucose levels Interventions included but were not limited to: Monitor for signs and symptoms of [DIAGNOSES REDACTED] and hyperglycemia Resident #14's 11/9/17 Physician order [REDACTED]. Humalog 100 unit/milliliter subcutaneous solution (slide scale) two times a day 2 Units Blood Sugar is 251-300 4 Units Blood Sugar is 301-350 6 Units Blood Sugar is 351-400 8 Units Blood Sugar is 401-450 During an observation of medication pass on 11/14/17 at approximately 5:14 p.m., LPN (Licensed Practical Nurse) #1 was observed preparing to obtain a blood sugar check on Resident #14. LPN #1 was observed to wash her hands for approximately 20 seconds. LPN #1 then walked to her equipment that she had placed on a paper towel on Resident #14's table and donned non sterile gloves. LPN #1, wiped down the glucometer meter with a disinfecting wipe and immediately walked to Resident #14's bed. LPN #1, explained to the Resident that she was going to obtain a finger stick for blood and asked if it was ok. LPN #1, wiped Resident #14's finger tip with an alcohol pad and used a lancet to prick Resident #14's finger tip. As LPN #1 went to place the drop of blood on the glucose strip, she stated, Oh, I didn't cut the machine on, I'll have to do this again. LPN #1 removed her gloves and washed her hands for approximately 10 seconds. LPN #14 donned clean gloves and wiped Resident #14's finger tip with alcohol and this time dried finger tip with paper towel. LPN #14 cut glucometer on and inserted strip into the meter. LPN #14 then using a lancet pricked Resident #14's finger tip, obtained a drop of blood, wiped the first drop away using a paper towel and applied the second drop of blood to the glucose strip. The results read 140. LPN #1 stated, He will not get insulin coverage as he is under 251. LPN #1 removed her gloves and then washed her hands for approximately 20 seconds. The Facility Policy and Procedure, titled, Personal Protective Measures Handwashing with a revision date of 6/23/16, documented the following: Appropriate handwashing must be performed for a minimum of 20 seconds under the following conditions: Before performing invasive procedures Before preparing or handling medications After contact with blood, After removing gloves The Facility provided a one page documented (page 55), titled, Infection Prevention and Control Manual for Long Term Care from Patient Care Guidelines. It documented the following: The meter will be disinfected after each use, according to the manufacturer's instructions. Visible debris will be removed with soap and water prior to disinfection. The glucometer will be disinfected with Sani-wipes containing a hypochloric solution. The Facility provided a copy of the printed information on the Sanitizing wipes container that LPN #1 used to clean the glucometer. It documented the following: TO DISINFECT AND DEODORIZE: To disinfect nonfood contact surfaces only; Unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for a full two (2) minutes. Let air dry. For heavily soiled surfaces sue a wipe to pre-clean prior to disinfecting. The Center for Disease Control (https://www.cdc.gov/infectioncontrol/pdf/guidelines/disinfection-guidelines.pdf) Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 documented the following: The choice of disinfectant, concentration, and exposure time is based on the risk for infection associated with use of the equipment and other factors discussed in this guideline. However, for these processes to be effective, health-care workers should adhere strictly to the cleaning, disinfection, and sterilization recommendations in this document and to instructions on product labels. Disinfection describes a process that eliminates many or all pathogenic microorganisms, except bacterial spores, on inanimate objects (Tables 1 and 2). In health-care settings, objects usually are disinfected by liquid chemicals or wet pasteurization. Each of the various factors that affect the efficacy of disinfection can nullify or limit the efficacy of the process. Interview:--------------------------------------- The facility administration was informed of the findings during a briefing on 11/14/17 at approximately 2:26 p.m. The facility did not present any further information about the findings. Definitions: 1. Diabetes Mellitus: Medline Plus documented: Diabetes is a disease in which your blood glucose, or blood sugar, levels are too high. Glucose comes from the foods you eat. Insulin is a hormone that helps the glucose get into your cells to give them energy. With type 1 diabetes, your body does not make insulin. With type 2 diabetes, the more common type, your body does not make or use insulin well. Without enough insulin, the glucose stays in your blood. You can also have prediabetes. This means that your blood sugar is higher than normal but not high enough to be called diabetes. Having prediabetes puts you at a higher risk of getting type 2 diabetes. 2. The facility staff failed to implement appropriate hand hygiene during a sacral wound *stage 2*pressure ulcer dressing change in addition to disinfect the over bed table after being used for wound care for Resident #1. Resident #1 was admitted to the nursing facility on 08/18/2017. [DIAGNOSES REDACTED].*femur fracture. The current Minimum Data Set (MDS) a 30-day assessment with an Assessment Reference Date (ARD) of 09/15/17 coded the resident with a 08 of a total possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. In addition, the MDS coded Resident #1 requiring total dependence of one with bathing, extensive assistance of two with transfers and mobility, extensive assistance of one with dressing, hygiene and toilet use, and limited assistance of one with eating. Resident #1 was coded frequently incontinent of bowel and bladder. In section M (Skin Conditions) of MDS 09/15/17 coded Resident #1 at risk for developing pressure ulcers, having a stage 1 or higher. Resident #1 was also coded 0 if resident have one or more unhealed pressure ulcer (s) at Stage 1 or higher. *Pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/). *Pressure Injury - Stage 2 (Partial-thickness skin loss with exposed dermis_ Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ *Right femur fracture - a hip fracture is a break in the upper part of the thigh bone (femur) where the thigh bone joins the pelvis to form the hip joint (www.webmd.com/osteoporosis/hip-fracture). Resident #1's care plan documented Resident #1 at risk for impaired skin integrity related to impaired mobility, incontinence and poor tissue perfusion. The goals: the resident will remain free of skin breakdown over the next 90 days. Some of the interventions include but not limited to: Pressure reducing mattress, check skin for redness, skin tears, swelling, or pressure areas. Report and signs of skin breakdown. The current treatment as of 11/10/17 is to cleanse sacrum wound with normal saline, apply barrier ointment, apply *[MEDICATION NAME] foam pad, cover with [MEDICATION NAME] dressing, off load area when every possible and change daily until resolved. *[MEDICATION NAME] is a foam dressing suitable for a wide range of wounds like venous leg ulcers, pressure ulcers or diabetic ulcers (www.molnlycke.us/advanced-wound-care-products/foam-dressings/[MEDICATION NAME]/). On 11/15/17 at approximately 10:00 a.m., the resident was observed lying in bed on a specialty mattress; in a supine position, resident was position to his left side with assistance of LPN #3. LPN #2 placed a clear plastic bag over the over bed table as the table barrier then placed all wound care supply items on the plastic bag covering the over bed table. LPN #2 performed wound care with the assistance of LPN #3. LPN #2 removed the dressing from the sacral wound, placed the soiled dressing inside a clear plastic bag, removed her gloves, went into the bathroom, got a pair of clean gloves from the glove holder on the bathroom wall, donned the new gloves, returned to the bedside, proceeded to clean the wound with normal saline, applied barrier cream to the wound followed with [MEDICATION NAME] the covered with a foam dressing. The wound nurse washed her hands using soap x 10 seconds then put her hands under the running water, rinsing off all the soap but continued to rub her hands together for 5 minutes. LPN #2 removed the clean plastic bag from the over bed table and dispose in the trash can. The surveyor if she was finished with completing her wound care, she replied, Yes I'm done, then walked out the room. On 11/15/17 at approximately 2:15 p.m., and interview was conducted with LPN #2 who stated, I should have removed my gloves after I removed the soiled dressing, washed my hands then put on another pair of gloves, cleaned the wound, remove my gloves, finish wound care then wash may hands again. The surveyor asked if the over bed table should have been disinfected after use, she replied No, I don't see why, I put the supplies in the plastic bag covering the table, the table was never touch, so I had no reason to clean it. The surveyor then asked, How long do you wash your hands after wound care, she replied 20 seconds, the surveyor informed LPN #2, she actually washed her hands using soap x 10 seconds then put her hands under the running water, rinsing off all the soap but continued to rub her hands together for 10 minutes with just water. An interview was conducted with the Director of Nursing (DON) on 11/16/17 at approximately 11:20 a.m., who stated, The nurse should have washed her hands before starting wound care, after removing the soiled dressing, remove gloves, wash hands, donned a new pair of gloves, clean the wound, remove gloves, wash hands again then put on another pair of gloves. The DON also stated, After removing the supplies from the over bed table, she should have clean the over bed table also. The facility administration was informed of the finding during a briefing on 11/17/17 at approximately 2:30 p.m. The facility did not present any further information about the findings. The facility's Policy - Personal Protective Measures - Handwashing (Last Revision - 6/23/16). Policy Statement -The purpose of this procedure is to provide guidelines to employees for proper and appropriate handwashing techniques that will aid in the prevention of the transmission of infections. Policy Interpretation and Implementation (Objectives) -To prevent the spread of infectious diseases. When to Wash Hands: Appropriate handwashing must be performed for a minimum of 20 seconds under the following conditions include but not limited to: - After having prolonged contact with resident. -After handling used dressings, specimen's containers, contaminated tissues, linen, etc. -After contact with blood, body fluids, secretions excretions, mucous membranes, or broken skin. -After handling potential contaminated with a resident's blood, body fluids, excretions or secretions. After removing gloves Procedure Guidelines: -Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds under a moderate stream of water, at a comfortable temperature.

Based on observation, resident interview, staff interview and facility documentation review the facility staff failed to ensure a complete and accurate clinical record for 1 of 16 residents (Resident #1) in the survey sample. The facility staff failed to ensure the Treatment Administration Record (TAR) for November 2017 was accurate for the application of *ted hose for Resident #1. The findings include: Resident #1 was admitted to the nursing facility on 08/18/2017. [DIAGNOSES REDACTED].*femur fracture. The current Minimum Data Set (MDS) a 30-day assessment with an Assessment Reference Date (ARD) of 09/15/17 coded the resident with a 08 of a total possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. *Ted hose are stockings that help prevent blood clots and swelling in your legs (https://www.drugs.com/cg/ted-hose.html). *Right femur fracture - a [MEDICAL CONDITION] is a break in the upper part of the thigh bone (femur) where the thigh bone joins the pelvis to form the hip joint (www.webmd.com/[MEDICAL CONDITION]/hip-fracture). On 11/14/17 at 12:20 p.m., during the initial tour, Resident #1 was observed lying in bed with his left leg hanging off the side of the bed; ted hose was not present to left lower extremity. During the review of Resident #1's Treatment Administration Record (TAR) on 11/14/17 at approximately 2:15 p.m., indicated the following order written on 08/28/17: ted hose to be donned in A.M. (morning) and removed every H.S. (night). On the same day at approximately 3:30 p.m., Resident #1 was sitting on the side of the bed without ted hose to bilateral lower extremities. The review of November 2017 Treatment Administration Record (TAR), the nurse had signed off on 11/14/17 that Resident #1's ted hose had been applied. An interview was conducted with Resident #1 on 11/14/17 approximately 3:30 p.m., the surveyor asked if his ted hose had been applied to his lower extremities today, he replied No, they haven't been on at all today. On 11/14/17 at approximately 5:00 p.m., Resident #1 was in the dining room waiting for his dinner tray. The surveyor observed the resident was not wearing his ted hose. On the same day at 5:20 p.m., the surveyor and the Director of Nursing (DON) walked to the dining room; the DON observed Resident #1 was not wearing his ted hose then stated, I expect for the nurse to follow physician orders [REDACTED]. The surveyor asked if Resident #1 has [MEDICAL CONDITION] to his lower extremities, she replied, Yes, that's more reason for him to have his ted hose on. The facility administration was informed of the finding during a briefing on 11/17/17 at approximately 2:30 p.m. The facility did not present any further information about the findings. The facility's policy: Charting (Revised 02/28/17). Policy Statement: -All services provided to the resident, or any changes in the resident's condition, she be recorded in the resident's medical record. Policy Interpretation and Implementation: -Entries must be recorded by the person rendering the service just after it was performed. -All unanticipated occurrences or changes in the resident's condition must be recorded.

Based on clinical record review, staff interviews, the facility staff failed to develop a psychoactive care plan for 1 of 16 residents (Resident #1) in the survey sample. The facility staff failed to develop a care plan for a Resident #1 who was receiving a psychoactive medication *[MEDICATION NAME]. The findings include: Resident #1 was admitted to the nursing facility on 08/18/2017. [DIAGNOSES REDACTED].*Adjustment disorder with depressed mood. *[MEDICATION NAME] is used to treat depression, obsessive-compulsive disorder (bothersome thoughts that won't go away and the need to perform certain actions over and over), panic attacks (sudden, unexpected attacks of extreme fear and worry about these attacks), posttraumatic stress disorder (disturbing psychological symptoms that develop after a frightening experience), and social anxiety disorder (extreme fear of interacting with others or performing in front of others that interferes with normal life) (https://medlineplus.gov/ency/article/ 5.htm). *Adjustment disorder with depressed mood is a group of symptoms, such as stress, feeling sad or hopeless, and physical symptoms that can occur after you go through a stressful life event (https://medlineplus.gov/ency/article/ 5.htm). The current Minimum Data Set (MDS) a 30-day assessment with an Assessment Reference Date (ARD) of 09/15/17 coded the resident with a 08 of a total possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. The residents MDS was coded for the usage of antianxiety and antidepressant medication. The section N on the MDS under medications read as follows: Indicate the number of DAYS the resident receiving the medication during the last 7 days, the MDS was coded for receiving an antidepressant for 7 days. The review of Resident #1's comprehensive care did not include a care plan for psychoactive medication. An interview was conducted with the MDS Coordinator on 11/15/17 at approximately 2:15 p.m., who stated Psychoactive medications are to be care planned but under the drug class and not the medication. The surveyor asked, is [MEDICATION NAME] a psychoactive medication and she it be care planned, the MDS Coordinator replied, Yes - it's a psychoactive medication and it should have been care planned. On the same day at approximately 4:10 p.m., the MDS Coordinator reviewed Resident #1's entire care planned then stated, It's not here, it wasn't care planned. On 11/16/17 at approximately 11:20 a.m., and interview was conducted with the Director of Nursing (DON) who stated, psychoactive medications should be care planned but under the drug class and not the medication. The facility administration was informed of the finding during a briefing on 11/17/17 at approximately 2:30 p.m. The facility did not present any further information about the findings. The facility's policy: Comprehensive Person-Centered Care Planning Guidelines (Revised 5/31/17). -Incorporate identified problem areas.

Based on observations and staff interview the facility staff failed to prepare foods under sanitary conditions. The findings include: An initial kitchen inspection was conducted on 01/27/16 at approximately 9:00 a.m., with Dietary Department #3. An interview was conducted on 01/27/16 at approximately 11:30 a.m., with Dietary Department #1 who was preparing a bread slurry (bread prepared for physician ordered pureed diets). Dietary Department #1 was asked how she knew what consistency (thickness) was required, she explained her process and stated: It's supposed to be baby food consistency and pointed to a sign on the wall which stated: Pureed Food is to be baby food consistency. An interview was conducted on 01/27/16 at approximately 11:38 a.m., with the Dietary Manager. When asked what consistency the pureed food was to be she stated: It's to be pudding consistency. When the Dietary Manager was informed that there was a posting in the preparation area stating the consistency was to be baby food consistency she left her enclosed office which was next to the kitchen, went into the area where the noon meal was being prepared and removed the sign from the wall above the machine which contained the bread waiting to be prepared by the cook for the pureed diets. She did not have her hair contained by either a hair net or a hat. When this was brought to the Dietary Manager's attention she stated: It is the policy of the facility that anyone in the kitchen or when food is being plated and served needs to contain their hair. I know I should have my hair contained when I went into the kitchen preparation area but I was so focused on the information that you had shared with me about the sign I guess I forgot. All other individuals who were in the kitchen preparation area wore hair nets to contain their hair. The kitchen policy was obtained and reviewed which stated hair was to be contained when in the kitchen/food preparation areas. Administration which consisted of the Administrator and the DON (director of nursing) were informed of the findings at a briefing conducted on 01/28/16 at approximately 3:30 p.m. No additional information was submitted for review.

Based on observation, clinical record review and staff interview it was determined for Resident #8, one of ten residents in the survey sample, that facility staff failed to assure her eye drops were available for administration. During the 1/27/16 evening medication pass and pour observation Resident's #8's Patanol 0.1% eye drops (to treat glaucoma) was not available for administration. The findings included: Resident #8 was admitted to the facility on [DATE]. Review of the resident's 11/09/15 quarterly Minimum Data Set (MDS) evidenced the resident was rarely understood but usually understands others. The brief interview for mental status could not be completed. The resident was noted with long and short term memory loss and was severely impaired in her ability to make daily decisions. For activities of daily living the resident required the limited or extensive assistance of one staff person. [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. During the 1/27/16 6 pm medication pass and pour observation Licensed Practical Nurse (LPN) #1 attempted to administer Resident #8's Patanol eye drops. LPN #1 stated to the surveyor that the drops were not in the medication cart. LPN #1 checked the computer and stated to the surveyor that the drops had been ordered but information back from the pharmacy evidenced that the prescription could not be refilled until 2/2/16. LPN #1 stated she would call the resident's physician and get an order to hold the eye drops until available from the pharmacy. LPN #1 was unable to state why the drops had run out almost a week prior to the refill date. The following morning (9:30 am - 1/28/16) the clinical record was reviewed and revealed a telephone order to hold the eye drops until available from the pharmacy. The clinical record also evidenced a similar order dated 1/8/16 to also hold the Patanol drops until available from the pharmacy. RN #1 was available at the nursing desk and during interview stated that the eye drops had been delivered and were now in the medication cart. RN #1 and the surveyor proceeded to the medication cart. The Patanol drop were in the drawer. RN #1 stated that the drops had apparently been delivered last night around 10 p.m. Further review of the clinical record did not evidence that the drops had been administered the prior evening when delivered. The Patanol drops were dated as opened on 1/28/16. The Director of Nurses was interviewed on 1/28/16 at 10 am. The DON stated that LPN #1 had come to her the evening before (after the medication pass) and let her know the Patanol drops were unavailable and the DON called the pharmacy and ordered the drops delivered stat or as soon as possible. The DON continued that she is the only one who can order the extra or stat delivery. During the interview the DON stated that because the resident receives the drops in both eyes twice a day one vial is not sufficient to last for 30 days. The DON was aware of the problem but thought the mix up had been resolved with the pharmacy to deliver twice a month. At 11:04 am the DON reported back to the survey team she had spoken with the pharmacy representative and the pharmacy computer had the information that the eye drops were to be delivered twice a month or every two weeks. The pharmacy representative had calculated that the vial that was being delivered to the facility would not support the resident receiving four drops a day (each eye twice a day) for a month. The DON stated she thought this had been settled with the pharmacy after the resident was without drops on 1/8/16 but it had not been. The pharmacy will now deliver two vials at a time to assure Resident #8 has the needed quantity.

Based on clinical record review, staff interviews and facility documentation review, the facility staff failed to immediately report (within 24 hours) to the administrator and the State survey and certification agency, an injury of unknown origin (IUKO) for 1 of 10 residents (Resident #10) in the survey sample. Resident #10 had IUKO on 6/5/14 with unexplained bruising and clavicle fracture which was not reported to the administrator and/or designee or the State until 6/11/14. The findings included: Resident #10 was admitted to the nursing facility on 1/14/14 with [DIAGNOSES REDACTED]. The resident was not present in the facility and a closed record review was conducted. The Minimum Data Set ((MDS) dated [DATE] coded the resident with a score of 5 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was severely impaired in the skills needed for daily decision making. The resident was totally dependent on two staff for transfers, walking on and off the unit, toilet use and bathing. Resident #10 was coded with a closed non-displaced clavicle fracture. Review of the nurse's notes dated 6/5/14 (Thursday) indicated the off going nurse (7/3) made the on coming nurse (3/11) aware of bruise to resident's neck of unknown origin. The Certified Nursing Assistant(CNA) observed the bruise to the left chest and left shoulder. The physician was notified on 6/6/14. On 6/9/14 the bruising had spread down the left arm with increased pain. The resident was sent to the local emergency roiagnom on [DATE] at 6:00 p.m. for x-rays, labs and further assessment. The x-rays revealed a left midclavicular fracture with soft tissue [MEDICAL CONDITION]; indication trauma. The Facility Reported Incident (FRI) dated 6/11/14 indicated the Director of Nursing (DON) informed the Administrator on 6/11/14 and a fax was sent to the State survey and certification agency 6/11/14. The follow-up investigation report was faxed to the State on 6/17/14. An interview was conducted with the Administrator on 2/11/15 at 1:00 p.m. She stated she was very upset when she found out the DON did not call her or fax notification of the IUKO within 24 hours of identification of the shoulder bruises to the State and other agencies. She stated they could not substantiate abuse or pinpoint a cause of the bruises and clavicle fracture, but did substantiate it was an injury of unknown origin and warranted reporting to the State and the 5 day follow up with results of the facility's investigation. The facility's policy and procedure entitled Resident Rights/Abuse Prevention, Investigation and Reporting dated 6/4/13 indicated "The facility identifies events, such as suspicious bruising of residents, patterns, and trends that may constitute abuse; and to determine the direction of the investigation, through established incident reporting procedures. Any alleged violations involving mistreatment, neglect, injuries of an unknown source and misappropriation of resident property, must be reported to the administrator immediately. Injuries of an unknown source would be reported to the designated office licensing agency within 24 hours of a report of an incident with follow-up no later than 5 working days following the initial report.

Based on observation, resident interview, staff interview, clinical record review, and review of the facility's policy the facility staff failed to ensure a resident who requires use of an indwelling catheter receives appropriate care and services to prevent urinary tract infection [MEDICAL CONDITION] for 1 of 10 residents (Resident #2), in the survey sample. The facility staff failed to implement interventions to minimize the potential for a UTI secondary to use of an indwelling catheter during transfers for Resident #2. The findings included: Resident #2 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set ((MDS) dated [DATE] coded Resident #2 with short and long term memory problems and severely impaired in the skills needed for daily decision making. In section "H" (Bladder and Bowel) Resident #2 was coded as utilizing an indwelling catheter. The medical record revealed Resident #2 had developed a Urinary Tract Infections [MEDICAL CONDITION], 1/24/14. The resident was treated with [MEDICATION NAME] 500 milligrams (mg) 1 tab by mouth every day times 10 days for the 3/22/14 UTI. Resident #2 was observed on 2/10/15 at approximately 2:10 p.m. seated in a geri-chair in her room. Two Certified Nursing Assistants (CNA)s prepared Resident #2 for the transfer from the geri-chair to the bed. CNA #2 put the indwelling catheter drainage bag in Resident #2's lap (approximately 60 millimeters of cloudy urine was noted in the tubing) and CNA #1 and CNA #2 began to attach the Hoyer pad to the Hoyer lift. Once the Hoyer pad was securely attached to the Hoyer lift Resident #2 was slowly ascended until the hips could clear the geri-chair. CNA #1 moved the geri-chair to allow the Hoyer lift space to travel with Resident #2 to the bed. Resident #2 was gently lowered onto the bed and the 2 CNAs rolled Resident #2 onto her left side, then onto her right side. CNA #2 asked CNA #1 to hand over the bedside drainage bag (which was still on Resident's #2 lap) after which, CNA #2 attached the bedside drainage bag to the bed frame. The surveyor asked CNA #1 and CNA #2 if the indwelling catheter clamp was applied prior to placement of the drainage bag in Resident ' s #2 lap. They both replied no. Further observation of the catheter tubing and the clamp revealed indeed the catheter tubing was not clamped and the opportunity for back flow was likely from the time the drainage bag was placed in Resident #2 lap until it was attached to the bed frame. An interview was conducted with the Director of Nursing (DON) on 2/10/15 at approximately 2:20 p.m. The DON stated the CNA is to notify the licensed nurse the resident with an indwelling catheter is ready to be transferred and the licensed nurse is to clamp the indwelling catheter tubing prior to the transfer and return directly after the transfer is completed and unclamp the tubing. The DON stated in-servicing of the staff would begin immediately to reiterate the importance of preventing urine back flow and increasing the opportunity for UTIs during transfers of Resident's utilizing an indwelling catheter. The facility's policy titled Catheter Care, Urinary dated 10/25/2002 did not address preventing urine back flow during transfers but procedure #3 stated the drainage bag must be held lower than the bladder at all times to prevent back flow into the urinary bladder. Procedure #4 Catheter Care, Urinary policy stated check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. The above findings were shared with the Administrator, Director of Nursing and Corporate Clinical Nurse on 2/12/15 at approximately 7:15 p.m. No additional information was provided.