Every finding on record at Landmark of Desoto

Based on staff interview, record review and facility policy review the facility failed to ensure informed consent was obtained prior to the initiation of psychotropic medications for 5 (five) of 5 residents reviewed for unnecessary medications. Resident #1, Resident #3, Resident #6, Resident #12, and Resident #38. Findings Include: Facility policy titled Psychotropic Medications, dated 02/25, stated, Consent for Anti-psychotic Medication Treatment shall be completed for new order of or increasing the dose of an anti-psychotic, psychoactive, or neuroleptic medication. The prescribing physician, or facility medical director shall complete Section I providing indications for use, diagnosis, risks, benefits, alternatives and course of therapy. Section II shall be completed by resident or resident representative. Resident #1 Record review of Resident #1's Order Summary Report revealed an order dated 2/13/26, Klonopin (anti-anxiety) 0.5 MG (milligram) oral tablet (Clonazepam) give 1 (one) tablet via PEG (percutaneous endoscopic gastrostomy) Tube every 8 (eight) hours as needed for agitation and combativeness. Further review revealed an order dated 1/29/26, Risperdal (antipsychotic) oral tablet give 1 (one) tablet via PEG-Tube two (2) times a day related to Generalized Anxiety Disorder. Record review of Resident #1's Consent for Anti-psychotic, Psychoactive or Neuroleptic Medication Treatment revealed a phone consent was obtained for Klonopin and Risperdal by the resident representative (RR) on 2/14/26, after the medications were initiated. Record review of the Face Sheet revealed the facility admitted Resident #1 on 1/28/26 with medical diagnoses including Encounter for Attention to Gastrostomy and Generalized Anxiety Disorder. Record review of the MDS with an ARD of 2/4/26 revealed under section C, a Staff Assessment for Mental Status indicated Resident #1's cognitive skills for daily decision making were moderately impaired. Resident #3 Record review of Resident #3's Order Summary Report revealed an order dated 10/13/25 for Mirtazapine Tablet 7.5 MG Give 1 tablet by mouth in the evening for depression. There was also an order dated 11/05/25 for Trazodone HCL (Hydrochloride) Oral Tablet 50 MG Give 25mg by mouth every 12 hours as needed for anxiety related to Dementia Record review of Order Summary Report also revealed an order dated 03/18/26 with an end date of 03/29/26 for Risperdal Oral Tablet 0.5MG (Risperidone) Give 1 (one) tablet every 8 hours as needed for behavioral disturbances related to Dementia . Record review of Resident #3's Consent for Anti-psychotic, Psychoactive or Neuroleptic Medication Treatment form revealed that the Resident Representative consented by phone on 03/19/26 for the Mirtazapine which was ordered on 10/13/25, for the Trazodone which was ordered on 11/05/25, and for the Risperdal which was ordered on 03/18/26. During an interview on 03/19/26 at 9:10 AM with Director of Nursing (DON), she confirmed that Resident #3's Consent for Anti-psychotic, Psychoactive or Neuroleptic Medication Treatment form was signed after she started taking the Mirtazapine, Trazodone, and the Risperdal. She further revealed that the medications should have been explained to the resident and/or family initially prior to administration and that they would get their process corrected. Record review of Resident #3's Face Sheet revealed an admission date of 10/01/25 and that she had diagnoses that included Dementia and Encephalopathy. Record review of Resident #3's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 01/13/26 under Section C - Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) Score of 06 which indicated that she had severe cognitive deficits. Resident #6 Record review of the Order Summary Report dated 3/19/2026 revealed active medication orders for Lorazepam Oral Tablet 0.5 milligram (mg), start date 8/15/2025; Donepezil HCl Tablet 10 mg, start date 10/2/2025; and Olanzapine Oral Tablet 2.5 mg, start date 10/2/2025. Record review of the Consent for Antipsychotic, Psychoactive or Neuroleptic Medication Treatment form revealed consent for Olanzapine 2.5mg daily, Donepezil 10 mg, and Lorazepam was signed by the provider 1/27/26 and obtained via telephone from the resident representative (RR) also on 1/27/2026. During an interview on 3/18/2026 at 2:20 PM, the DON stated the consent form dated 1/27/26 was the only consent form available. She stated, I got to it as soon as I could. I tried to get the Medical Director to complete them when the regulations changed. He did a few of them and then said he couldn't do them, gave his 30-day notice and never came back.Record review of the Face Sheet indicated Resident #6 was admitted to the facility on [DATE] with medical diagnoses that included senile degeneration of brain, dementia and bipolar disorder. A record review of the MDS with an ARD of 2/25/26, revealed under section C that a BIMS was not conducted because the resident was rarely or never understood. Resident #12 Record review of Resident #12's Order Summary Report revealed an order with start date of 11/04/25 for Haloperidol Decanoate IM (Intramuscular) Solution 50 MG/ML to inject 50 mgs intramuscular one time a day starting on the 14th every month related to Schizophrenia, unspecified. Record review of Resident #12's Consent for Anti-psychotic, Psychoactive or Neuroleptic Medication Treatment form revealed that the Resident Representative signed the form on 12/18/25 which was after the Anti-psychotic medication, Haloperidol Decanoate, was initiated. An interview on 03/19/26 at 9:07 AM with DON, revealed that she initially completed the consents for antipsychotic medications, but due to increased workload, she asked the medical director to complete them during his rounds. She revealed that due to the lengthy process, the Medical Director requested that she complete the consent forms for him to sign. DON confirmed that Resident #12's consent was signed after starting the Haldol medication and further revealed that the medication should have been explained to the resident and/or family first. Record review of Resident #12's Face Sheet revealed an admission date of 02/10/25 and that she had diagnoses that included Unspecified Dementia and Schizophrenia. Record review of Resident #12's MDS with ARD of 02/18/26 under Section C - Cognitive Patterns revealed a BIMS score of 15 which indicated that she had no cognitive deficits. Resident #38 Record review of Resident #38's Order Summary Report revealed an order dated 7/15/24, Duloxetine (antidepressant) 30 MG give 1 (one) tablet orally two times a day related to Major Depressive Disorder. Record review of Resident #38's Consent for Anti-psychotic, Psychoactive or Neuroleptic Medication Treatment revealed the resident signed the consent acknowledging the risks and benefits of the drug Duloxetine on 1/27/26, which was not completed timely for informed consent. An interview with the DON on 3/19/26 at 9:18 AM revealed she initially completed the psychotropic consents; however, due to workload, she requested the medical director complete them during resident visits. She stated the medical director verbalized the process took too long and requested that she complete the consents for him to sign. She confirmed the consents were not provided to the resident and/or families in advance of treatment and therefore did not represent true informed consent. Record review of the Face Sheet revealed the facility admitted Resident #38 on 8/29/22 with medical diagnoses that included major depressive disorder, recurrent. Record review of the MDS with an ARD of 12/29/25 revealed under section C, a BIMS summary score of 15, indicating Resident #38 was cognitively intact.

Based on record review, staff interview, and facility policy review, the facility failed to ensure that the physician reviewed and responded to pharmacy recommendations for gradual dose reduction (GDR) and failed to ensure as-needed (PRN) psychotropic medication orders included a stop date for four (4) of five (5) residents. (Residents #1, #6, #12, and #38) Findings Include: Review of the facility policy Gradual Dose Reduction (GDR) for Psychotropic Medications with revision date of 11/17 revealed A Gradual Dose Reduction (GDR) is a stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued. Within 1st (first) year after admission on psychotropic or after initiation: GDR in 2 (two) separate quarters, with at least one month between attempts. After 1st (first) year GDR annually Review of facility policy titled Psychotropic Medications with review date 2/2025, revealed, .as needed (PRN) orders for psychotropic medications will be limited to 14 days unless the physician identifies the rationale to extend the medication beyond 14 days. PRN anti-psychotic drugs will be limited to 14 days and will not be renewed unless the physician evaluates the resident for appropriateness of the medication.The facility shall implement gradual dose reductions (GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication. Resident #1 Record review of Resident #1's Order Summary Report revealed an order dated 2/13/26, Klonopin (anti-anxiety) 0.5 MG (milligram) oral tablet (Clonazepam) give 1 (one) tablet via PEG (percutaneous endoscopic gastrostomy) Tube every 8 (eight) hours as needed for agitation and combativeness without a stop date. An interview with the Pharmacy Consultant on 3/18/26 at 2:20 PM revealed he was aware that Resident #1 was ordered PRN (as needed) klonopin without a stop date and stated he had sent a notification to the provider the previous month. He confirmed the PRN order remained unaddressed. An interview with the Director of Nursing (DON) on 3/18/26 at 2:32 PM confirmed Resident #1's as needed Klonopin order should have had a stop date after 14 days and then be re-evaluated for continued need. Record review of the Face Sheet revealed the facility admitted Resident #1 on 1/28/26 with medical diagnoses including Encounter for Attention to Gastrostomy and Generalized Anxiety Disorder. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/4/26 revealed under section C, a Staff Assessment for Mental Status indicated Resident #1's cognitive skills for daily decision making was moderately impaired. Resident #6 Record review of Resident #6's March Medication Administration Record (MAR) revealed a physician order for Lorazepam Oral Concentrate 1 milligram (mg)/0.5 milliliter (mL), give 0.5 mL by mouth every two (2) hours as needed for anxiety, with a start date 8/13/2025; however, the order did not have a stop date. Record review of Resident #6's March MAR revealed a physician order for Lorazepam Oral Concentrate 2 milligram/milliliter, give 1 mL by mouth every two (2) hours as needed for anxiety, with a start date 8/13/2025; however, the order did not have a stop date. During an interview on 3/18/2026 at 2:20 PM, the DON confirmed the two (2) as needed (PRN) Lorazepam orders did not have a stop date. She stated the hospice nurse and the resident's family did not want the medication discontinued. Review of a pharmacy recommendation related to Ativan 0.5 mg daily, dated 2/23/2026, revealed no evidence the physician reviewed the recommendation. Review of the admission Record indicated Resident #6 was admitted to the facility on [DATE] with a medical diagnosis that included senile degeneration of brain, dementia and bipolar disorder. A review of the MDS with an ARD of 2/25/26, revealed under section C that a BIMS was not conducted because the resident was rarely or never understood. Resident #12 During an interview on 03/19/26 at 9:07 AM with DON, she revealed that the facility's psychiatrist was the one responsible for completing the GDR's and addressing the recommendations. She revealed that their psychiatrist quit about three months ago and now the Medical Director was responsible. DON revealed that the medical director currently had the pharmacist recommendations in his folder, but none had been addressed nor returned to them. She confirmed that the purpose of the GDR's was to ensure residents' medications were maintained on the lowest effective dose possible. Record review of Resident #12's Pharmaceutical Consultant Report revealed that the last completed Psychoactive GDR was dated 02/11/25. Record review of Resident #12's Consultant Pharmacist Recommendation dated 12/29/25 revealed that notices were sent to the provider to consider dose reductions for Trazodone and Haldol and they were not addressed. Record review of Resident #12's Order Summary Report revealed an order dated 01/17/23 for Trazodone HCL (hydrochloride) 25mg (milligrams) for 1 tablet by mouth at bedtime and an order dated 11/04/25 for Haloperidol Decanoate IM (Intramuscular) Solution 50mg (milligrams)/ml (milliliter) to inject 50mg intramuscularly one time a day starting on the 14th every month and ending on the 14th every month related to Schizophrenia. Record review of Resident #12's Face Sheet revealed an admission date of 04/18/19 and that she had diagnoses that included Unspecified Dementia, Anxiety, and Schizophrenia. Record review of Resident #12's MDS with ARD of 02/18/26 under Section C - Cognitive Patterns revealed a BIMS Score of 15 which indicated that she was cognitively intact. Resident #38 Record review of Resident #38's Order Summary Report revealed an order dated 7/15/24, Duloxetine (antidepressant) 30 MG give 1 (one) tablet orally two times a day related to Major Depressive Disorder. Record review of the Consultant Pharmacist Recommendation dated 12/29/25 revealed a notice was sent to the provider to consider a dose reduction for duloxetine 30 mg which remained unaddressed. An interview with the DON on 3/18/26 at 2:32 PM revealed the facility's psychiatrist quit in December 2025 without notice, and at that time he was responsible for completing the GDR's and addressing the pharmacist recommendations. She revealed the medical director currently had the pharmacist recommendations in his folder; however, none had been signed or addressed. She confirmed the purpose of the GDR's was to ensure residents were maintained on the lowest effective dose and to prevent overmedication. Record review of the Face Sheet revealed the facility admitted Resident #38 on 8/29/22 with medical diagnoses that included major depressive disorder, recurrent. Record review of the MDS with an ARD of 12/29/25 revealed under section C, a BIMS summary score of 15, indicating Resident #38 was cognitively intact.

Based on observation, staff interview, record review and facility policy review, the facility failed to ensure the medication error rate was five (5) percent (%) or less for six (6) of thirty-three medication opportunities. Medication error rate of 18.18%.Findings Include: Review of the facility policy titled Administration of Medications revised 3/25 revealed under, Procedure . 3. Drugs and biologics are administered no more than one hour before or no more than one hour after the dosage time on the order. Also revealed under, Oral Medication Administration Procedure: . 3. Verify the physicians order, comparing the medication label to the MAR (Medication Administration Record) to verify the following:a. Right medicationb. Right dosagec. Right routed. Right timee. Right resident. Record review of Resident #17's Medication Administration Record (MAR) revealed the following medications were scheduled for administration at 9:00 AM: Lisinopril 10 milligrams (hypertension), Multivitamin liquid (supplement), Hydroxyzine 10 milligrams (anxiety), Metformin 500 milligrams (diabetes), and Levetiracetam solution 12 milliliters (epilepsy). An interview on 3/18/26 at 7:35 AM with Licensed Practical Nurse (LPN) #1 revealed she had already administered Resident #17's 9 AM medications. She acknowledged she gave the medications early, identified this as a medication error, and confirmed this did not follow nursing standards of practice for medication administration. She confirmed medications could only be given one hour before and one hour after the scheduled time. During an observation of med pass on 3/18/26 at 8:03 AM, LPN #1 prepared Resident #43's medications and stated the resident was out of prednisone 5 milligram tablets. The medication was not administered. LPN #1 stated she would write the medication down on her list to be faxed to the pharmacy and re-ordered, confirming the medication would not be available today. Record review of Resident #43's MAR revealed an order dated 1/21/26, Prednisone oral tablet give 1 (one) tablet by mouth one time a day related to Bronchitis due at 8 AM. A follow up interview with LPN #1 on 3/18/26 at 10:32 AM revealed Resident #43's prednisone was still not available. She confirmed the resident could have respiratory changes by missing a dose. Review of the facility's Total Medication Error Rate following reconciliation indicated the medication error rate was 18.18 % (percent). An interview with the Director of Nursing (DON) on 3/18/26 at 1:45 PM stated that prednisone was a medication that was kept in the emergency drug kit in the medication room. She stated she was not notified that Resident #43 was out of prednisone and stated if the medication was not in the emergency kit, the order still could have been faxed to the pharmacy, and they would have called it in to the backup pharmacy. The DON confirmed the resident should not miss a dose of medication and acknowledged medications were to be given 1 hour before or 1 hour after the scheduled time, confirming the med errors and of which could cause unwanted side effects. Record review of the Face Sheet revealed the facility admitted Resident #17 on 7/27/22 with medical diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/20/26 revealed under section C, a Staff Assessment for Mental Status indicated Resident #17's cognitive skills for daily decision making were severely impaired. Record review of Resident #43's Diagnoses List revealed the facility admitted the resident on 1/20/26 with medical diagnoses including Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation and Bronchitis. Record review of the MDS with an ARD of 1/27/26 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #43 was cognitively intact.

Based on observation, interview, record review, and facility policy review, the facility failed to have the call light accessible for Resident #30, this was for one (1) of 24 residents reviewed. Findings Include:Review of facility policy titled, Resident Call Light System, dated 07/25, revealed, A call light system is in place and operative in facility. This system allows individual residents to access a system that notifies nursing that the resident has a need . An observation and interview on 03/17/2026 at 10:50 AM observed Resident #30 lying in her bed and alert to name being called. A fall mat was on the floor next to the bed with bed in the lowest position. Observed a sign above the bed reminding resident to call for assistance, Please call, don't fall. Use the call button for assistance. Observed that call light was not within reach. Interview with the resident at that same time, asked if she knew what to do if she needed help and resident stated, I push the red button. Interview and observation on 03/17/26 at 10:56 AM with Licensed Practical Nurse (LPN) #2 stated resident is a fall risk, and she recently returned from hospital stay for a Urinary tract infection (UTI). LPN #2 walked into room and confirmed that Resident #30's call light was not easily accessible for the resident, and it should be. The call light was observed between the bed and the wall and was not reachable by the resident. Interview and observation on 3/17/26 at 1:04 PM with Certified Nursing Assistant (CNA) #1 confirmed that the call light should be within reach for the resident. She stated that the call light got dislodged with care this morning and she did not place it back in reach for the resident. Record review of the Face Sheet revealed the facility admitted Resident #30 on 3/24/25 with diagnoses that included chronic obstructive pulmonary disease.Record review of the Minimum Data Set with an Assessment Reference Date of 12/10/25 revealed a Brief Interview for Mental Status score of 09 which indicated moderately impaired cognition.

Based on record review, staff interview, and facility policy review, the facility failed to ensure the interdisciplinary team (IDT) reviewed and revised the resident's comprehensive care plan to reflect changes in the resident's condition for one (1) of eighteen (18) residents reviewed. (Resident #18)Findings include:Review of facility policy titled Care Plan Process with review date 3/26, revealed, Regulations require facilities to complete, at a minimum and at regular intervals, a comprehensive, standardized assessment of each resident's functional capacity and needs, in relation to several specified areas.The comprehensive care plan is an interdisciplinary communication tool. The IDT will minimally include the attending physician, Registered Nurse (RN) with responsibility for the care of the resident, a nurse aide with responsibility for the resident, a member of food and nutrition services staff, the resident and the resident's representative (s) to the extent practicable, and any other disciplines as appropriate such as social services, activities, therapy, etc.The care plan must be reviewed and revised periodically, on an ongoing basis to reflect the services provided or arranged and must be consistent with each resident's written plan of care. The facility shall use the results of the assessments to develop, review, and revise the resident's comprehensive plan of care.Record review of Care Plan Review forms dated 3/13/2026, 12/16/2025, and 9/26/2025 revealed the Social Services Director was the only member of the Interdisciplinary Team (IDT) to sign the form for these meetings. The forms indicated the Resident Representative attended via telephone. Record review of Progress Notes dated 9/25/2025, revealed, contact (responsible party legal name) for scheduled care plan. No response.During an interview on 03/19/2026 at 9:00 AM, the Minimum Data Set (MDS) Coordinator and MDS Nurse stated the MDS team develops the assessment calendar and provides it to the Social Worker (SW), who schedules care plan meetings with the resident and/or resident representative either in person or by telephone. They stated the IDT includes MDS nurses, therapy, Social Services, Activities, and Dietary, and that care plan meetings are conducted quarterly in conjunction with MDS assessments. The MDS Nurse stated the SW is responsible for ensuring care plan meetings are conducted and that IDT members sign the Care Plan Review form during the meetings to document attendance. During an interview on 03/19/2026 at 9:10 AM, the Administrator confirmed the Social Worker invites the resident and/or resident representative and that care plan meetings are held on Tuesdays, Thursdays, and as needed. She stated the IDT meets and the SW documents the meetings. Regarding Resident #18, the Administrator stated the resident was cognitively and physically able to participate in care plan meetings and be involved in her care. She further stated her expectation was for facility policy to be followed and for residents to be involved in their care to the extent possible. Record review of the admission Record indicated Resident #18 was admitted to the facility on [DATE] with medical diagnoses that included End Stage Renal Disease.A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/4/26, revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #18 was cognitively intact.

Based on observation, interview, record review, and facility policy review the facility failed to provide services to maintain or improve range of motion by not ensuring a physician ordered splint was applied daily for 1 (one) of 2 (two) residents reviewed. Resident #17. Findings Included:Record review of the facility policy Range of Motion with revision date of 01/24, revealed that the purpose was To improve or maintain joint mobility and muscle strength and To prevent contractures Observations on 03/17/25 at 10:55 AM and on 03/18/26 at 8:15 AM revealed Resident #17 lying in bed, he was non-verbal with his eyes open. His right hand was contracted and there was no wrist splint device in place. It was observed that there was a hand splint on the seat of the wheelchair that was against the wall. An interview and observation on 03/18/26 at 1:50 PM with Registered Nurse (RN) #1, revealed that they only had one resident requiring hand splints in the facility. She revealed that Resident #17 had received therapy services in the past and they had put a hand splint on him but since he had been discharged from them, he did not wear one. An observation with RN #1 in Resident # 17's room confirmed that there was a hand splint in his wheelchair in the corner of the room and his name was written on it. She stated, I don't know why that is in here, I've never put a hand splint on him. RN #1 confirmed that his right hand was contracted. She revealed that she wasn't aware there was an order for a splint to be put on, further stating that there wasn't anything on his MAR (Medication Administration Record) or TAR (Treatment Administration Record) to indicate that he needed to wear the splint every day. RN #1 revealed that not wearing a hand splint could cause the contracture to get worse. An interview on 03/18/26 at 2:15 PM with Director of Nursing, revealed that Resident #17 was supposed to wear a hand splint for four hours every day. DON viewed and confirmed the order for the hand splint to be placed for four hours a day and stated she didn't realize it wasn't getting done. She also reviewed Resident #17's TAR and confirmed the order was not put in correctly and it did not carry over for the nurses to know to do it. DON revealed that by not applying the hand splint daily as ordered, it could result in worsening of the contracture. An interview on 03/18/26 at 2:30 PM with Director of Rehab revealed that they had worked with Resident #17 in the past on stretching exercises to see if he would be able to straighten out his hand. She revealed that back in the summer of 2025, they ordered him and other residents hand splints, and they started putting the splint on Resident #17 for four hours a day. She revealed that they also educated the nurses and the nurses were applying the splint, and it was their responsibility to ensure it was on. Director of Rehab revealed that failure to apply the hand splint daily as ordered could result in the contracture worsening. Record review of Resident #17's Order Listing Report revealed an order dated 05/26/25 to apply right wrist splint for 4 hours per day. 2-hour skin checks under splint/brace for redness irritation, swelling, breakdown and adequate circulation/sensation prn (as needed) while splint in place every day shift for contracture prevention. Record review of Resident #17's March 2026 TAR revealed no order to apply the wrist splint every day. Record review of Resident #17's Face Sheet revealed an admission date of 07/27/22 and that he had diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side and Contracture of Right Hand.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure proper positioning and management of an indwelling urinary catheter drainage system for one (1) of one (1) resident reviewed for urinary catheter. Resident #11 Findings Include: Review of the facility policy titled Perineal Care, revised 1/24, revealed under Resident with Catheter: . 7. Ensure tubing is not positioned above the level of the bladder.An observation conducted on 3/17/26 at 11:29 AM revealed Resident #11 lying in bed with a urinary catheter drainage bag attached to the lower portion of the bed frame.Record review of Resident #11's Order Summary Report revealed an order dated 7/3/25, Foley catheter care Q (every) shift and PRN (as needed).During an observation of catheter care provided to Resident #11 by Certified Nurse Aide (CNA) #1 and Registered Nurse (RN) #1 on 3/18/26 at 11:00 AM, the urinary drainage bag was removed from the lower bed frame and placed in the bed with the resident during catheter care. This positioning resulted in urinary backflow from the drainage bag into the tubing.An interview with RN #1 on 3/18/26 at 11:12 AM confirmed the urinary drainage bag was not positioned appropriately to allow for proper drainage during catheter care and stated the urine could reflux and increase the risk for a urinary tract infection.Record review of the Face Sheet revealed the facility admitted Resident #11 on 7/2/25 with medical diagnoses including Diverticulosis of Intestine without Perforation and Pressure Ulcer of Sacral Region, Stage 3.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/13/26 revealed under Section C, a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #11 was cognitively intact.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure insulins were properly stored in accordance with manufacturer's guidelines to maintain safety and effectiveness for one (1) of two (2) medication carts observed. 300 hall Findings Include:Review of the facility policy titled Medication Storage, revised 11/17, revealed, Storage, supplies and equipment necessary for appropriate temperatures and conditions per the manufacturer's specifications.An observation of the 300 hall medication cart on 3/18/26 at 9:45 AM, with Licensed Practical Nurse (LPN) #1, revealed the following insulins were in use and either exceeded the manufacturer's 28-day room temperature storage limit or were not dated when opened:Resident #2 - Open vial of Novolog that was undated.Resident #3 - Open vial of Humalog dated 12/23/25.Resident #17 - Open vial of Insulin Aspart that was undated.Resident #51 - Humalog KwikPen that was undated. Record review of the manufacturer's storage instructions for Humalog and Novolog (Insulin Aspart) revealed that once opened, these insulins may be stored at room temperature for up to 28 days, after which the product should be discarded.An interview with LPN #1 on 3/18/26 at 9:52 AM revealed that if insulin did not have an open date, there would be no way to determine if the insulin was still safe to administer. She stated that insulin was good for 90 days after removal from refrigeration. LPN #1 confirmed that out-of-date insulin would not be as effective and could result in residents' blood glucose not being controlled.An interview with the Director of Nursing on 3/19/26 at 8:32 AM revealed that insulins stored on medication carts should be checked by nursing staff to ensure they are labeled with an open date and are not beyond the 28-day use period, after which they should be discarded.

Based on observation, staff interview, record review and facility policy review the facility failed to properly disinfect a glucometer after use, in accordance with infection control standards during one (1) of 6 (six) medication administration passes observed and failed to ensure contact precautions were in place for one (1) of five (5) residents reviewed for infection control. Resident #30.Findings Included: Review of the facility policy Infection Control Policy for General Cleaning and Maintenance of Equipment with revision date of 02/26 revealed that .Critical and invasive resident care devices (e.g. (exempli gratia), glucometers) shall be cleaned and disinfected per manufacturers' recommendations Record Review of Policy for Control of Multidrug-Resistant Organism (MDRO) Infection,latest review date 08/21 revealed, It is the policy of this facility to place residents in contact and/or droplet precautions if they are displaying symptoms of active multidrug-resistant organism (MDRO) infection An infection is considered to be active when MDROs enter the body and multiply in tissues, causing clinical manifestation of disease and immune response . An observation on 03/18/2026 at 11:05 AM revealed that Licensed Practical Nurse (LPN) #1, failed to clean and disinfect a glucometer correctly after exiting room [ROOM NUMBER]. She used a Micro Kill Two wipe, she wiped down the front and back of the glucometer and placed it immediately back inside the storage pouch. An interview on 03/18/26 at 11:08 AM with LPN #1, revealed that she always cleaned the glucometers after use. She revealed that she cleaned the glucometer on front and back and left the machine open to air until it was dry before she placed it back in the drawer. She revealed that she was not aware that she must leave the glucometer wet for 2 (two) minutes and that she cleaned it the way she was taught in nursing school. LPN #1 revealed that the purpose of correctly cleaning glucometers was to prevent cross contamination and the possible spread of infection. An interview on 03/18/26 at 2:00 PM with Director of Nursing (DON), revealed that the nurses were supposed to clean the glucometers following each use. She revealed that they were supposed to clean the glucometer front and back and then wrap it up with the wipe for at least two minutes prior to storing it. She revealed that not cleaning the glucometer correctly could cause the spread of infection including blood borne pathogens. Record review of the Manufacturer Instructions for the micro-kill two germicidal wipes revealed that it disinfects hard, nonporous surfaces in 2 (two) minutes. Instructions for use revealed, If present, use a wipe to remove visible soil prior to disinfecting. Unfold a clean wipe and thoroughly wet surface. Allow surface to remain visibly wet for contact time(s) listed on the label . Resident #30 Record review revealed a urine culture was obtained for Resident #30 on 02/24/2026 and lab reported on 03/01/2026 with culture results of Extended-Spectrum Beta-Lactamase-Producing (ESBL). Interview on 03/18/26 at 2:01 PM with the DON stated, I don't remember an ESBL diagnosis, but I'll go check. Interview on 03/18/26 at 2:45 PM with LPN #2 verified that the resident was diagnosed with ESBL according to the 03/01/2026 lab report, but she confirmed that she was unaware that the resident had this diagnosis and confirmed that the resident was not on contact precautions. Interview on 03/18/26 at 3:09 PM the DON confirmed Resident #30's lab results and stated, When I looked at the lab results, I didn't see the ESBL. I did miss that. DON confirmed that resident should be on contact precautions, but precautions were not initiated. Interview on 03/19/26 at 9:50 AM with the DON stated she has been doing the Infection Prevention (IP) role for about six (6)-eight (8) months after the nurse left and stated I don't know what they would do if I was out. I'm the only one with IP certification and I have voiced my concerns. Record review of the Face Sheet revealed the facility admitted Resident #30 on 3/24/25 with diagnoses that included Chronic Obstructive Pulmonary Disease.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure the accuracy of resident assessments by inaccurately completing section H (bowel and bladder) of the Minimum Data Set (MDS) for one (1) of 18 sampled residents. Resident #11.Findings Include: Review of the facility policy titled Resident Assessment, revised 9/19, revealed, An assessment will be completed on each resident utilizing the MDS (Minimum Data Set). The reason for the assessment, schedule, and timeframes will be according to the guidance of the Resident Assessment Instrument (RAI) Manual. An observation conducted on 3/17/26 at 11:29 AM revealed Resident #11 lying in bed with a urinary catheter drainage bag attached to the lower portion of the bed frame. Record review of Resident #11's Quarterly MDS with an Assessment Reference Date (ARD) of 12/19/25 revealed under Section H (Bladder and Bowel), item H0100 an indwelling catheter was not indicated. Record review of Resident #11's December Treatment Administration Record (TAR) revealed an order dated 7/7/25, Change catheter and catheter bag monthly and PRN (as needed). An interview with the MDS Nurse on 3/19/26 at 8:17 AM confirmed an error was made on December 2025 MDS and did not capture Resident #11's indwelling catheter. She stated the MDS should be accurate to ensure appropriate care was provided to the resident. Record review of the Face Sheet revealed the facility admitted Resident #11 on 7/2/25 with medical diagnoses including Diverticulosis of Intestine without Perforation and Pressure Ulcer of Sacral Region, Stage 3. Record review of the MDS with an ARD of 3/13/26 revealed under Section C, a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #11 was cognitively intact.

Based on observation, staff interviews, record review, and facility policy review, the facility failed to develop a comprehensive care plan for a resident with pressure ulcers for two (2) of 20 sampled residents. Resident # 28 and Resident # 209 Findings Include: Review of the facility policy titled Care Plan Process with a revision date of 8/17 revealed, .The Care Plan must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Resident #28 A review of the Skin & Wound Evaluation dated 9/19/24 revealed that Resident #28 acquired an unstageable pressure ulcer on the right fourth (4th) ring finger on 9/19/24. The quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 9/16/24 indicated that Resident #28 had a functional limitation in the range of motion (ROM) in the upper extremity on one side. A review of the comprehensive care plan for Resident #28 showed that no pressure reduction interventions were in place to reduce the risk of pressure ulcers associated with the resident's right fourth finger. On 10/29/24 at 8:30 AM, during an interview with the Wound Treatment Nurse she explained that Resident #28 had developed a pressure ulcer on the right fourth ring finger due to pressure from fingers contracted in a fist. She acknowledged that pressure relief measures should have been implemented to prevent pressure ulcers on Resident #28's fingers. During an interview with MDS Nurse #1 and MDS Nurse #2 on 10/29/24 at 8:45 AM, they stated that the purpose of the care plan is to inform staff of the resident's required care. They confirmed that there was no care plan in place to prevent skin breakdown related to the right-hand contracture and agreed that such a plan should have been established. Record review of the Admission Record revealed the facility admitted Resident # 28 on 5/31/21 with a diagnosis of Cerebral Infarction. Resident #209 On 10/29/24 at 11:20 AM, an interview with the Wound Treatment Nurse revealed, Resident #209 had a new pressure wound on the right Achillies area. Record review revealed a care plan was not developed for Resident #209's wound care or pressure ulcer on the right Achilles. On 10/29/24 at 3:50 PM, an interview with the Administrator (ADM) confirmed Resident #209's wound care plan was not developed. An interview with the MDS Nurse #1 on 10/30/24 at 10:40 AM revealed the purpose of care plan development was so that anyone who looks at the wound knew the level of care needed. Record review of the Admission Record revealed the facility admitted Resident #209 on 10/9/24 with a medical diagnosis of Displaced Fracture of the Lower Epiphysis of Right Femur. 47874

Based on observation, record review, resident and staff interview the facility failed to provide treatment and services to prevent pressure ulcers for two (2) of five (5) residents observed with pressure ulcers. Resident #28 and Resident # 209 Findings Included: Record review of facility policy Pressure Ulcer Prevention and Treatment Intervention Guidelines, revised 10/22, revealed C. Protection from Fiction or Shear .4. Provide padding for casts, braces, splints, oxygen tubing, shoes etc. as needed to prevent friction. 5. Remove orthotics on a regular basis for skin inspection .Therapy Department Interventions .3. Explore possible therapy interventions for .c. Splinting/orthotic modifications . 1. Provide pressure ulcer topical treatments as ordered Resident #28 A review of the Skin & Wound Evaluation dated 9/19/24, revealed that Resident #28 acquired an unstageable pressure ulcer on the right fourth (4th) ring finger on 9/19/24. Record review revealed measurements of 1.4 centimeters (cm) area, 1.4 cm length, 1.3 cm width and depth not applicable (n/a). The quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 9/16/24 Section GG revealed revealed Resident #28 had a functional limitation in the range of motion in the upper extremity on one side. A record review of Order Listing Report for September and October 2024 revealed no orders for pressure relief devices for Resident # 28. During an observation and interview with Licensed Practical Nurse (LPN) #2 on 10/29/24 at 8:00 AM, Resident #28 was observed with a palm shield in place on the right hand. LPN #2 confirmed that Resident #28 had a contracture in the right hand and stated that the palm shield was applied only after the pressure ulcer developed on the right 4th ring finger. She verified that no splinting or other pressure relief interventions were in place before the pressure ulcer developed. In an interview with the Wound Treatment Nurse on 10/29/24 at 8:30 AM, she explained that Resident #28 had developed a pressure ulcer on the right fourth ring finger due to pressure from the fingers being contracted in a fist. She stated that when she identified the pressure ulcer, she contacted therapy to request a pressure relief device. She acknowledged that pressure relief measures should have been in place to prevent pressure ulcers on Resident #28's fingers. She confirmed that there were no orders or documentation for the use of the palm shield. In an interview with the Rehabilitation Director on 10/30/24 at 9:00 AM, she verified that Resident #28 did not have a palm shield before developing the pressure ulcer on the right 4th finger and confirmed that she was consulted, and the shield was implemented after the ulcer appeared. Record review of the Admission Record revealed the facility admitted Resident # 28 on 5/31/21 with a diagnosis of Cerebral Infarction. Resident #209 An observation and interview with Resident #209 on 10/29/24 at 10:16 AM revealed, she was lying in bed with an immobilizer to the right leg. The resident verbalized she had an unrepaired femur fracture and revealed she had a new sore that developed under the brace since she admitted . She explained that she followed up with her orthopedic doctor last week, and he asked her to use foam under the brace, but the facility did not have any foam. An interview with the Wound Treatment Nurse on 10/29/24 at 11:20 AM revealed Resident #209 had a new pressure wound caused by the immobilizer on the Achilles area. She explained that she was notified by the Therapy Rehab Director on 10/21/24 that the residents' immobilizer was sliding down and had caused a sore. She revealed she had been treating the wound since she was made aware, but the treatment order was not added to the Treatment Administration Record (TAR) until 10/26/24, and she had not staged the wound. The Wound Nurse confirmed Resident #209's skin had not been assessed under the immobilizer every day to determine if the resident had any skin breakdown. Record review of the Wound Evaluation dated 10/22/24 revealed the wound to the right Achilles was not staged and measured 0.94 cm in length and 0.56 cm in width, with no determination on depth. Review of the October 2024 Treatment Administration Record for Resident #209 revealed an order, dated 10/26/24, Clean open area to right heel with NS (normal saline) and pat dry, apply Xeroform and cover with bandage every other day until resolved with a discontinue date of 10/29/24. Also revealed an order, dated 10/29/24, Clean open area to right Achilles with NS (normal saline) and pat dry, apply TAO (triple antibiotic ointment) and cover with bandage every other day until resolved. Record review of the Order Listing Report revealed there was not a physician order for Resident #209's leg immobilizer or to monitor the skin under the brace for skin breakdown. An interview with the Director of Nursing (DON) on 10/29/24 at 12:50 PM confirmed, Resident #209 did not have an order for the right leg immobilizer. She revealed it was not clear to her why the staff would not have called and followed up on how the resident was supposed to wear it. Record review of the Physician Consultation Report dated 10/24/24 revealed under, Findings: . Pressure sores where hinges are present. Also revealed under, Recommendations: When pt is in bed open brace completely to relieve pressure; Apply thin layer of foam to posterior calf and thigh portion of brace. An interview with the Wound Treatment Nurse on 10/29/24 at 2:30 PM confirmed she did not implement the orders recommended by the Orthopedic Physician. She revealed the foam would have been too thick under the brace and stated, I don't think foam would work. She revealed Resident #209 had told her the hospital applied foam under the immobilizer, and it was too tight. An interview with the Administrator (ADM) on 10/29/24 at 2:48 PM, confirmed the skin should be assessed underneath an immobilizer daily to ensure there was no skin breakdown caused by the device. She confirmed Resident #209's wound was avoidable, if the skin under the immobilizer had been assessed. She revealed the physician's recommendations should have been followed. An interview with the Therapy Rehab Director on 10/30/24 at 9:10 AM revealed she usually had to take Resident #209's immobilizer off to reposition it correctly. She revealed she observed the area to the resident's leg and reported it to the nurse on duty on 10/20/24. She stated the nurse thought the brace had rubbed the area on the leg, and she needed something to pad the area for support. The therapist revealed they placed a towel under the brace that day for extra protection, and she told the Wound Treatment Nurse the following day. An interview with the Wound Treatment Nurse on 10/30/24 at 10:25 AM confirmed Resident #209's wound was avoidable if the proper monitoring under the brace had been done. Record review of the Admission Record revealed the facility admitted Resident #209 on 10/9/24 with a medical diagnosis of Displaced Fracture of the Lower Epiphysis of Right Femur. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/16/24 revealed under, section C, a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated Resident #209 was cognitively intact. 47874

Based on staff interviews and record reviews, the facility failed to submit accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) as required for the third quarter (Q3) of fiscal year (FY) 2024 (April 1-June 30). Findings include: Record review of a letter, on facility letter head, signed by the Administrator, revealed that the facility does not have a policy related to Payroll Based Journal (PBJ) submission. A record review of the facility's PBJ Staffing Data Report for Q3 FY 2024 revealed that the facility triggered for excessively low weekend staffing. In an interview on 10/29/24 at 12:45 PM, the Administrator stated that the facility had not submitted accurate PBJ staffing data to CMS for the third quarter of FY 2024. She explained that the corporate office was responsible for submitting PBJ staffing data for the facility; she provided the agency/contract staffing hours, while the corporate office pulls hours for facility staff from payroll records. She noted that administrative staff were sometimes reassigned to provide direct resident care when there are call-ins, but there was currently no way to report this as direct care, which contributed to the PBJ reporting error.

Based on observation, staff interview, record review, and facility policy review, the facility failed to provide appropriate care services for (1) one of (5) resident care observations. (Resident # 57) Findings include: A review of the facility policy titled, Perineal Care, latest revision date 01/24 revealed.Resident with Catheter: 4.) Using a clean washcloth or wash wipe, start at the meatus and wash the tubing in a circular motion away from the body . Rinse using the same method . An observation of catheter care with Certified Nurse Assistants (CNA) #1 and CNA #2 for Resident #57 on 10/29/24 at 11:34 AM, revealed CNA #1 cleaned one side of the urinary catheter from the urinary meatus downward with a clean soapy wet washcloth, and then cleaned the other side with a clean area section of the washcloth. CNA #1 then placed the dirty washcloth into the clean water in the wash basin, rinsed it out and used the same dirty washcloth to rinse the urinary catheter tubing/urinary meatus all in the same swipe wearing the same gloves worn during cleaning process In an interview with CNA #2 on 10/29/24 at 11:56 AM, she revealed that she was in the room only to help CNA #1 if she needed any help. She confirmed that CNA #1 contaminated the clean water in the basin when she put the dirty washcloth in it. She then stated CNA #1 should also have used a clean washcloth to rinse the resident. In an interview with CNA #1 on 10/29/24 at 11:59 AM, she revealed she did not even realize she forgot to change her gloves as well as she used the same dirty washcloth to rinse Resident #57's meatus and catheter tubing. She stated that it was cross contamination and could lead to infections. In an interview with the Infection Control/Treatment Nurse on 10/29/24 at 12:12 PM, she revealed that the CNA should have performed hand hygiene and used a clean washcloth to rinse the perineal area after cleansing the resident to prevent cross contamination of bacteria. She stated that failing to do this could lead to urinary tract infections for the resident. Record review of the Admission Record revealed the facility admitted Resident # 57 on 9/16/24 with diagnoses including Neuromuscular dysfunction of the bladder. Record review of Resident #57's Section C of the Minimum Data Set (MDS) dated [DATE] revealed on a Brief Interview for Mental Status (BIMS) score was 15, indicating the resident was cognitively intact. In Section H Bladder and Bowel item H0100 revealed the resident had an indwelling urinary catheter.

Based on observation, resident and staff interview, and facility policy review, the facility failed to ensure a resident's environment was free from accident hazards, as evidenced by, medications left at bedside for one (1) of twenty sampled residents. Resident #58 Findings Include: Review of the facility policy titled Medication Storage with a revision date of 11/17 revealed under, There shall be storage areas provided that assure adequate space, equipment and security for medications within the facility . An observation and interview on 10/28/24 at 9:50 AM, revealed Resident #58 lying in bed and on the bedside table was a six (6) ounce bottle of red spray liquid with a label that read, Sore Throat Spray and a one (1) fluid ounce white bottle that read, Lubricating Eye Drops. The resident revealed that she used the eye drops about six times a day for dry eyes and administered it herself. She revealed that she used the sore throat spray as needed for a sore throat. She explained the staff knew she had it because it had been on the table since she was admitted to the facility. An interview with Licensed Practical Nurse (LPN) #1 on 10/28/24 at 10:30 AM, confirmed Resident #58 had medications at her bedside. She revealed the resident did not have a physician order for the medication and the resident could be using the medication too often without staff monitoring, or a confused resident could come along and take it. An interview with the Administrator (ADM) on 10/29/24 at 8:58 AM, revealed the residents were not supposed to have medications at bedside. She confirmed Resident #58 could take too much, or she could have a reaction to the medications, and that all medications should be secured and put away. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/10/24 revealed under Section C, a Brief Interview for Mental Status (BIMS) summary score of 12, which indicated Resident #58 was moderately cognitively impaired. Record review of the Admission Record revealed the facility admitted Resident #58 on 10/4/24 with a medical diagnosis of Cellulitis of the left lower leg.

Based on resident and staff interview, record review, and facility policy review, the facility failed to honor a resident's right to make health care decisions related to cardiopulmonary resuscitation (CPR) for one (1) of 20 sampled residents. Resident #58 Findings Include: Review of the facility policy titled Advance Directives with a revision date of ,d+[DATE] revealed under, Policy: The facility recognizes that all adults have a fundamental right to make decisions relating to their own medical treatment, including the right to accept or refuse medical care. Also revealed under, Procedure: . The resident will be encouraged to participate in all aspects of decision-making regarding care and treatment. Statements by a competent resident regarding his/her desire to accept or refuse treatment will be documented in the resident's clinical record. Record review of the Advanced Directive Consent for Resident #58 revealed, the consent was initialed and signed by a family member dated [DATE] and that Resident #58 did not sign the consent. An interview with Resident #58 on [DATE] at 8:10 AM, revealed the facility had not gone over the advanced directives consent or code status with her. She revealed she would like to make her own healthcare decisions because she was still able. She confirmed she did not have a medical Power of Attorney (POA) established and explained she wanted everything done to save her life, should something happen. An interview with the Admission Coordinator on [DATE] at 8:24 AM, confirmed she did not go over the advanced directives and code status with Resident #58 on admission. She explained that she allowed a family member to sign the consent because the family member was the Resident Representative (RR). The Admission Coordinator confirmed she should have spoken with the resident regarding her wishes. She revealed Resident #58 was cognitive and able to make her own healthcare decisions, and she did not have a medical POA to make decisions for her. An interview with the Administrator on [DATE] at 8:56 AM, confirmed Resident #58 was cognitive and should have been allowed to sign her consent related to code status on admission. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed under, section C, a Brief Interview for Mental Status (BIMS) summary score of 12, which indicated Resident #58 was moderately cognitively impaired. Record review of the Admission Record revealed the facility admitted Resident #58 on [DATE].

Based on observation, staff interview, and facility policy review, the facility failed to provide privacy for one (1) of 20 residents reviewed as evidenced by a resident who was left uncovered and visible from the hallway. Resident # 17 Findings Include: A review of the facility's Dignity and Respect policy, revised on 7/22, stated: A facility must treat each resident with dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of their quality of life, recognizing each resident's individuality. The facility shall protect and promote the rights of the resident . Residents will be examined and treated in a manner that maintains bodily privacy . An observation from the hallway on 10/28/24 at 9:30 AM, revealed Resident #17's door was open and was lying in bed uncovered, with an adult incontinence brief on the resident, stomach exposed, with the Percutaneous Endoscopic Gastrostomy (PEG) tube visible. In a follow-up observation from the hallway on 10/28/24 at 9:55 AM, Resident #17 was still lying uncovered in bed, with an adult brief, stomach, and PEG tube exposed, and with the door open and privacy curtain pulled back. An observation and interview on 10/28/24 at 10:20 AM, with Licensed Practical Nurse (LPN) #1 confirmed that Resident #17's door and privacy curtain were open and that the resident was in bed uncovered, with their hospital gown partially up, revealing an adult brief. The LPN stated that the resident never stays covered but acknowledged that staff should be keeping the privacy curtain pulled so that the resident was not visible from the hallway. In an interview on 10/29/24 at 9:00 AM, the Director of Nursing (DON) confirmed that Resident #17 being uncovered, with the brief and PEG tube visible from the hallway, was a dignity concern. Record review of the Admission Record revealed the facility admitted Resident #17 on 7/27/22 with a diagnosis of Cerebral Infarction.

Based on observation, staff interview, record review, and facility policy review, the facility failed to maintain a system of medication records that enables periodic accurate reconciliation and accounting for all controlled medications for (1) one of (3) three narcotic storage areas reviewed. Findings include: A review of the facility policy titled, Drug-Controlled Substances, latest revision 11/17 revealed, Regulations require that the facility have a system in place to account for the receipt, usage, disposition, and reconciliation of all controlled medications . A controlled drug count is to be done at the beginning of each shift by the outgoing and on-coming nurses . An observation of the narcotic box in the medication room refrigerator with Licensed Practical Nurse (LPN) # 1 on 10/29/24 at 8:30 AM, revealed four (4) vials of Emergency Drug Kit (EDK) Lorazepam two (2) mg/ml (milligram/milliliter). LPN #1 revealed she and the other medication nurse on duty have access to the narcotic box in the refrigerator. She then confirmed the Lorazepam was not counted every shift with the other narcotics on the medication carts with the ongoing and off going shifts. LPN #1 also revealed she was unaware how long the Lorazepam vials had been in the refrigerator. In an interview with the Pharmacy Consultant on 10/29/24 at 8:35 AM, he confirmed that the medication nurses should be reconciling the EDK Lorazepam in the medication room narcotic box every shift. He then revealed that a potential concern from not reconciling narcotics is potential narcotic diversion. In an interview with LPN #2 on 10/29/24 at 10:10 AM, she stated she has a key to the narcotic lock box in the medication room refrigerator and was aware there was Lorazepam in the narcotic box. She then confirmed that the Lorazepam was not reconciled every shift with the other narcotics on the medication cart and is not listed in her narcotic count book. She stated a concern from not counting the narcotic every shift was it could have been missing, and we would not know when it went missing. A review of an Emergency Box Requisition form with the Pharmacy Consultant on 10/29/24 at 10:20 AM, revealed the four vials of Lorazepam in the medication room lock box were delivered on 5/04/23. He revealed after further observation of the Lorazepam, the EDK requisition form to be counted each shift was still in the refrigerator with the box of Lorazepam vials. The pharmacy Consultant then confirmed the Lorazepam was never added to either medication cart-controlled record books for the nurses to reconcile every shift. In an interview with the Director of Nursing (DON) on 10/29/24 at 10:30 AM, she confirmed the EDK Lorazepam should have been added to the narcotic count book to be counted each shift.

Based on observations, staff interviews, record review, and facility policy review, the facility failed to provide personal hygiene to residents as evidenced by chapped peeling lips, long nails with a brown substance underneath, and yellow substance on teeth for two (2) of 18 residents sampled for activities of daily living (ADL'S). Resident #23, and #39. Findings include: Record review of the facility policy titled, Activities for Daily Living with a revision date of 12/20 revealed .Procedure: 1. ADLs to be resident-specific and reflect current resident status . Resident #23 An observation on 8/14/23 at 3:43 PM, of Resident #23 revealed, him lying in bed, non-verbal, with long fingernails on both hands that measured three-eights (3/8) inch with a brown substance underneath. The resident was observed with a thick layer of yellow substance on upper and lower teeth. An observation and interview on 8/15/23 at 10:05 AM, with Certified Nurse Aide (CNA) #4 confirmed that Resident #23 had long nails with a brown substance underneath. She revealed that the treatment nurse cuts and cleans the resident's nails. She confirmed that the resident had a thick yellow substance on his upper and lower teeth and stated, It's probably some plaque or something. She revealed that she used lemon glycerin swabs, or the pink mouth swabs every shift for oral hygiene and acknowledged she did not brush his teeth. An observation and interview on 8/15/23 at 10:10 AM, with Licensed Practical Nurse (LPN) # 2 confirmed that Resident #23 had long dirty nails. She revealed that the resident should get his nails cleaned as part of his routine bath by the aide. She revealed that a Registered Nurse (RN) must trim his nails because he was a diabetic, but the aides can clean them. LPN #2 revealed the aides use mouth swabs to perform oral care on the resident. An observation and interview on 8/15/23 at 10:30 AM, with the Director of Nursing (DON) confirmed that Resident #23 had long nails with a brown substance underneath. She stated, They need cut and cleaned. She also confirmed that the resident had a yellow substance adhering to his upper and lower teeth. She revealed that the aides were using lemon glycerin or pink swabs for oral care, but they were not brushing his teeth. The DON confirmed that dental caries or gingivitis could result. She also confirmed that the resident could scratch himself or the staff with the long nails. Record review of the August Electronic Treatment Administration Record (ETAR) revealed, Diabetic Fingernail Care Per RN As Needed with an order date of 7/27/23 with no documentation that fingernail care had been performed for Resident #23. Record review of the Face Sheet for Resident # 23 revealed the resident was readmitted to the facility on [DATE] with medical diagnoses that included encounter for Attention to Gastrostomy, Type 2 Diabetes Mellitus, and Cerebral Infarction due to Embolism. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/17/23 revealed under section C, a Brief Interview for Mental Status (BIMS) score of 00, indicating Resident #23 never/rarely makes decisions or understood. Section G revealed Resident #23 requires total dependence with personal hygiene. Resident #39 On 08/14/23 at 02:25 PM, an observation revealed Resident #39 lying in bed, and unable to converse with the State Agent (SA). The resident is tube fed and her upper and lower lips were dry, cracked, and peeling. On 08/14/23 at 03:28 PM, the SA observed Resident #39 lying in bed awake and her upper and lower lips were dry, cracked, and peeling. On 8/15/23 at 8:43 AM, revealed Resident #39 lying in bed awake. Her upper and lower lips were dry and cracked with a peeling substance noted on the lips. On 08/15/23 at 11:00 AM, an observation and interview with Certified Nursing Assistant (CNA) #1 revealed Resident #39 lying in bed awake. CNA #1 revealed she is the shower aide and was giving the resident a bed bath. She confirmed the resident's lips were very dry and cracked when she came in to give her a bath, she revealed it was peeling bad and that's why I started putting the moisturizer on her lips. She revealed the aide that is assigned to the resident is supposed to make sure that they do oral care, especially for her since she is a mouth breather and it looked like her lips hadn't been done in a while. On 08/15/23 at 11:17 AM, an interview with CNA #2 revealed, she was assigned to Resident #39 yesterday and today. She revealed this morning when she came in, she didn't notice her dry lips and used the pink swab. She confirmed she didn't do mouth care yesterday and hasn't applied any moisturizer for the past two days. She revealed we are supposed to do mouth care every day and whenever the resident needs it. On 08/15/23 at 11:25 AM, an interview with Licensed Practical Nurse (LPN) #1 revealed, she is assigned to the resident today and had been in her room several times this morning doing care to her peg (percutaneous endoscopic gastrostomy) tube. She confirmed that she noticed the resident's lips were dry and cracked and peeling this morning and revealed she is feisty and some days lets me put moisturizer on her and someday's not. She revealed she didn't try to put moisturizer on her and told the bath aide that was getting ready to give her a bath that her lips were dry and cracked and the bath aide said she would take care of it. On 08/15/23 at 12:00 PM, an interview with CNA #1, in the presence of the Director of Nurses (DON), confirmed Resident #39's lips were very dry and peeling when she went in to give her a bath this morning and when she cleaned the side of the lip it started bleeding. She revealed she cleaned her lips off and applied moisturizer to them. An interview on 08/15/23 at 12:15 PM, the DON revealed mouth care is supposed to be done at least once a shift and as needed. She revealed that they use lemon or pink swabs and Resident #39 also uses moisturizer. A record review of the facility's Face Sheet for Resident #39 revealed an admitted [DATE] with diagnoses that included Alzheimer's disease, Depression, and Adult Failure to Thrive. A record review of the MDS with an ARD of 7/24/2023 revealed there was no BIMS score due to Resident #39 being severely impaired-never/rarely made decisions. 47874

Based on staff interviews, record review and facility policy review, the facility failed to a implement a comprehensive care plan for a resident requiring oral care and a resident requiring nail care and for two (2) of 18 residents care plans reviewed. Resident #23 and #39 Findings include: A review of the facility policy titled, Care Plan Process with a revision date of 08/17 revealed, Regulations required facilities to complete, at a minimum and at regular intervals, a comprehensive, standardized assessment of each resident's functional capacity and needs, in relation to a number of specified areas (e.g., customary routine, vision, and continence). The results of the assessment, which must accurately reflect the resident's status and needs, are to be used to develop, review, and revise each resident's comprehensive person-centered plan of care . Resident #23 Record review of Resident # 23's Care Plan with a problem on set date of 9/14/2016 revealed RESIDENT IS DEPENDENT WITH ADLS (Activities of Daily Living) Approaches . PROVIDE AM/PM CARES . Record review of Resident #23's Care Plan with a problem onset date of 6/10/2019 revealed, RESIDENT HAS A DX (diagnosis) OF DIABETES MELLITUS (DM) .Approaches . DIABETIC FINGERNAIL CARE PER RN AS NEEDED . An observation on 8/14/23 at 3:43 PM, revealed Resident #23 lying in bed, non-verbal with long fingernails on both hands that measured three-eights (3/8) inch with a brown substance underneath. The resident was observed with a thick layer of yellow substance on his upper and lower teeth. An observation and interview on 8/15/23 at 10:30 AM, with the Director of Nursing (DON) confirmed that Resident #23 had long nails with a brown substance underneath. She stated, They need cut and cleaned. She also confirmed that the resident had a yellow substance adhering to his upper and lower teeth. She revealed that the aides were using lemon glycerin or pink swabs for oral care, but they were not brushing his teeth. An interview with the Minimum Data Set (MDS) Nurse on 8/15/23 at 12:05 PM, revealed she was responsible for developing the comprehensive care plans. She revealed she looked over Resident #23's physician orders and the resident to determine what kind of assistance the resident would need. She confirmed that Resident #23's care plan for diabetic finger nail care and oral care was not followed. She revealed the purpose of the care plan was to be a guide for the staff as to what care to provide for the resident. An interview with the Director of Nursing (DON) on 8/15/23 at 12:10 PM, confirmed that Resident #23s care plan was not followed for nail and oral care. Resident #39 Record Review of Resident #39's Care Plan problem with onset of 01/01/2021 revealed Resident is edentulous .Approaches .Assist resident with maintaining good oral hygiene . A review of the Care Plan problem with onset of 01/01/2021 revealed Resident needs assist with ADL's . Approaches Offer and assist with ADLs as needed . An observation on 08/14/23 at 02:25 PM, Resident #39 revealed she was lying in bed, unable to converse with State Agent (SA) and was being tube fed. Resident #39's upper and lower lips were dry, cracked, and peeling. An observation on 08/14/23 at 03:28 PM, revealed Resident #39 was lying in bed awake. Her upper and lower lips were dry, cracked, and peeling. An observation on 08/15/23 at 08:43 AM, revealed Resident #39 lying in bed awake with her upper and lower lips dry and cracked with a peeling substance noted on the lips. On 08/15/23 at 11:50 AM, an interview with the MDS nurse revealed she is responsible for developing the comprehensive care plan, and the care plans are developed for each individual resident so the staff will know how to take care of them. She confirmed the care plan for Resident #39 was not followed for oral care. An interview on 08/15/23 at 12:00 PM, Certified Nursing Assistant (CNA) #1, in the presence of the Director of Nurses (DON), confirmed Resident #39's lips were very dry and peeling when she went in to give her a bath this morning. An interview on 08/15/23 at 12:15 PM the DON revealed mouth care is supposed to be done at least once a shift and as needed. She confirmed the oral hygiene care plan was not implemented for the resident. 47874

Based on observation, record review, staff interview, in-service review, and policy review, the facility failed to ensure that glucose meters were cleaned and disinfected per facility policy before and after use between each patient; failed to ensure that the staff changed gloves and washed their hands appropriately during the blood glucose testing for two (2) of eight (8) observations. This affected Resident #9 and Resident #10. Licensed Practical Nurse (LPN) #1 obtained blood glucose by finger stick for Resident #9 and did not clean and disinfect the glucose meter before or after the procedure as per facility policy. LPN #1 did not change her gloves or wash her hands per facility policy to prevent possible cross contamination. LPN #1 obtained blood glucose for Resident #10 without cleaning and disinfecting the glucose meter, changing gloves or washing her hands. (Resident #9 and Resident #10 are room mates). The facility also failed to ensure that three (3) employees hired since 4/11(LPN #1, LPN #2, and RN #2) were trained and performed a return demonstration on the cleaning and disinfecting of the glucose meter before and after use as per facility policy. There were no systems in place to monitor the cleaning and disinfecting of the glucose meter before and after use since 9/10/10. There were 25 resident's identified as requiring finger stick blood glucose levels due to the [DIAGNOSES REDACTED]. These actions put all 25 residents at risk to cause harm, or likely to cause serious injury, harm, impairment, or death to a resident was identified to be an Immediate Jeopardy on 9/8/11 at 10:40 a.m. The Administrator, Corporate Nurse and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) at that time. The facility provided an acceptable credible allegation of compliance on 9/9/11 at 2:00 p.m. and after verification of corrective actions the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered to the " E " level which constitutes no actual harm with potential for more than minimal harm. Findings include: Observation on 9/7/11 beginning at 3:50 p.m. revealed that Licensed Practical Nurse (LPN) #1 removed the glucose meter from a drawer in the medication cart and placed it on top of the medication cart. LPN #1 retrieved a lancet, pair of gloves, alcohol prep and the bottle of test strips. (The test strips are used for all residents on that hall way requiring blood glucose testing). LPN #1 donned gloves; went into Resident #9's room; and placed the glucose meter and the bottle of test strips on the over bed table with out cleaning the table or providing a barrier. LPN #1 picked the bottle of test strips up using her gloved hands and removed one (1) test strip. Then, placed the bottle of strips on the over bed table. LPN #1 performed the finger stick blood glucose procedure and told Resident #9 the results. Afterwards, LPN #1 used the same gloved hands, retrieved the glucose meter, used test strip (that had already been ejected from the glucose meter), alcohol prep, and lancet in her gloved hands. LPN #1 opened the door to the room and then placed the items on the medication cart. LPN #1 placed the lancet into the sharp's disposal on the medication cart. LPN #1 placed the glucose meter on top of the medication cart. She did not clean or disinfect the glucose meter. LPN #1 did not remove the used gloves. LPN #1 opened the medication cart and removed Resident #9's Insulin and a syringe. LPN #1 removed a syringe from the cart, drew up the correct dosage of Insulin; and went and administered the Insulin. LPN #1 removed her gloves and then charted the dosage of Insulin on the Medication Administration Record (MAR). LPN #1 donned gloves and took the same glucose meter, a pair of gloves, lancets, bottle of strips, and an alcohol prep in her ungloved hands to Resident #10's room. (Resident #9 and #10 are room mates). LPN #1 placed the blood glucose meter and the bottle of strips on the over bed table. The over bed table was not cleaned and there was no barrier in use. LPN #1 donned gloves. LPN #1 performed the blood glucose testing and placed the glucose meter, used test strip, lancet and used alcohol wipe in her gloved hands. LPN #1 opened the door to the room with her gloved hands. LPN #1 went out in the hallway to the medication cart and placed the glucose meter on top of the medication cart, and placed the lancet and glucose strip in the sharp's container. Then, LPN #1 opened the medication cart and removed an insulin vial and a syringe for Resident #10. LPN #1 went into the room and administered Resident #10's insulin. Then, returned to the hallway and disposed of the insulin syringe in the sharps container. LPN #1 removed her gloves and began to document on the MAR. At the completion of the Resident #10's insulin administration, Licensed Practical Nurse (LPN) #1 stated that she was going to obtain another resident's finger stick blood sugar test. Since the glucose meter was not cleaned and had possible contaminates of blood due not being cleaned or disinfected, LPN #1 was asked at what point would she clean and disinfect the glucose meter. LPN #3 stated that she should have used the Santiwipes to clean the glucose meter before and after it was used and between residents. LPN #1 stated "I was nervous." LPN #1 stated that she had worked at the facility about four (4) months and had never been checked off on cleaning and disinfecting the glucose meter. LPN #1 stated that she knew she was supposed to use the Super Sanities to clean the glucometer. LPN #1 also stated that she was supposed to wash her hands after she removed her gloves. She stated that she did not know that she was supposed to use a barrier between the glucose meter and the over bed table or on the medication cart. LPN #1 stated that she did not realize that she had possibly contaminated the resident's door and medication cart by not changing gloves. Interview with the Director of Nurses (DON) on 9/7/11 at 4:15 p.m. was conducted due to Licensed Practical Nurse (LPN) #1 not cleaning and disinfecting the glucose meter before and after use and the possible blood contamination of the glucose meter and the medication cart. The issue of not changing gloves appropriately was also discussed. The DON stated that all nurse's are trained on cleaning and disinfecting the glucose meter at the time of hire and that a check off was also completed. The DON stated that the facility had no resident's with a known blood borne pathogen. The DON stated that there was one (1) resident on isolation. The Resident did not receive blood glucose testing. The DON went immediately and cleaned and disinfected the glucose meter and the medication cart with the Sanicloth. The container of test strips that were used for the testing and placed on both residents over bed tables was discarded. The DON stated that she was going to have an in-service with the two (2) nurse ' s that were present about cleaning and disinfecting the glucose meter. An interview on 9/7/11 at 5:00 p.m. with the DON revealed that that was no documentation that LPN #1 was trained or was checked off as per facility policy on cleaning and disinfecting the glucose meter before and after use between patients. Interview with the Administrator on 9/8/11 at 7:15 a.m. was conducted requesting all in-services since the last survey of 7/9/10, at which time infection control regarding the cleaning and disinfecting of the glucose meters was a deficient practice. A request for all nursing personnel records to review for orientation in using the glucose meters was made. Record review revealed that Resident #9 moved into the home on 5/13/10 with [DIAGNOSES REDACTED]. Review of the August 2011 signed physician's orders [REDACTED]. " Record review revealed that Resident #10 moved into the home on 12/3/08 with [DIAGNOSES REDACTED]. Review of the August 2011 signed physician's order [REDACTED]. " Review of 15 Nursing Personnel Files revealed that there were three (3) nurse's that did not have current orientation or check offs on file. This included Licensed Practical Nurse (LPN) #1 with a date of hire of 4/7/11; LPN #2 with a date of hire of 4/5/11; and Registered Nurse #2 with a date of hire of 5/17/11. Review of the plan of correction for the survey of 7/8/2010 stated: " Administrator, DON, Staff Development nurse, and/or designee will make random rounds weekly to ensure that glucometers are being cleaned and disinfected per policy. Any deficiencies will be reported weekly to the QI committee for follow-up until resolved. " Interview on 9/8/11 at 10:40 a.m. with the Administrator and the Director of Nurses (DON) revealed that there were no documented rounds since 9/10/10. The DON stated that since they had a follow up survey and was cleared, QA (Quality Assurance) decided it would be alright to discontinue the rounds. The DON stated that the Pharmacy Consultant made rounds on 3/21/11 with a nurse on the second shift; and on 7/29/11 on the first shift and had no documentation that a problem existed with cleaning and disinfecting the glucose meter. Observation on 9/8/11 at 10:45 a.m. revealed that Licensed Practical Nurse (LPN) #3 was preparing to obtain finger stick blood glucose from Resident #12. LPN #3 sanitized her hands using a hand gel. LPN #1 opened the med cart and removed the glucose meter from a basket inside the cart. LPN #3 stated that she used this (basket) as her barrier with a paper towel in the cart. LPN #3 sanitized the glucose meter with a Saniwipe. LPN #3 donned gloves. Then, LPN #3 retrieved a lancet, test strip and alcohol pad and carried them into Resident #12's room. LPN #3 held all the equipment in her gloved hand, performed the blood glucose testing and then carried the equipment out of the room and used the Saniwipe to clean and disinfect the glucose meter. Then, LPN #3 removed her gloves. Observation on 9/8/11 at 10:00 a.m. revealed that Licensed Pracrical Nurse (LPN) #3 sanitized her hands and donned gloves. LPN #3 cleaned and disinfected the glucose meter with the Saniwipe and gathered her supplies to obtain a blood glucose test for Resident #10. LPN #3 carried all the supplies into the room and held them in her gloved hands. After the procedure, LPN #3 carried all the supplies out to the medication cart to discard. She cleaned the glucose meter with a Saniwipe and placed it in the basket in the med cart. Then, removed her gloves and sanitized her hands. Interview with LPN#3, at that time, revealed that she had worked at the facility for [AGE] years. LPN #3 stated that she had been checked off in the past for glucose testing and was checked off yesterday (9/7/11) afternoon. Observation on 9/8/11 at 11:00 a.m. of Licensed Practical Nurse (LPN) #4 revealed that she was preparing to obtain finger stick blood glucose for Unsampled Resident A. LPN #4 cleaned and sanitized the glucose meter with a Saniwipe. Then, LPN #4 placed the glucose meter on a paper towel barrier. LPN #4 retrieved the test strip, lancet and alcohol prep. LPN #4 washed her hands and donned gloves. LPN #4 placed all supplies in her gloved hands and entered Un-sampled Resident A's room. After the completion of the procedure, LPN #4 brought the supplies to the med cart and disposed of the sharps. Then, LPN #4 cleaned the glucose meter with the Saniwipe. Interview with LPN #4 at the completion of the glucose testing procedure revealed that she had attended an in-service this morning (9/7/11) regarding cleaning and disinfecting the glucose meter. The two (2) observations of Licensed Practical Nurse (LPN) #3 and LPN #4 revealed that they both had different techniques as to how they obtained the glucose testing. LPN #3 held the glucose meter in her hands and did not place any item on the over bed table that would require a barrier. LPN #4 used a barrier. Review of the home's "Blood Glucose Testing/(Name of Glucometer)" policy, revised 3/11, noted: "Each Nurse using the Oracle Blood Glucose Monitor must be trained and checked-off in its use before performing tests. Before testing your first glucose test with the Oracle System, wash and dry your hands well. Perform any other safety protocols set forth by your facility. Clean meter before entering room. Place glucose meter on a paper towel when placed on any surface in resident's room. After obtaining the glucose reading: Eject the used test strip and dispose of the strip. Re-clean meter. Wash hands. When returning glucose meter to med cart or treatment cart, place on a clean paper towel. To Properly Maintain (Name of Blood Glucose Monitoring Systems) noted: " Always clean the meter after use. Gently wipe and clean surface of the meter with a disinfectant wipe per facility policy. Please follow all facility infection control policies when using the meter. Store the meter in its case, in a clean dry place. (The facility policy uses Saniwipes)." Review of the home's "Hand washing Standard Precautions" policy, revised 04/06, noted: "Staff will wash hands and other skin surfaces immediately and thoroughly if contaminated with blood or other body fluids. Hands will be washed immediately after gloves are removed." Review of the home's "Hand Hygiene" policy, revised 10/09, noted: "The following is a list of some situations that require hand hygiene: Before and after performing any invasive procedure (e.g. finger stick blood sampling); and after, removing gloves or aprons. " Observation on 9/8/11 at 4:05 p.m. revealed that Licensed Practical Nurse (LPN) #5 went into Resident #9's room and cleaned the over the bed table with a Saniwipe; washed her hands; donned gloves; placed a paper towel on the medication cart as a barrier; then cleaned the glucose meter with a Saniwipe and placed the glucose meter on the barrier. LPN #5 removed her gloves. LPN #5 performed the blood glucose testing with out any infection control issues noted. When LPN #5 removed her gloves, she performed hand washing. After the completion of the testing, LPN #5 stated that she had attended a mandatory in-service just before her shift started today regarding cleaning and disinfecting the glucose meter and hand washing. Observation on 9/9/11 at 6:00 a.m. of Licensed Practical Nurse (LPN) #6 providing a blood glucose check for Unsampled Resident B revealed that she cleaned and disinfected the glucose meter according to facility policy. LPN #6 also washed her hands and changed gloves appropriately. LPN #6 stated that she had attended training on 9/8/11 regarding the aforementioned issues. Observation on 9/9/11 at 6:15 a.m. of Licensed Practical Nurse (LPN) #7 providing a blood glucose test by fingerstick for Resident #9 revealed that she cleaned and disinfected the glucose meter according to facility ' s policy. LPN #7 also provided hand washing and glove changes appropriately. She stated that she attended training and was checked off for the use of the glucose meter, glove changing and hand washing on 9/8/11. Interview with the Administrator and the Director of Nurses (DON) on 9/8/11 at 12:00 p.m. revealed that Staff Development Nurse #1 was supposed to be keeping up with the staff orientation and the check off/ return demonstrations for all new hires. The Administrator stated that it was determined in May of 2011 that this was not being completed. Staff Development Nurse #1 was let go. Staff Development Nurse #2 was hired on 5/25/11. The DON stated that the facility was not aware until 9/7/11, during the survey, that they still had missing orientation and check offs regarding the cleaning and disinfecting of the glucose meters before and after use. Interview with the Director of Nurses on 9/9/11 at 10:00 p.m. revealed that they had a QA (Quality Assurance) meeting after hours on 9/8/11 with the Medical Director to discuss the issues regarding infection control. The Medical Director discussed the measures implemented for the Allegation of Compliance with the staff. The facility provided the following credible Allegation of Compliance (AoC) on 9/9/11 at 2:00 p.m. Allegation of Compliance "The glucose test strips that were taken into resident #9 and resident #10's room by Licensed Practical Nurse #1 on 9/7/11 at 3:50 p.m. and 4:00 p.m. were discarded by the Director of Nurses on 9/7/11 at 4:10 p.m. The medication cart and the glucose meter were then cleaned and disinfected with saniwipes by the Director of Nurses on 9/7/11 at 4:15 p.m. Licensed Practical Nurse #1's date of hire was 4/18/11. There was no documented evidence to show that Licensed Practical Nurse #1 had been trainer or checked off via return demonstration upon hire regarding facility policy, entitled Blood Glucose Testing (Name of Glucose Meter), implementation 2/2011, due to different brand of glucometer. At that time, Staff Development Nurse #1 had been responsible for ensuring that orientation checklists for licensed nurses were completed prior to working the floor. The orientation check list consists of performing the test, glucometer usage, documentation, and control checks. Failure to complete licensed nurse orientation checklists for new hires and other quality assurance issues resulted in the removal of Staff Development Nurse #1 from the position on 5/20/11. New Staff Development Nurse was hired 5/25/11. Staff Development Nurse did not go back to ensure licensed nurse orientation checklists were completed on current employees until problem was identified on 9/7/11. Staff Development Nurse inserviced on 9/8/11 by the Director of Nurses on new hire packets; nursing orientation checklist to be completed with each new hire; no new hire to work the floor until they have been checked off per licensed nurse orientation checklist. Personnel records of all nursing staff were not reviewed by the Administrator and Administrative Assistant until 9/7/11 at 4:45 pm which revealed that the licensed nurse orientation checklist was completed on all full time nurses, with the exception of Licensed Practical Nurse #1 and two part-time nurse ' s (Registered Nurse #2 and Licensed Practical Nurse #2). Inservice training for nursing staff had been conducted on 3/11/11 at 3:00 pm by Staff Development Nurse #1 regarding Blood Glucose Testing/(Name of Glucose Meter) policy. Inservice training had been conducted on 4/18/11 on Handwashing policy and Hand Hygiene policy by Staff Development Nurse #1. Weekly monitoring through random rounds to ensure the glucometers were cleaned and disinfected with sanicloths was done7/29/10 until 9/10/10. It was determined by the Quality Improvement Committee that the deficient practice was resolved 9/10/10. The pharmacy consultant monitored blood glucose tests on 3/21/11 with second shift nurse, and discussed when to disinfect glucometer, and 7/29/11 with first shift nurse, with no disinfecting issues noted. The pharmacy consultant reviewed the glucometer disinfection with the nurses on 5/23/11. Licensed Practical Nurse #1 was disciplined 9/07/11 at 4:30 pm by the Administrator and Director of Nurses. The disciplinary action was due to substandard work quality, carelessness, and violation of company policies and procedures, for failure to clean and disinfect the glucometer. The policy entitled Blood Glucose Testing /(Name of Glucose Meter), with a revision date of 3/2011 (due to title change), states that the meter is placed on a paper towel on the med cart or in the resident's room as a barrier. The meter is to be cleaned before and after use with sanicloths and then returned to the case in the med cart. One on one inservices with nursing staff were started on 9/7/11, at 4:30 pm by the Director of Nurses, Staff Development Nurse, and/or Assessment Nurse on Blood Glucose testing and each nurse performed return demonstration of blood glucose tests to include cleaning and disinfecting the glucometer with sanicloths, use of a paper towel for the barrier, glove usage and handwashing, before being allowed to return to the floor. The Medical Director was notified of Licensed Practical #1 ' s noncompliance for cleaning and disinfecting the glucometer by the Director of Nurses on 9/7/11 at 5:45 pm. The Medical Director was satisfied with plan of action that had been implemented and had no further instructions. There are four (Name of Brand) glucometers in the facility, two of which are located on each med cart and two are in the med room. There are twenty-five diabetic residents that reside in the facility. All twenty-fivc diabetic residents were identified as being at risk of not receiving proper cleaning and sanitizing of glucometers. All twenty-five residents were assessed by the Medicare Nurse Case Manager and Treatment Nurse for any signs and symptoms of infection. Assessment results were documented in the medical records on 9/8/11. There were no signs and symptoms of infections identified during the assessments as a result of the improper cleaning and disinfecting of the glucometers. No residents currently in facility have any known blood borne pathogens. All inservice was conducted for the nursing staff on 9/07/11 at 4:30 pm by the Director of Nurses, Staff Development Nurse, and/or Assessment Nurse. The inservice consisted of the Blood Glucose Testing/(Name Brand of Glucometer) policy. Return demonstration of blood glucose testing were conducted by the Director of Nurses, Staff Development Nurse, and/or Assessment Nurse on 9/7/11 at 4:40 pm. The facility also had a Directed Inservice held on 9/8/11 at 2:30 pm with nurses on the Blood Glucose Testing (Name of Glucometer) policy, Handwashing policy, and Hand Hygiene policy by Registered Nurse #1. No nurse will be allowed to work until they have been inserviced on the Blood Glucose testing policy, Handwashing policy, and Hand Hygiene policy, and checked off by return demonstration on performing blood glucose tests per facility policy. The Medical Director was informed of the deficient practice, cited as an immediate jeopardy, on 9/8/11 by the Director of Nurses at 7:30 pm. A Quality Assurance meeting was conducted on 9/8/11 at 7:30 pm with the Medical Director, Administrator, Director of Nurses and Quality Improvement Nurse. The plan of correction was discussed with the Medical Director at this time, and he was satisfied with the course of action. No further instructions were given. All nurses employed by facility will not be allowed to work until they are inserviced on Blood Glucose Testing policy, Handwashing policy, and Hygiene and checked off through return demonstration. The Director of Nurses, Medicare Nurse Manager, Assessment Nurse, and /or Staff Development Nurse will make rounds each shift for one week beginning 9/8/11, then daily for one week, then weekly for two weeks, then monthly for three months to ensure that nurse are adhering to the facility Blood Glucose Testing policy, Handwashing policy and Hand Hygiene policy. Any nurse hired, to include new contract nurses, from 9/8/11 will not be allowed to work until they are inserviced on Blood Glucose Testing policy, Handwashing policy, and Hand Hygiene Policy, and have been checked off on return demonstration. Administrator will audit nurses personnel records after two weeks of hire to ensure licensed nurse orientation checklist is completed. Pharmacy Consultant to provide additional inservicing to nursing staff to include glucometer testing on 9/12/11 at 2:00 pm. All negative findings will be taken to the Quality Improvement committee weekly for follow-up and resolution by the Administrator. Quality Assurance committee to meet monthly for three months, then quarterly for nine months to review the findings from audits of rounds made to ensure adherence to Blood Glucose Testing, Handwashing, and Hand Hygiene policies for follow-up and resolution of any negative findings. " Random observations, staff interviews, and in-service reviews from 9/8/11 to 9/9/11 confirmed that the facility had implemented corrective actions. The observations confirmed that the facility staff were using the same technique per facility policy to clean and disinfect the glucose meter, washing hands, and changing gloves. The Immediate Jeopardy (IJ) was removed on 9/9/11 at 2:00 p.m. and the scope and severity was lowered to an "E" level which constitutes no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

Based on observation, record review, staff interview and policy review the facility failed to ensure that infection control measures were monitored regarding cleaning and disinfecting the glucose meter before and after use; hand washing and glove changing as per facility policy. Licensed Practical Nurse (LPN) #1 did not clean or disinfect the glucose meter before and after use per facility policy; and did not wash hands and change gloves as facility policy for two (2) of eight (8) glucose testing observations. The facility failed to ensure that three (3) staff members (LPN #1, LPN #2 and RN (Registered Nurse) #2) were oriented and checked off for the use of the glucose meter, to include cleaning and disinfecting, glove changing and handwashing. There were 25 resident's identified as requiring finger stick blood glucose levels due to the [DIAGNOSES REDACTED]. These actions put all 25 resident's at risk to cause harm, or likely to cause serious injury, harm, impairment, or death to a resident was identified to be an Immediate Jeopardy on 9/8/11 at 10:40 a.m. The Administrator, Corporate Nurse and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) at that time. The facility provided an acceptable credible allegation of compliance on 9/9/11 at 2:00 p.m. and after verification of corrective actions the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered to an "E" level which constitutes no actual harm with potential for more than minimal harm. Findings include: Cross refer findings to F441 for the facility's failure to ensure that the Quality Assurance (QA) program at the facility continued to monitor infection control in the facility.

Based on observation, record review, staff interview, in-service review, and policy review, the facility failed to ensure that glucose meters were cleaned and disinfected per facility policy before and after use between each patient; failed to ensure that the staff changed gloves and washed their hands appropriately during the blood glucose testing for two (2) of eight (8) observations. This affected Resident #9 and Resident #10. Licensed Practical Nurse (LPN) #1 obtained blood glucose by finger stick for Resident #9 and did not clean and disinfect the glucose meter before or after the procedure as per facility policy. LPN #1 did not change her gloves or wash her hands per facility policy to prevent possible cross contamination. LPN #1 obtained blood glucose for Resident #10 without cleaning and disinfecting the glucose meter, changing gloves or washing her hands. (Resident #9 and Resident #10 are room mates). The facility also failed to ensure that three (3) employees hired since 4/11(LPN #1, LPN #2, and RN #2) were trained and performed a return demonstration on the cleaning and disinfecting of the glucose meter before and after use as per facility policy. There were no systems in place to monitor the cleaning and disinfecting of the glucose meter before and after use since 9/10/10. There were 25 resident's identified as requiring finger stick blood glucose levels due to the [DIAGNOSES REDACTED]. These actions put all 25 residents at risk to cause harm, or likely to cause serious injury, harm, impairment, or death to a resident was identified to be an Immediate Jeopardy on 9/8/11 at 10:40 a.m. The Administrator, Corporate Nurse and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) at that time. The facility provided an acceptable credible allegation of compliance on 9/9/11 at 2:00 p.m. and after verification of corrective actions the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered to the " E " level which constitutes no actual harm with potential for more than minimal harm. The Immediate Jeopardy (IJ) was removed on 9/9/11 at 2:00 p.m. and the scope and severity was lowered to an "E" level which constitutes no actual harm with the potential for more than minimal harm that is not immediate jeopardy. Findings include: Cross refer findings to F441 for the Administrations failure to ensure that the facility staff was implementing infection control measures to prevent possible cross contamination.