Every finding on record at Life Care Center of Evergreen

Based on observations, record review and interviews, the facility failed to store, prepare and distribute food in a sanitary manner in the main kitchen. Specifically, the facility failed to: -Ensure employees performed hand hygiene appropriately during meal service; and, -Ensure food was labeled, dated and disposed of timely. Findings include: I. Ensure employees performed hand hygiene appropriately during meal service A. Professional reference The Colorado Retail Food Regulations, (3/16/24) and retrieved on 5/20/25 read in pertinent part, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the toilet room; after coughing, sneezing, using a handkerchief or disposable tissue; using tobacco products, eating, or drinking; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; before donning gloves to initiate a task that involves working with food; and after engaging in other activities that contaminate the hands. (2-301.15) B. Facility policy and procedure The Safe Food Handling policy, revised 4/26/23, was provided by the nursing home administrator (NHA) on 5/15/25 at 6:18 p.m. The policy read in pertinent part, Associates shall wash their hands in accordance with the hand hygiene policy and current food code guidelines, before handling or consuming food including working with clean equipment and utensils, and: After coughing sneezing or blowing nose, after touching the hair, mouth or touching tobacco products, during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks, before donning gloves to initiate a task that involves working with food and after engaging in any other activities that contaminate the hands. C. Observations During a continuous observation on 5/14/25, beginning at 11:15 a.m. and ending at 12:17 p.m., the following was observed during the meal preparation and service in the main kitchen: At 11:25 a.m. dietary aide (DA) #1 blew his nose into a tissue. DA #1 wiped his nose with the tissue and discarded the tissue in a garbage can. -Without washing his hands, DA #1 picked up a room delivery tray, placed it on the trayline, picked up silverware rolled in a linen napkin and placed it on the tray. At 11:32 a.m. DA #1 touched his face, scratched his neck with his left hand and continued to assemble meal trays for room delivery. At 12:01 p.m. DA #1 touched his face twice with his left hand. Without washing his hands, DA #1 picked up two four ounce bowls of dessert and placed them on a meal tray for delivery. At 12:04 p.m. DA #1 touched his nose with his left hand,and without washing his hands picked up a heated room delivery base and placed it on the counter. DA #1 pulled a meal delivery cart forward, then covered a plated meal with a lid. DA #1 picked up the room delivery base and placed it under the plated meal. DA #1 picked up a can of soda and a drinking glass with the same hand, filled the glass with ice and placed them both on the assembled meal tray for delivery. D. Staff interviews Cook (CK) #1 and DA #2 were interviewed together on 5/15/25 at 2:30 p.m. CK #1 said the staff received hand hygiene training online during their employee onboarding at the facility. CK #1 said the staff should wash their hands if they changed tasks, after removing disposable gloves or putting gloves on. DA #2 said hand hygiene should be conducted after touching a contaminated surface. The divisional registered dietitian (DRD) was interviewed on 5/15/25 at 2:30 p.m. The DRD said hand hygiene should be conducted after coughing, sneezing or after adjusting your glasses with your hands. The NHA was interviewed at 5:00 p.m. The NHA said hand hygiene training was always provided upon hire. The NHA said if an issue with hand hygiene was identified in an observation by any manager there would be follow up education provided to the staff member. The NHA said dietary staff were included in hand hygiene training provided by the infection preventionist (IP) for the facility. II. Ensure time and temperature control food was labeled, dated and disposed of timely A. Professional reference The Colorado Retail Food Regulations, (3/16/24) and retrieved on 5/20//25 read in pertinent part, Commercially processed food: open and hold cold, refrigerated, ready-to-eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, the day the original container is opened in the food establishment shall be counted as day one and the day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. (3-501.17) B. Facility policy and procedure The Safe Food Handling policy, revised 4/26/23 was provided by the nursing home administrator (NHA) on 5/15/25 at 6:18 p.m. The policy read in pertinent part, The facility must store, prepare, distribute and serve food in accordance with professional standards for food service safety. Local, state and federal regulations are followed when handling food. Snacks and other food items sent from the foodservice department will be handled safely in regard to temperature, labeling and storage. C. Observations The initial main kitchen tour was conducted on 5/12/25 at 9:30 a.m. The following was observed in the walk in refrigerator: -A clear uncovered plastic container that contained shredded cheese in the walk in refrigerator was not marked with a label or date; -A metal pan covered with plastic wrap that contained cheese and was not marked with a label or date; -A container covered with plastic wrap labeled with green chili and a use by date of 5/8/25; -Turkey pastrami opened and approximately half the product remaining, covered with plastic wrap and written date of 4/17/25; -A container of buttermilk with a printed best by date of 4/29/25; and, -A metal pan with five raw chicken breasts in a clear plastic bag not dated or labeled. During the initial main kitchen tour on 5/12/25 at 9:30 the following was observed in the reach-in refrigerator: Five clear plastic containers with lids and different food in each container. The containers were not labeled or dated. D. Staff interviews CK #1 was interviewed on 5/15/25 at 2:30 p.m. CK #1 said meats used for meals were typically pulled from the freezer the day prior to service and then cooked the next day. The DRD was interviewed on 5/15/25 at 2:30 p.m. The DRD said food items that were not dated should be discarded. The DRD said the kitchen staff did rounds to check product dates in the refrigerators. The NHA was interviewed on 5/15/25 at 5:00 p.m. The NHA said the facility registered dietitian (RD) would do a monthly walk through in the kitchen with a specific focus with sanitation, but would start doing the walk through more frequently in the future.

Based on interviews and record review, the facility failed to ensure one (#45) of one residents reviewed for radiology and diagnostic services, received timely care out of 32 sample residents. Specifically, the facility failed to schedule and obtain magnetic resonance imaging (MRI - diagnostic imaging) in a timely manner for Resident #45. Findings include: I. Facility policy and procedure The Diagnostic Services policy, revised on 9/24/24, was provided by the nursing home administrator (NHA) on 5/15/25 at 6:15 p.m. It revealed in pertinent part, The facility will ensure that diagnostics services meet the needs of residents. The facility is responsible for the quality and timeliness of services whether services are provided by the facility or an outside resource. II. Resident #45 A. Resident status Resident #45, age greater than 65, was admitted on [DATE]. According to the May 2025 computerized physician's orders (CPO), diagnoses included a history of displaced fracture of right acetabulum (a break in the ball-and-socket portion of the hip joint) and infection of a surgical site. The 3/14/25 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) score of 13 out of 15. The 3/14/25 MDS assessment revealed his most recent physical therapy regimen was started 3/13/25. He had received physical therapy two days during the seven day look-back period. The 11/25/24 MDS assessment revealed he used a manual wheelchair, required substantial assistance for most transfers and toileting, was dependent on assistance for bathing and required set-up assistance with eating. B. Resident interview Resident #45 was interviewed on 5/12/25 at 4:39 p.m. Resident #45 said the scheduling coordinator (SC) was working with him to get a MRI that was ordered a month ago. He said she had not been much help. He said she just kept telling him she would look into it. He said the MRI was ordered because he had increased pain in his right hip and leg. He said he could not lift his right leg anymore. He said it hurt the most when he tried to straighten it. He said he could ride the bicycle in the gym, but standing and walking were very painful. He said after trying to walk in physical therapy, he would have increased pain for the next two days. C. Record review Review of Resident #45's May 2025 CPO revealed a physician's order for a MRI without contrast of the lumbar spine and right hip, ordered 4/14/25 at 12:01 p.m. by the nurse practitioner (NP). On 5/13/25 at 9:24 a.m. the MRI order was marked as complete and discontinued by the MDS coordinator (MDSC). -However, the appointment for the MRI was never scheduled by the facility (see interviews below). A review of Resident #45's electronic medical record (EMR) revealed the following progress notes: An NP noted, dated 11/9/24, revealed Resident #45 had returned to the facility after an open reduction internal fixation (ORIF) procedure on 11/2/24, to repair a fracture of his right upper leg/hip. A PCP note, dated 3/12/25, revealed that Resident #45 was frustrated with his evaluation by the orthopedic surgeon. He said he was not happy with his visit. The surgeon reviewed his Xrays and told him there was nothing wrong and then left the room. The resident said he was continuing physical therapy but still felt like something was wrong with his right hip. A NP note, dated 4/1/25, revealed that the resident's orthopedic clinic notes were reviewed with the resident. The notes documented the radiograph (Xray) showed routine healing but did reveal areas where it appeared a suture had moved. The orthopedic note documented to continue with physical and occupational therapy and follow up in six weeks for a repeat Xray. An Xray would be repeated as recommended. A NP note, dated 4/14/24, revealed Resident #45 had ongoing right lower extremity weakness and pain. He had trace dorsiflexion (upward movement of the foot towards the shin) but he was apparently able to do some walking. The note documented that given the resident's ongoing issues, the NP recommended obtaining a MRI of the lower back and hip, and initiating a referral for a new orthopedic doctor. The resident agreed and the NP was going to place the new outpatient orders for a MRI. A PCP note, dated 4/16/25, revealed Resident #45's surgical and more recent Xrays were reviewed with the resident. The resident continued to have significant hip pain to the point where he was debilitated and unable to walk. The note documented the NP recommended to obtain a second opinion with a different orthopedic surgeon and the NP had made the referrals. The facility said the resident was no longer participating in physical therapy. A NP note, dated 4/18/25, documented the plan was to continue with the second opinion following the MRI. A nursing note, dated 4/21/25, documented Resident #45 had called his original orthopedic surgeon's office and canceled his follow-up appointment. The resident said he wanted to pursue a second opinion elsewhere. -A review of Resident #45's electronic medical record (EMR) revealed a referral form for the MRI was not completed and sent, until 5/13/25 (see interview below). A PCP note, dated 5/14/25, documented Resident #45 reported he was supposed to have a MRI of his hip this week to assess his continued hip pain. The facility said the resident was using the gym and exercise equipment, but was not receiving formal physical therapy anymore. -Review of Resident #45's EMR did not reveal documentation that the resident had received a MRI since it was recommended on 4/14/25 by the NP. III. Staff interviews The SC was interviewed on 5/14/25 at 9:36 a.m. The SC said after the doctor ordered a test, the nurse verified it and then the order went directly to her or as a transportation request form filled out by the nurse. She said she usually received the orders right away but she did not receive Resident #45's transportation form from nursing until this month (May 2025). She said the MRI order was dated 4/14/25. She said she sent a fax on Tuesday (5/13/25) at 1:10 p.m. to the resident's new doctor for a MRI of the lumbar spine and right pelvis. The SC said the office required a referral. She said she filled out the referral form for the MRI and appointment, and the NP signed it on 5/12/25 (during the survey). She said she did not know why the order did not get to her until May 2025, but it was possible that the order had disappeared from their electronic charting system. She said once the appointment was scheduled, the resident received a blue appointment reminder sign, which was usually a week before. The MDSC was interviewed on 5/14/25 at 3:33 p.m. The MDSC said the standard practice was when the date of an order had passed, it was deleted from the system under the assumption that it had been completed already. She said that appointments and orders that were over a month old got deleted so that the system did not get cluttered. She said that the director of nursing (DON) and the SC were the ones who dealt with the follow-through of the orders. The NP was interviewed on 5/14/25 at 3:45 p.m. The NP said that an Xray obtained by the facility (2/19/25) revealed that Resident #45 had some medial displacement. The NP said the resident returned to his surgeon, who said there was nothing wrong with Resident #45's hip despite the Xray findings. He said that prompted him and the resident to obtain a second opinion in April 2025. The NP said typically, a resident should be able to get an appointment confirmation sooner than a month. He said when a resident needed an appointment outside of the facility, he entered an order and then the nurse filled out a form and gave it to the SC. He said the SC made the appointments. The NP said he made a lot of outpatient referrals, so there might have been a backlog. He said the SC often complained about not hearing back from the offices she called. He said he frequently updated Resident #45 on the status of his MRI. The DON was interviewed on 5/15/25 at 11:59 a.m. The DON said that outpatient MRI appointments could take a month or two to schedule, unless it was emergent. She said that the SC obtained the MRI order just recently. She said Resident #45 had had a lot of imaging done, and had changed doctors several times, which made it confusing. She said the SC was very efficient in ensuring the schedule was done and appointments were scheduled. The DON said that when Resident #45 canceled his appointment in March, 2025 they thought that that was the appointment associated with the MRI. She said the MRI did appear in more recent notes though and she had heard that he wanted to change orthopedic doctors again. She said that for the past several months, even though the resident had been cleared by orthopedics to do weight bearing, he had not been wanting to bear weight. She said the resident was more compliant now, but for a few months he did not like what the orthopedic doctor was saying or what the imaging found. The PCP was interviewed on 5/15/25 at 12:47 p.m. He said that because of the facility's population and location, they did sometimes run into problems related to logistics and getting referrals and tests completed timely. IV. Facility follow-up On 5/16/22 at 2:27 p.m. (after the survey) the NHA provided additional documentation that indicated Resident #45 was scheduled for a MRI on 5/22/25 at 12:20 p.m.

Based on observations, record review and interviews, the facility failed to act upon the pharmacist's recommendations in a timely manner for two (#27 and #20) of five residents out of 32 sample residents. Specifically the facility failed to: -Ensure two medications which potentially contributed to falls for Resident #27 were discontinued, per the pharmacist and physician's recommendations; and, -Ensure Resident #20's serum sodium levels were obtained timely after the pharmacist recommended the laboratory work to be completed. Findings include: I. Facility policy and procedure The Pharmacy Recommendations policy and procedure, revised 11/19/24, was provided by the nursing home administrator (NHA) on 5/13/25 at 6:46 p.m. It revealed in pertinent part, Medication regimen review (MRR) is a thorough evaluation of minimizing adverse consequences and potential risks associated with medication. MRRs are done for residents who experience an acute change of condition and for whom an immediate MRR is requested after appropriate staff have notified the resident's physician, the medical director (MD) and the director of nursing (DON) about the acute change. II. Resident #27 A. Resident status Resident #27, age 72, was admitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included displaced fracture of the greater trochanter of the left femur (left hip fracture), age-related osteoporosis with current pathological fracture, chronic obstructive pulmonary disease (chronic lung disease) and hyperlipidemia (high cholesterol). The 3/18/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. He was independent with rolling in bed, eating, oral hygiene and moving from lying to sitting in bed position. He required partial assistance for sitting to standing, toilet transfers and shower transfers. Walking 10 feet was not attempted due to medical conditions or safety concerns. The MDS assessment indicated Resident #27 had fallen since the prior assessment. It indicated one fall was with a minor injury and one fall was without injury. B. Record review Review of Resident #27's May 2025 CPO revealed the following physician's orders: Tizanidine (muscle relaxer) 2 milligrams (mg) one tablet three times a day for muscle relaxant related to fracture of the superior rim of left pubis, ordered 1/20/25. Atorvastatin calcium (cholesterol lowering medication) 80 mg one tablet by mouth at bedtime for hyperlipidemia, ordered 11/15/23. Review of Resident #27's May 2025 medication administration record (MAR) revealed Resident #27 received all of his scheduled doses of Tizanidine and atorvastatin calcium. The 2/8/25 medication regimen review (MRR), conducted by the pharmacist, for Resident #27 was received from the NHA on 5/13/25 at 6:46 p.m. The pharmacist had recommended to the physician to discontinue one or more medications that could have been a contributing factor to Resident #27's recent falls. The medications included tizanidine, pregabalin, buprenorphine, escitalopram, trazodone, oxycodone and atorvastatin. The physician reviewed the pharmacist's recommendations on 2/11/25 and recommended discontinuing Resident #27's atorvastatin and tizanidine. -However, tizanidine and atorvastatin were not discontinued and Resident #27 continued to receive the medications (see physician's orders above). III. Resident #20 A. Resident status Resident #20, age 88, was admitted on [DATE]. According to the May 2025 CPO, diagnoses included delusional disorder, depression, pain and dementia with mood disturbances. The 3/17/25 MDS assessment revealed Resident #20 was cognitively intact with a BIMS score of 14 out of 15. She was independent with transfers, toileting, bed mobility and walking and required set-up assistance with dressing. The MDS assessment revealed the resident received antipsychotic, antidepressant and opioid pain medications. B. Record review Review of Resident #20's May 2025 CPO revealed the following physician's orders: Sertraline hydrochloride (hcl) (antidepressant medication) 100 milligram (mg) tablets. Give 200 mg by mouth one time a day for depression, ordered 8/15/24. Olanzapine (antipsychotic medication) 5 mg. Give half a tablet by mouth one time a day related to delusional disorder and unspecified dementia with mood disturbances, ordered 5/21/24. Olanzapine 5 mg tablet. Give one tablet by mouth at bedtime related to delusional disorder and unspecified dementia with mood disturbances, ordered 5/21/24. Tramadol HCl (opioid pain medication) 50 mg tablets. Give half a tablet by mouth three times a day for chronic pain syndrome, ordered 5/29/24. The 3/7/25 pharmacisit's MMR report revealed that Resident #20 received Sertraline, Olanzapine,and Tramadol, which could cause or worsen hyponatremia (low sodium) or syndrome of inappropriate antidiuretic hormone secretion (SIADH), which could cause water retention and low sodium levels. Resident #20's most recent serum sodium level was 134 milli-equivalents per liter (mEq/L) on 2/10/25 (normal sodium levels are 135 mEq/L to 145 mEq/L). The pharmacist recommended obtaining a serum sodium level on the next convenient lab day, four weeks after dose changes,and periodically thereafter. The primary care provider (PCP) agreed with the recommendation and signed the form on 3/14/25. -However, review of Resident #20's electronic medical record (EMR) did not reveal documentation that the serum sodium level was ordered or obtained. IV. Staff interviews The DON was interviewed on 5/15/25 at 11:00 a.m. The DON said the MRR completed by the pharmacist on 2/8/25 for Resident #27 was an intervention in response to one of his falls. She said it was the responsibility of the physician to respond to the pharmacist's recommendations and return their response to the facility. She said it was the physician's responsibility to enter physician's orders into the residents' electronic medical records (EMR) following a pharmacy review. She said nursing staff generally followed up to ensure the pharmacist's recommendations and physician's orders in response to the recommendations were completed. The DON said Resident #27's physician was new to the facility in February 2025 and the facility had since provided education with the physicians and medical director about ensuring they entered physician's orders in the residents' EMRs following a medication change due to a pharmacy review. The DON said the primary care physician (PCP) entered the physician's orders into the residents' EMRs for the specific lab test that was to be drawn, but the nurse entered the physician's orders for the actual physical lab draw. The DON said she did not find an order for a serum sodium level for Resident #20 in the resident's EMR. She said the facility could obtain blood work any day of the week, so it should not have taken several weeks to obtain. She said the blood work normally would be drawn within a day or two of the physician's order being placed. The PCP was interviewed on 5/15/25 at 12:45 p.m. The PCP said he received the recommendations from the pharmacy and had 30 days to get back to the facility with answers to the pharmacist's recommendations. He said he normally got back to the facility within a week. He said it was a team approach to get the physician's orders he recommended based on the pharmacist's recommendations entered into the EMR. The PCP said sometimes he entered the orders and other times it was the nurses. He said sometimes things were missed in regards to the communication of whether the physician or the nurses were entering the physician's orders into the EMR. The PCP said he recommended discontinuing Resident #27's tizanidine and atorvastatin calcium in February 2025 but the medications somehow got missed being discontinued. The PCP said he could re-check Resident #20's sodium level at any time. He said he thought Resident #20 had her annual wellness visit soon, at which time a sodium level would be drawn anyway. 50690

Based on observations, record review and interviews, the facility failed to ensure residents with indwelling catheters received the appropriate care and services according to professional standards for one (#57) of two residents reviewed for catheter care out of 32 sample residents. Specifically, the facility failed to: -Obtain physician's orders for the use and care of Resident #57's catheter; and, -Maintain documentation for Resident #57's catheter care and maintenance. Findings include: I. Facility policy and procedure The Indwelling Urinary Catheter (Foley) Management policy, revised 6/27/23, was provided by the nursing home administrator (NHA) on 5/15/25 at 6:18 p.m. It read in pertinent part, The facility will ensure that residents admitted with a urinary catheter, or determined to need a urinary catheter for medication indication will have the following areas addressed: timely and appropriate assessments related to the indication for use of an indwelling catheter; identification and documentation of clinical indications for the use of a catheter, as well as criteria for the discontinuance of the catheter when the indication for use is no longer present; insertion, ongoing care and catheter removal protocols that adhere to professional standards of practice and infection prevention and control procedures; response of the resident during the use of the catheter, and ongoing monitoring for changes in condition related to potential catheter associated urinary tract infection (CAUTI), recognizing, reporting and addressing such changes. II. Resident #57 A. Resident status Resident #57, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included protein-calorie malnutrition, sepsis (infection of the blood), acute respiratory failure, chronic obstructive pulmonary disease (COPD), obstructive and reflux uropathy (blockage of the urinary tract) and stage 2 pressure ulcer. The 4/7/25 minimum data set (MDS) assessment indicated the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 11 out of 15. The resident needed substantial assistance from staff for most activities of daily living. The MDS assessment documented the resident had an indwelling urinary catheter. B. Observations On 5/12/25 at 11:31 a.m. Resident #57 was lying in bed with his urinary catheter bag clipped to his bed. C. Record review Resident #57's comprehensive care plan documented he had a foley catheter, initiated 4/3/25. Pertinent interventions, initiated on 4/3/25, included providing catheter care every shift and educating the resident and/or family regarding indwelling catheter and care. Pertinent interventions, initiated on 4/4/25, included checking the tubing for kinks each shift, following enhanced barrier precautions and observing the resident for and document pain/discomfort due to the catheter. A 4/4/25 physician note written at 9:37 a.m. documented Resident #57 was admitted to the facility with obstructive uropathy and was to continue indwelling uropathy. A review of Resident #57's May 2025 CPO revealed the following physician orders: -Trial of void (assessment for catheter removal): discontinue the foley catheter post void (emptying the bladder) residual (PVR) and notify the provider if the result was greater than 300 millimeters (ml). If the resident cannot void after six hours, then perform a bladder scan and notify the provider of results regardless of the result, ordered 4/9/25 to 4/12/25. -Insert indwelling foley catheter and catheter care order set, ordered 4/11/25. A 4/12/25 administration note documented at 1:03a.m. that Resident #57 had a foley catheter in place after two of two void attempts resulted in retention. A 4/12/25 administration note documented at 10:51 a.m. that Resident #57 had an indwelling foley catheter placed. -The facility failed to obtain physician's orders for the flushing and maintenance of Resident #57's indwelling urinary catheter, and there was no documentation of urinary catheter care or maintenance on the May 2025 treatment administration record (TAR). A 5/12/25 skilled progress note written at 12:22 p.m. documented Resident #57 had a foley catheter draining clear yellow urine, catheter care was given each shift and with every incontinent episode. -However, a review of Resident #57's progress notes from 5/2/25 through 5/12/25 revealed between 5/2/25 and 5/10/25 there was no documentation of catheter care for Resident #57. III. Staff interviews The NHA was interviewed on 5/15/25 at 3:45 p.m. The NHA said the facility utilized a checklist when a resident admitted to the facility that included the resident's diagnoses. The NHA said Resident #57's checklist documented he had a catheter but the facility did not have a physician's order for the catheter and catheter care but should obtain an order. The DON was interviewed on 5/15/25 at 5:00 p.m. The DON said the facility did perform catheter care for the resident and catheter care was documented in the resident's progress notes. -However, review of Resident #57's electronic medical record (EMR) did not include documentation that indicated catheter care was consistently provided.

Based on observations and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically the facility failed to: -Ensure resident rooms were cleaned and disinfected properly; and, -Ensure staff administered medications in a hygienic manner. Findings include: I. Failure to clean residents room appropriately A. Facility policy and procedure The Daily Room Cleaning policy, revised 7/19/23, received from the nursing home administrator (NHA) on 10/26/23 at 1:22 p.m. It revealed in pertinent part, the cleanliness of each resident room was maintained on a daily basis by the housekeeping staff to provide fresh, clean, and sanitary environment and reduce the potential for nosocomial infections. B. Observation On 10/25/23 at 10:02 a.m. housekeeper (HSK) #1 and HSK #2 were observed cleaning resident room [ROOM NUMBER] a double occupancy room. HSK #1 performed hand hygiene and applied gloves she started in the bathroom spraying the walls, toilet, sink, toilet riser with a clorox disinfectant. HSK#1 took an orange rag that was soaked in Stride all purpose cleaner and began wiping down the bathroom starting with handrails, walls, handles of the toilet riser, cord for bathroom call light, top of the toilet, back of toilet, toilet riser seat down the legs of riser. Wearing the same gloves HSK#1 reached into the wet mop pad bucket that contained several mop pads, took one out, rang it out then applied Clorox spray to the mop pad and began mopping the bathroom floor. While mopping HSK #1 touched the toilet riser handles with her contaminated gloves. -HSK #1 failed to change her contaminated gloves before touching the toilet riser handles. HSK #2 was cleaning the room while HSK #1 was cleaning the bathroom. HSK#2 performed hand hygiene applied gloves, took an orange rag, rang it out and sprayed it with Clorox. HSK #2 wiped the main door handle, then cleaned the bedside table for bed A top to bottom, continued to the sink counter moving resident personal items. HSK #2 picked up a personal water cup with gloves touching the spout where a resident would drink from that had touched the rag with the cleaner on it. HSK #2 continued to clean bed B bedside table top to bottom, heater vent, night stand for bed B then bed A night stand. HSK #2 then collected a new rag to clean the mirror with glass cleaner. -HSK #2 failed to change out the rag between bed A and bed B side of the room. On 10/25/23 at 10:18 a.m. HSK #1 and HSK #2 were observed cleaning room [ROOM NUMBER] a private room. HSK #2 sprayed a rag with Clorox then began wiping down the bedside table, the dresser including handles, the sink, counter, the closet along with handles and she wiped down the cloth recliner. -HSK #2 used the same soiled rag to clean the recliner, closet and counter after cleaning the sink which was considered dirtier. HSK #1 sprayed down the bathroom with Clorox the towel rack, toilet, toilet riser, sink and handrails. HSK#1 took a rag she rang out from the bin containing Stride cleaner she then started to wipe down the bathroom. HSK #2 wiped down the towel rack, the sink, handrails, the toilet and toilet riser, wiped the hand rails again, the handle to flush toilet and the light switch. -HSK #2 cleaned the handrail and light switch with the same rag she cleaned the toilet with. C. Staff interviews HSK #1 was interviewed on 10/26/23 at 9:59 a.m. She said bathrooms were to be cleaned from the cleanest area to the dirtiest. HSK #1 said she should have not cleaned the handrails again with the same rag she cleaned the toilet with because the toilet was considered dirtier than the hand rail and she could have introduced germs to the hand rail. HSK #2 was interviewed on 10/26/23 at 9:59 a.m. She said a double occupancy room should be cleaned with a different rag to prevent infections from being spread from one resident side of the room to the other. The housekeeping and laundry manager (HLM) was interviewed on 10/26/23 at 11:25 a.m. She said rooms were to be cleaned from the cleanest to the dirtiest areas and if a room was a double occupancy, each side should be cleaned with a different rag to prevent spread of germs from one side to the other side of the room. The HLM said high touch areas of a room were to be cleaned daily like the call light, bed control and bedside tables. The HLM said all rooms were cleaned every other day except Saturday when no housekeepers were scheduled but had staff on call for emergent situations. The infection preventionist (IP) was interviewed on 10/26/23 at 12:41 p.m. She said housekeepers were educated to clean from the cleanest to the dirtiest areas to help infection prevention. II. Failed to administer medication in a hygienic manner A. Professional reference According to the Center for disease control (CDC) control and prevention, Hand Hygiene Basics retrieved on 10/30/23 from: https://www.cdc.gov/handhygiene/providers/guideline.html (2020), it read in pertinent part, healthcare providers should practice hand hygiene at key points in time to disrupt the transmission of microorganisms to patient including before patient contact; after contact with blood, body fluids, or contaminated surfaces (even if gloves worn); before invasive procedures; and after removing gloves (wearing gloves was not enough to prevent the transmission of pathogens in a healthcare settings). B. Facility policy and procedure The Administration of Medication policy and procedure, reviewed 8/24/23, was received from the NHA on 10/26/23 at 1:22 p.m. it revealed in pertinent part, the facility will ensure medications were administered safely and appropriately. C. Observations On 10/24/23 at 9:49 a.m. registered nurse (RN) #1 was observed administering medications to Resident #203. RN #1 dispensed medication according to physician orders, took medications to the room, took the resident's blood pressure, then handed the medication cup to the resident. Resident #203 then poured medications onto his bed side table. RN #1 then touched the medication with her bare hands pushing them into a pile on the table. Resident #203 said he took them one at a time as he lined the pills up one-by-one using his fingers. RN #1 then started lining up the pills in a line for Resident #203 with her bare fingers. When Resident #203 was done taking his medications RN #1 exited the residents room returning to the medication cart. -RN #1 did not perform hand hygiene, she touched medication with her barehands and failed to perform hand hygiene after touching the medications. At 10:22 a.m. RN #1 began preparing medications for Resident #202 a pill fell on the medication cart she attempted to pick it up with the medication cup but ended up just pushing it around on the medication cart. RN #1 then sanitized her hands, collected a glove and picked up the medication and placed it into the medication cup. RN #1 then took the medication to Resident #202 to be administered. -RN #1 failed to dispense medication in a hygienic manner and continued to administer the medication to a resident. D. Staff interview RN #1 was interviewed on 10/24/23 at 1:48 p.m. She said hand hygiene should be completed before preparing medications and after medications have been administered to a resident to help prevent infection as hands could transfer germs. RN #1 said nurses were not to touch medications with their bare hands as it could transfer germs. RN #1 said the medication that fell on the cart should have been discarded and new one dispensed as the cart could have been dirty and transferred germs onto the pill. The director of nursing (DON) was interviewed on 10/26/23 at 10:49 a.m. She said hand hygiene should be completed by nursing staff before preparing medication and after administration to prevent infection. The DON said nurses should not touch medications with their bare hands because of the increased the risks of infection.

Based on interviews, observations and record review, the facility failed to consistently serve food that was palatable and at a safe and appetizing temperature. Specifically, the facility failed to ensure resident food was palatable in taste and texture. Findings include: I. Facility policy and procedure The Resident Satisfaction with Food and Dining policy and procedure, revised 4/25/23, was provided by the nursing home administrator (NHA) on 10/26/23 at 12:00 p.m. It revealed in pertinent part, The facility will have a process in place to monitor the quality of food and beverages delivered to the residents. Each resident received and the facility provides food prepared by methods that conserve nutritive value, flavor and appearance; food and drink that is palatable, attractive and at a safe and appetizing temperature. II. Resident interviews Resident #2 was interviewed on 10/23/23 at 10:43 a.m. She said food was mediocre, not so good and sometimes it was just barely warm. Resident #1 was interviewed on 10/23/23 at 2:18 p.m. She said the food was mediocre and cold at times and not cooked all the way from frozen state, especially at breakfast. Resident #48 was interviewed on 10/23/23 at 3:55 p.m. He said food at the facility was mediocre and not like home cooking. Resident #13 was interviewed on 10/24/23 at 2:30 p.m. She said there was one cook that caused quite a problem with the quality and temperatures of food at the facility. III. Observations A test tray for a regular diet was evaluated by three surveyors immediately after the last resident had been served their room tray for lunch on 10/25/23 at 12:25 p.m. The test tray served consisted of turkey pot pie, breadstick and broccoli and peach pie for dessert. The peach pie was served pureed because no regular peach pie servings were available. The breadstick was overcooked and snapped in half when it was pulled apart. The breadstick crust and crumb were dry and crusty on each end and difficult to bite down on. Half of the breadstick remained soft inside. The broccoli was overcooked, a green-gray color and did not hold its shape, while some of the broccoli pieces served were mushy. The puree peach pie lacked peach flavor and the pie crust tasted undercooked. IV. Staff interviews The nutrition services manager (NSD) and the divisional registered dietitian (DRD) were interviewed on 10/26/23 at 11:30 a.m. The NSD said the facility did not serve breadsticks very often. The NSD said the staff made about 12 more breadsticks to finish the meal. The breadstick for the test tray came directly out of the oven and was not cooked correctly. The NSD said it was possible the broccoli was one of the last portions or the minced and moist broccoli for the modified texture. The DRD said the breadsticks should be warmed up and steamed lightly for moisture and a hard one was sent to the test tray. The DRD said a little moisture from the steamer works great for the breadsticks. The DRD said she thought the broccoli on the test tray was the moist and minced broccoli produced for a modified texture diet. The DRD said the kitchen staff were overproducing the amount of food at meals and the staff cut back the extra production. The DRD said in trying to manage product, not waste food and decreasing leftovers. The staff just cut their food production amounts to short and served the minced and moist broccoli instead of regular texture for the test tray. Both the DRD and the NSD said the peach pies were fully cooked before being pureed for meal service.

Based on observations, record review and interviews, the facility failed to ensure menus met the needs of residents and were followed for mechanically altered diets. Specifically, meal portion sizes were served incorrectly for resident with puree diet orders. Findings include: I. Facility policy and procedure The Therapeutic Diets policy and procedure, revised 4/25/23, was provided by the nursing home administrator (NHA) on 10/26/23 at 12:00 p.m. It revealed in pertinent part, Therapeutic diets will be provided as prescribed by the attending physician or per state guidelines. The intent of this is to ensure the residents receive and consume foods in the appropriate form and/or the appropriate nutrient content as prescribed by a physician to support the treatment and plan of care for each resident and in accordance with his or her goals and preferences. A modified texture diet is specifically prepared to alter the consistency of food and/or beverage in order to facilitate oral intake. Associates responsible for preparation and service of therapeutic and modified diets will have adequate knowledge of those diets. All therapeutic and modified diets are extended on the menu and posted on the serving line. II. Lunch meal 10/24/23 A. Record review The menu included the main entree consisting of sweet and sour meatballs with sweet and sour sauce, steamed rice, italian vegetable blend and garlic bread. The dessert was fresh cantaloupe. A review of resident diets on 10/17/23 at 8:30 a.m. revealed five residents had physician orders for a puree diet. Menu extensions were provided by the divisional registered dietitian (DRD) on 10/23/23 at 10:11 a.n. The menu called for a #8 scoop (0.5 cup) of puree sweet and sour meatballs, a #8 scoop (0.5 cup) of puree steamed rice and #8 scoop (0.5 cup) of italian vegetable blend. B. Observations During observations of the tray line for lunch service on 10/24/23 incorrect scoop sizes were used to portion food for residents who received a puree diet. A #16 blue scoop (0.25 cup) was used instead of a #8 gray scoop (0.5 cup) which resulted in 50% of the portion listed on the menu extension serving sizes. -The sweet and sour meatballs portion for the puree diet was served as 0.25 cup portion with the #16 blue scoop instead of the 0.5 cup portion with the #8 scoop. -Mashed potatoes were substituted for puree rice. The mashed potatoes were served as a 0.25 cup portion with the #16 blue scoop instead of the 0.5 cup portion with the #8 scoop. -The puree vegetables were served as a 0.25 cup portion with the #16 blue scoop instead of the 0.5 cup portion with the #8 scoop. III. Staff interviews The nutrition services manager (NSD) and the DRD were interviewed on 10/26/23 at 11:30 a.m. The NSD said the facility had not had this many residents with puree diet orders until recently and it was something new for the cooks at the facility. The NSD said she would provide education to the staff on the incorrect portions. The DRD said she spoke to the cooks who served lunch service on 10/24/23 regarding the puree scoop sizes. The DRD said the facility pulled the blue scoops out of rotation after that lunch meal and other small portioned scoops the facility did not use to ensure incorrect portion utensils were not used on the line. The DRD said she did not want the scoops used or accessible to the staff. The DRD said she asked one of the cooks who served lunch on 10/26/23 why the staff used the incorrect scoop because he had his dietary manager certification. The DRD said the cook told her he knew better and he said he just zoned out from putting the correct scoop in the hot food pans on the line.

Based on observations and interviews, the facility failed to ensure all drugs and biologicals used in the facility were properly stored in one out of three medication carts. Specifically, the facility failed to ensure medication carts were locked when left unattended and medications were not left unattended. Findings include: I. Facility policy and procedure The Storage and Expiration Dating of Medications, Biologics policy, revised 7/21/22, was received from the nursing home administrator (NHA) on 10/16/23 at 1:22 p.m. It revealed in pertinent part, the policy sets forth the procedures relating to the storage and expiration of medications, biologics, syringes and needles. Facility should ensure that all medications and biologics, including treatment items, were securely stored in a locked cabinet/cart or locked medication room that was inaccessible by residents and visitors. II. Observations On 10/24/23 at 9:37 a.m. the north cart on the first floor was observed unlocked without a licensed nurse present. The cart remained unlocked until 9:45 a.m. At 10:32 a.m. registered nurse (RN) #1 was observed administering medications. RN #1 dispensed one tablet of Lisinopril (blood pressure medication) into a medication cup when she was called away to assist a staff member with resident care. RN #1 failed to lock up the Lisinopril medication in the cup and one medication card containing 13 doses of Lisinopril. RN #1 was in a resident room not in sight of the medication cart or medications left on top of the cart. RN #1 returned to her medication cart at 10:36 a.m. III. Staff interviews RN #1 was interviewed on 10/24/23 at 10:43 a.m. She said she should have locked up all the medications in the cart before leaving to assist the resident. RN #1 said keeping medications locked when nurses were not at the cart was important to prevent a resident accidentally getting ahold of the wrong medications. RN #1 said medication carts were to be kept locked when a nurse was not present to prevent someone from accessing them. The director of nursing (DON) was interviewed on 10/26/23 at 10:49 a.m. She said nurses should not leave any medications unattended and needed to lock them in the cart if they need to step away. The DON said keeping medications secured was for resident safety.

Based on observations, record review and staff interviews, the facility failed to ensure it was free of medication error rates of five percent or greater. Specifically, the medication pass observation error rate was 10.71%, or three errors out of 28 opportunities for error and affected three of four residents reviewed. Findings include: I. Facility policy The Administration of Medications policy and procedure, revised on 5/6/22, was provided by the nursing home administrator (NHA) on 7/13/22 at 1:40 p.m. It documented, in pertinent part, The facility will ensure medications are administered safely and appropriately per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Staff who are responsible for medication administration will adhere to the 10 Rights of Medication Administration: -Right Drug; -Right Resident; -Right Dose; -Right Route; -Right Time and Frequency; -Right Documentation; -Right Assessment; -Right to Refuse; -Right Evaluation; and, -Right Education and Information. II. Medication Errors 1. Registered nurse (RN) #1 was observed preparing and administering medications to Resident #8 on 7/12/22 at 7:35 a.m. RN #1 prepared [MEDICATION(S)] (anti-anxiety medication) 10 mg (milligrams) 2 (two) tablets, [MEDICATION(S)] ([CONDITION(S)] medication) 40 mg 1 (one) tablet, Senna S (constipation medication) 2 tablets, Vitamin D3 (supplement) 1,000 IU (international units) 2 tablets, [MEDICATION(S)] (medication for neuropathic pain) 600 mg 1.5 tablets, [MEDICATION(S)] (pain medication) 50 mg 1 tablet and Tylenol (pain medication) 325 mg 2 tablets and administered them to Resident #8. The [MEDICATION(S)] 600 mg half tablet was individually packaged with an expiration date of 7/9/22. Cross-reference F760 failure to ensure residents are free from significant medication errors. RN #1 was interviewed immediately following the administration. She said the packaging on the medication card looked as though the date of expiration was 12/9/22 and acknowledged it had been crossed out with the new expiration date of 7/9/22. She said she needed to take the information to the director of nursing for review and contact the pharmacy for follow-up. 2. Licensed practical nurse (LPN) #1 was observed preparing and administering medications to Resident #6 and Resident #4 on 7/12/22 at 7:50 a.m. and 8:03 a.m. LPN #1 prepared [MEDICATION(S)] (antidepressant medication) 20 mg 1 tablet, [MEDICATION(S)] (diabetic medication) 750 mg 1 tablet, Trajenta (diabetic medication) 5 mg 1 tablet, [MEDICATION(S)] (hypertension medication) 50 mg 1 tablet, [MEDICATION(S)] (constipation medication) 17 gm (grams), and [MEDICATION(S)] (insulin) [MEDICATION(S)] 16 units for Resident #6. She dialed the [MEDICATION(S)] to 16 units. She did not prime the [MEDICATION(S)]. LPN #1 administered all PO (by mouth) medications to Resident #6 and administered the 16 units of [MEDICATION(S)] to Resident #6 in her right arm. Cross-reference F760 failure to ensure residents are free from significant medication errors. LPN #1 prepared Aspirin (prophylactic) 81 mg 1 tablet, [MEDICATION(S)] (allergy medication) 180 mg 1 tablet, [MEDICATION(S)] (for [CONDITION(S)]) 40 mg 1 tablet, [MEDICATION(S)] (urticarial [CONDITION(S)]) 25 mg 1 tablet, [MEDICATION(S)] ([CONDITION(S)]) 150 mcg (microgram) 1 tablet, [MEDICATION(S)] (diabetes medication) 500 mg 1 tablet, [MEDICATION(S)] (hypertension medication) 0.5 tablet, [MEDICATION(S)] (allergy medication) 10 mg 1 tablet, Potassium (potassium replacement medication) 20 meq (milliequivalents) 1 tablet and vitamin D3 (supplement) 1,000 IU 1 tablet and administered them to Resident #4. According to Resident #4's July 2022 electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #1 was interviewed immediately afterwards. She said the [MEDICATION(S)] needed to be primed routinely and she primed the insulin pen sometimes. She acknowledged the [MEDICATION(S)] needed to be primed with 2 units prior to administration to ensure the resident received their accurate dose of medication. She acknowledged she did not administer the correct dose of [MEDICATION(S)] to Resident #4, she said she would contact the physician to clarify the dose. III. Administrative interviews The DON and regional nurse consultant (RNC) were interviewed on 7/12/22 at 1:48 p.m. The DON said the nurses were educated on how to prime insulin pens prior to administration. She said LPN #1 knew how to prime the insulin pen, but she was nervous. She said the pharmacist completed medication pass with the nurses monthly, and she would check to see if LPN #1 had a recent medication pass competency and she planned to provide LPN #1 additional education/training. They said they clarified the order for [MEDICATION(S)] to include the over the counter dose of 180 mg instead of 30 mg. The DON was interviewed a second time on 7/13/22 at 11:31 a.m. She said she notified the pharmacy regarding the error and change in expiration date of the Resident #8's [MEDICATION(S)]. She said she was told the medication ([MEDICATION(S)] 600 mg half tablet) had a 28 day expiration date. She acknowledged the medication error. She planned to provide training regarding the decreased end date of the [MEDICATION(S)] when split in half. IV. Facility follow-up The NHA provided copies of education dated 7/12/22 for LPN #1 and 7/13/22 for RN regarding the 10 rights of Medication Administration (see above). Additionally, LPN #1's training included proper priming of the [MEDICATION(S)] with 2 units prior to administering, giving blood pressure medications within parameters (on 6/13/22) and RN #1's training included looking at expiration dates of medication prior to administering.

Based on interviews, and record review, the facility failed to develop and implement policies and procedures related to influenza and pneumococcal immunizations for one (#48) of five reviewed for immunizations out of 33 sample residents. Specifically, the facility failed to ensure Resident #48 received the pneumococcal vaccination for more than nine months after he consented to receive it on 9/28/21. Findings include: I. Professional reference According to the centers for disease control and prevention (CDC), Pneumococcal Vaccine Recommendations (Page last reviewed: 1/24/22) retrieved on 7/18/2022 from: https://www.cdc.gov/vaccines/vpd/pneumo/hcp/index.html. It read in pertinent part, CDC recommends routine administration of pneumococcal conjugate vaccine (PCV15 or PCV20) for all adults [AGE] years or older who have never received any pneumococcal conjugate vaccine or whose previous vaccination history is unknown. II. Facility policy The Influenza Vaccine and Pneumococcal Vaccine Policy for Residents, revised 12/31/21, was provided by the nursing home administrator (NHA) on 7/14/22 at 9:17 a.m. It read in pertinent part, Purpose: to facilitate the delivery of appropriate vaccinations in a timely manner, to increase the levels of vaccination coverage, and to decrease the morbidity and mortality rate of influenza and pneumococcal diseases. The resident's medical record includes documentation that indicates, at a minimum, the following: that the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and that the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindications or refusal. III. Resident #48 A. Resident status Resident #48, above [AGE] years old, was admitted on [DATE], with initial admission 4/21/21. According to the July 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/18/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. He required extensive assistance with one person for bed mobility, transfers, walking in the room, dressing, toilet use, bathing, and personal hygiene. The MDS further revealed that the resident's pneumococcal vaccination was not up to date and reason for not receiving was he was not eligible due to medical contraindication. -However, there was no documentation that the vaccine was offered or that there was a medical contraindication. B. Record review 1. Immunization record Review of the immunization record revealed Resident # 48 had not been offered or received the pneumococcal vaccination. 2. Consent Resident #48 immunization consent, dated 9/28/21, documented consent was verbally given by the resident and signed by two nurses. The resident representative line was left blank and did not indicate which resident representative, if any, was present or spoken to. Further review of Resident #48's record revealed there was no documentation of the pneumonia vaccination being offered or given to the resident. 3. Progress notes Review of all progress notes from 9/17/21-7/12/22 revealed the following related to vaccines and immunizations. On 9/21/21 progress note related to Resident #48 receiving his first COVID-19 vaccine at Evergreen fire station. On 9/22/21 progress note related to Resident #48 having no adverse effects relative to recent COVID-19 vaccination. On 10/14/21 progress note related to Resident #48 receiving his second dose of the Pfizer COVID-19 vaccine. Family and resident consented and resident was considered fully vaccinated on 10/29/21. On 11/2/21 progress note related to Resident #48 consented to receiving the annual flu vaccine, and received the vaccine on 10/29/21 at 2:00 p.m. to left arm, no adverse reaction noted. -However there were no progress notes related to Resident #48 being offered or receiving the pneumococcal vaccine. IV. Staff interviews The infection preventionist (IP) was interviewed on 7/13/22 at 2:24 p.m. The IP acknowledged upon review of records that Resident #48 had not been given his pneumococcal vaccine. The IP said she did not find any specific notes in the progress notes and said the progress notes was where she would document if she spoke with the resident or family. The IP said that the family signed the consent on 9/29/21 for the pneumonia vaccine. The IP said it was signed by the nurse as a verbal consent upon admission and another nurse signed as well. The IP said the nurse got verbal consent upon admission but it did not say which resident representative was spoken to. The IP said after the consent the pneumococcal vaccine was not administered. The IP said she was not sure where the process failed but would follow up on it. The NHA was interviewed on 7/14/22 at 9:17 a.m. She said she understood there had been identified an opportunity for Resident #48 to receive a pneumococcal vaccine and since bringing it to their attention he had now received the vaccine. The NHA said they followed up when brought to their attention yesterday and the facility did an audit, and no other residents had signed consents and had not received the vaccine. The NHA said they did an audit on consents for pneumococcal and influenza vaccines and one root cause of why the vaccine could have been missed was the form changed to two separate consent forms. The NHA said the facility went through the admission charts and prepared the charts with the correct documents. The NHA said with regards to all residents who were eligible for the pneumococcal vaccine they had consents redone if needed, and vaccines were offered and given yesterday. The NHA said an audit of the paperchart consents showed some inconsistencies and the facility did brand new consents for everyone. The NHA said they found opportunities about how to make sure the vaccine system stayed strong. The NHA said the facility looked at an internal audit and they developed a tool for admissions checklist, to provide more clarity. The NHA said nurses will now submit the checklist to medical records and grand rounds will check consents with new admissions at that time. The NHA said the facility initiated education of the admission audit, and general nurse education of the three part process-consent, administer and document. The NHA said the facility saw inconsistencies and they followed up and want the consent paper form and progress notes to match with consistency. The director of nursing (DON) and IP were interviewed on 7/14/22 at 10:55 a.m. The DON said the admitting nurse went through all consents with the resident and/or power of attorney (POA). The DON said if the nurse talked to a family member it should either be written on the consent form or in the progress notes. The DON said resident/POA education was done at the time of administering the vaccine. The DON said residents who have given consent for a pneumococcal vaccine, should be offered and given the vaccine in order to prevent pneumonia. V. Facility follow up After being brought to the facility's attention the following information was provided: Received from the NHA on 7/14/22 at 10:15 a.m. attesting that on 7/13/22 the facility performed a full-house audit on the following: paper flu and pneumonia consents in current resident charts; flu and pneumonia vaccine status and documentation in electronic medical records; and admissions, ready to go blank charts. Documentation of an inservice presented by the DON on 7/13/22 to the nursing staff regarding influenza and pneumococcal vaccine and nursing expectations. Revealed that the admitting nurse will obtain consent for the influenza (given October 1-March 31) and Pneumococcal from resident or resident POA will be accountable to administer the vaccine. If verbal consent was obtained the nurse will document on the consent form who gave verbal authorization. The nurse will obtain an order from the primary care physician. The nurse then will chart in the medical record that it was given under the immunization tab. Documentation of an inservice presented by the DON on 7/13/22 to the nursing staff regarding the nursing admission checklist, note initials and signature required, and detailed consent and immunization information required. Progress noted date 7/14/22 at 9:54 a.m. was received from the IP on 7/14/22 at 10:54 p.m. It revealed that the IP had spoken with the family representative of Resident #48 regarding the pneumococcal vaccine. The IP said the family acknowledged that they had previously spoken about no known history of vaccine administration, however the resident representative stated the resident had always given importance to vaccinations in the past when he managed his own care, this had caused delay with consent in the past. The IP provided education to the resident and family and said the CDC had approved the PSV20 for patients with unknown pneumonia vaccine history. The resident and residents representative gave consent to receive the PCV20: vaccine was administered with no complications, resident tolerated well. The vaccine information sheet (VIS) was provided to the resident and administration details were noted in the electronic medical records immunization record.

Based on observations, interviews and record review the facility failed to ensure residents were kept free from significant medication errors for two (#6 and #8) of four reviewed out of 33 sample residents. Specifically, the facility failed to ensure: -An insulin pen was primed before administered to Resident #6, to ensure the correct insulin dose was given; and, -Resident #8 did not receive expired medication. Cross-reference F759 failure to ensure the facility was free of medication error rates of five percent or greater. Findings include: I. Professional reference According to the [MEDICATION(S)] pen (2020), How to use your [MEDICATION(S)] Pen, retrieved on [DATE] from https://www.[MEDICATION(S)].com/dam/jcr:817aed9c-a,d+[DATE]cd6-a6b3-d93d8aba629a/[MEDICATION(S)]-[MEDICATION(S)]-pen-guide.pdf read in pertinent part, Perform a safety test, dial a test dose of 2 (two) units. Hold the pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test. If no insulin comes out, repeat the test 2 more times. If there is still no insulin coming out, use a new needle and do the safety test again. Always perform the safety test before each injection. Never use the pen if no insulin comes out after a second needle. According to the Cleveland Clinic, [MEDICATION(S)], reviewed [DATE], retrieved on [DATE] from https://my.clevelandclinic.org/health/drugs/ -[MEDICATION(S)] read in pertinent part, [MEDICATION(S)] and generic forms of [MEDICATION(S)] tablets may be broken into two pieces. You can take the second half for your next dose. Don't use the half-tablet beyond 28 days after the whole tablet was cut or broken. II. Facility policy The Administration of Medications policy and procedure, revised on [DATE] was provided by the nursing home administrator (NHA) on [DATE] at 1:40 p.m. It documented, in pertinent part, The facility will ensure medications are administered safely and appropriately per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Staff who are responsible for medication administration will adhere to the 10 Rights of Medication Administration: -Right Drug; -Right Resident; -Right Dose; -Right Route; -Right Time and Frequency; -Right Documentation; -Right Assessment; -Right to Refuse; -Right Evaluation; and, -Right Education and Information. III. Failure to ensure Resident #6's insulin [MEDICATION(S)] was primed prior to administration A. Resident #6's status Resident #6, age 95, was admitted on [DATE]. According to the [DATE] computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] minimum data set (MDS) assessment revealed Resident #6 was moderately impaired with a brief interview for mental status (BIMS) score of nine out of 15. She did not exhibit behaviors or reject care. She received insulin injections the past seven days. B. Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] The [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . C. Observation and interview Licensed practical nurse (LPN) #1 was observed preparing and administering medications to Resident #6 on [DATE] at 7:50 a.m. LPN #1 prepared [MEDICATION(S)] (insulin) [MEDICATION(S)] 16 units for Resident #6. She dialed the [MEDICATION(S)] to 16 units and administered it to the resident in her right arm. She did not prime the [MEDICATION(S)] prior to administration. LPN #1 was interviewed immediately afterwards. She said the [MEDICATION(S)] needed to be primed routinely and she primed the insulin pen sometimes. She acknowledged the [MEDICATION(S)] needed to be primed with 2 units prior to administration to ensure the resident received their accurate dose of medication. IV. Failure to ensure Resident #8 received unexpired medication A. Resident #8's status Resident #8, age less than 60, was admitted on [DATE]. According to the [DATE] CPO diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] MDS assessment revealed Resident #8 was cognitively intact with a BIMS score of 14 out of 15. She did not exhibit behaviors or reject care. She received pain medication routinely and as needed. She experienced occasional pain in the past five days. B. MAR The [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . C. Observation and interview Registered nurse (RN) #1 was observed preparing and administering medications to Resident #8 on [DATE] at 7:35 a.m. RN #1 prepared [MEDICATION(S)] 600 mg 1.5 tablets administered them to Resident #8. The [MEDICATION(S)] 600 mg half tablet was individually packaged with an expiration date of [DATE]. RN #1 was interviewed immediately following the administration. She said the packaging on the medication card looked as though the date of expiration was [DATE] and acknowledged it had been crossed out with the new expiration date of [DATE]. She said she needed to take the information to the director of nursing for review and contact the pharmacy for follow-up. V. Administrative interviews The DON and regional nurse consultant (RNC) were interviewed on [DATE] at 1:48 p.m. The DON said the nurses were educated on how to prime insulin pens prior to administration. She said LPN #1 knew how to prime the insulin pen, but she was nervous. The DON was interviewed a second time on [DATE] at 11:31 a.m. She said she notified the pharmacy regarding the error and change in expiration date of the Resident #8's [MEDICATION(S)]. She said she was told the medication ([MEDICATION(S)] 600 mg half tablet) had a 28 day expiration date. She acknowledged the medication error. She planned to provide training regarding the decreased end date of the [MEDICATION(S)] when split. The medical director was interviewed on [DATE] at 11:44 a.m. She said she was in contact with the pharmacy regarding the medication error (administering [MEDICATION(S)] beyond its expiration date). She said the facility had reviewed the incident, and she requested that the pharmacy send a 600 mg tablet and 300 mg capsule to ensure the resident received the ordered medication of 900 mg. She said she did not want it to become an issue at any of the other facilities she served. She said a consulting pharmacist was working on an action plan regarding how they dispensed medications with a shortened expiration date. The pharmacist was interviewed on [DATE] at 12:04 p.m. He said he was notified by the facility on [DATE] regarding staff administering [MEDICATION(S)] 600 mg split tablet beyond its use date and had been researching and brainstorming with other managers regarding dispensing [MEDICATION(S)] 600 mg split tablets. He said he was notified (received a safety alert) by his corporate office via memo sometime in 2021 that if the pharmacy dispensed [MEDICATION(S)] 600 mg split tablets, which was a film coated tablet, the beyond use date was shortened 28 days. He said he was in the process of researching the efficacy regarding splitting the [MEDICATION(S)] tablet, and just started the first draft of the pharmacy action plan to possibly include dispensing/switching the resident to 300 mg increment capsules, and possibly labeling the medication with alert to ensure staff administering the medication knew the medication had a shortened beyond use date. The pharmacist was interviewed a second time on [DATE] at 9:30 a.m. He said the shortening of the end date of [MEDICATION(S)] was something the manufacturer recommended, but there was nothing in the documentation in which he researched which suggested any major concerns. He said his clinical judgment would lead him to suspect that the efficacy of the medication ([MEDICATION(S)]) was reduced if given past its expiration date.

Based on observations, record review, and interviews the facility failed to ensure all drugs, biologicals, were properly labeled/stored/removed in one of four medication carts and two of two medication storage rooms. Specifically, the facility failed to ensure expired injectables, suspensions, and tablets were labeled correctly and removed timely from one of four medication carts and from two of two medication storage room refrigerators. Findings include: I. Facility policy The Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles policy, dated 12/1/17, revised 4/5/19, provided by the director of nursing (DON) on 3/23/21 at 3:40 p.m., read in pertinent part: -Facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier. -Once any medication or biological package is opened, the facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. -Facility should destroy and reorder medications and biologicals with soiled, illegible, worn, makeshift, incomplete, damaged or missing labels or cautionary instructions. II. Manufacturer recommendations The manufacturer's package insert instructions for the [MEDICATION(S)] influenza vaccine read in pertinent part: -Once the stopper of the multi-dose vial has been pierced the vial must be discarded within 28 days. The manufacturer's package insert instructions for the [MEDICATION(S)] (Mantoux) [MEDICATION(S)] solution read in pertinent part: -A vial of [MEDICATION(S)] which has been entered and in use for 30 days should be discarded. The manufacturer's recommendation for opened insulin is for it to be discarded after 28 days. III. Observations and interviews On 3/23/21 at 9:00 a.m., review of the medication cart and the medication storage room on the 1 South hall with licensed practical nurse (LPN) #1 revealed the following expired/unlabeled injectables, suspensions, and tablets: -One bottle of Magic Mouthwash (Diphenhydramine, [MEDICATION(S)] 2%, antacid) oral suspension in the medication cart. The pharmacy label indicated the medication was compounded on 2/4/21 and the beyond use date at room temperature was 21 days (2/25/21). -One bottle of [MEDICATION(S)] (antihistamine) 10 milligram (mg) with 25 tablets remaining that expired January 2021. -One [MEDICATION(S)] insulin pen that was still in use and had been opened 2/7/21. -One bottle of [MEDICATION(S)] (antifungal) oral suspension was dated 2/10/21 and was no longer used by the resident. -One unlabeled, opened vial of [MEDICATION(S)] insulin in a box that was also unlabeled. The vial was three quarters full and was dated 3/25/21. The box had a date of 2/6/21 that had been marked through and written above it was 3/25/21. -The 1 South medication storage room refrigerator contained a bottle of [MEDICATION(S)] (antibiotic) that was half full, dated 2/26/21 with instructions on the label to administer for 14 days and was no longer in use. There was also an opened vial of [MEDICATION(S)] (flu vaccine) that was dated 2/13/21. LPN #1 said she did not know who was responsible for reviewing the medication carts and medication storage rooms to remove expired and discontinued medications and liquids. She said she thought the unit manager or the night shift nurses were supposed to do it and she did not know if the pharmacist ever came in to review them. The DON said the vial of insulin in the unlabeled box just needs to be pitched because she could not begin to guess why it was in use, why the vial was dated 3/25/21 or why the box had two different dates on it. On 3/23/21 at 10:00 a.m., review of the second floor medication storage room refrigerator with LPN #4 revealed an opened vial of [MEDICATION(S)] solution dated 1/21/21. LPN #4 said she did not know how long the medication was good once it had been opened. IV. Additional interviews On 3/23/21 at 10:30 a.m. LPN #4 said she removed the vial of [MEDICATION(S)] solution from the refrigerator and disposed of it because she was unsure if it was still good. The DON and the nursing home administrator (NHA) were interviewed on 3/24/21 at 10:02 a.m. The DON said all the nurses were responsible for reviewing the medication carts and the medication storage rooms for any expired medications or those no longer in use and that responsibility was not designated to any particular shift. She said the unit managers should also conduct audits of the medication carts and storage rooms. The DON said all nurses should check expiration dates on medications and make sure the carts were clean when they opened the carts to complete their medication pass. The NHA said the pharmacist used to come to the facility to conduct audits prior to the pandemic but their contract would not allow them to enter the building since the start of the pandemic. She said once the facility had been cleared of any COVID-19 positive residents, the first visit from the pharmacist was on 3/9/21. The NHA said as of right now we will start a full audit of all med carts and storage rooms.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of Coronavirus disease (COVID-19) and infection for four of four hallways including the facility kitchen. Specifically the facility failed to: -Ensure staff properly donned and doffed personal protective equipment (PPE) in the kitchen and in two of four hallways (one of which was the COVID-19 positive unit); -Ensure staff were [MEDICATION NAME] proper hand-hygiene etiquette and offering resident's appropriate hand-hygiene at meal times; and, -Ensure housekeeping was performing proper gloving technique when moving from one cleaning task to the next. Findings include: I. Professional reference According to the Centers for Disease Control (CDC) Personal Protective Equipment; Questions and Answers, last updated 8/8/2020, accessed 10/4/2020 and retrieved from https://www.cdc.gov/coronavirus/2019-ncv/hcp/respirator-use-faq.html, included the following recommendations: Gloves: It is important for HCP (healthcare personnel) to perform hand hygiene after removing PPE. Hand hygiene should be performed by using an alcohol based hand sanitizer that contains 60-95% alcohol or washing hands with soap and water for at least 20 seconds. If hands are visibly soiled, soap and water should be used before returning to alcohol-based hand sanitizer. The Centers for Disease Control and Prevention (CDC), (6/25/2020) Preparing for COVID-19 in Nursing Homes, Core Practices, accessed 10/4/2020 and retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html read in pertinent part, Care must be taken to avoid touching the respirator, facemask, or eye protection. If this must occur (e.g., to adjust or reposition PPE), healthcare providers should perform hand hygiene immediately after touching PPE to prevent contaminating themselves or others. According to the CDC guidance, Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19, dated 6/3/2020, accessed 10/2/2020 and retrieved from https://www.cdc.gov/coronavirus/2019ncov/downloads/A_FS_HCP_COVID19_PPE.pdf read in part, -PPE must be donned correctly before entering the patient area. -PPE must remain in place and be worn correctly for the duration of work in potentially contaminated areas. PPE should not be adjusted. -Face masks should be extended under the chin. -Both your mouth and nose should be protected . According to the Centers for Disease Control and Prevention (CDC) Preparing for COVID-19: Long-term Care Facilities, Hand Hygiene Recommendations, last updated 5/17/2020, retrieved on 10/6/2020 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, included the following recommendations of using an alcohol-based hand rub (ABHR) with 60-95% alcohol in healthcare settings due to the evidence of better compliance compared to soap and water. Hands should either be washed with soap and water or an ABHR for at least 20 seconds when visibly soiled, before eating and after using the restroom. II. Facility policy and procedures The Coronavirus (COVID-19) policy, no date when initiated, was provided by the nursing home administrator on 10/1/2020 at 5:28 p.m. documented in pertinent part, the purpose was to provide a framework to minimize the risk of potential exposure to the Coronavirus COVID-19 in the long-term care facility. The facility will follow the core principles of COVID-19 infection prevention as outlined below and defined by CMS (centers of Medicare and Medicaid) and CDC (Centers of Disease Control) to mitigate COVID-19 entry into the facility. Screening of all who enter the facility for signs and symptoms of COVID-19 and denial of entry of those with signs and symptoms; Hand hygiene (use of alcohol-based hand rub is preferred); Face covering or mask (covering mouth and nose); Social distancing at least six feet between persons; Instructional signage throughout the facility and proper visitor education on COVID-19 signs and symptoms, infection control precautions, other applicable facility practices; Cleaning and disinfecting high frequency touched surfaces in the facility often, and designated visitation areas after each visit; Appropriate staff use of personal protective equipment (PPE); Effective cohorting or residents, and; Resident and staff testing conducted as required at 42 CFR 483.80(h) (see QSO-20-38-NH). Use of face masks and face coverings: Healthcare personnel (HCP) should wear a facemask at all times while they are in the healthcare facility. The Personal Protective Equipment (PPE) policy, revised 5/29/2020, provided by the NHA 10/1/2020 at 5:28 p.m. documented in part: Purpose: To reduce the risk of and prevent the spread of infection to patients, visitors and staff. The facility should train associates on personal protective equipment (PPE), this training should include but not limited to; Appropriate don/doff process Appropriate use, based on care activities Appropriate extended or reuse of PPE, based on national/local recommendations How to obtain PPE supplies and who to contact when replacements are needed. The Hand Hygiene for Residents policy, reviewed on 4/16/2020, was provided by the nursing home administrator (NHA) on 9/30/2020 at 10:45 a.m. It documented the purpose of this policy was to decrease the risk of transmission of infection by enabling residents to perform appropriate hand hygiene. It documented staff would encourage and assist the residents as needed to ensure proper hand hygiene through handwashing or the use of an alcohol-based hand rub. It documented hand hygiene should be offered/performed prior to the handling and/or consumption of food or drink. III. Observations and interviews Room tray pass was observed on 1 North (yellow status hall) on 9/28/2020 from 4:45 p.m. through 5:30 p.m. During this observation period, CNA #2 was observed serving trays to residents in three separate rooms without offering any type of hand hygiene to the residents prior to eating their meals. The meal served that evening were soft shell tacos, a ready-to-eat food On 9/28/2020 beginning at 4:53 p.m. through 5:20 p.m. supper meal pass was observed on 2 South (yellow zone hall). CNA #7 and the activity director (AD) were observed delivering trays to residents in five rooms without offering any hand hygiene to the residents prior to eating their meals. The residents in these rooms received the main entrée which was soft shell tacos and a cupcake for dessert, which were considered ready-to-eat foods. On 9/29/2020 at 11:10 a.m. cook (#1) was in the kitchen at the back prep table. He had his mask down underneath his chin while preparing dessert cups for the supper meal. He then pulled his mask back up over his mouth and nose and touched the front of the mask with his bare hands and continued to prepare the dessert cups. He did not sanitize his hands before preparing the dessert cups. After replacing the mask over his mouth and nose, one strap of the respirator was pulled up and around the top of his head; the other strap was dangling loose and not properly placed around the back of his neck. Following the observation the cook was interviewed. He said that he had pulled his mask down to take a drink of water and acknowledged that he had not sanitized his hands. He said the mask was to be worn at all times covering the face fully. A room tray pass was observed on 1 North on 9/29/2020 from 12:05 p.m. through 12:35 p.m. At 12:12 p.m., RN #1 was observed not offering one of the male residents in room [ROOM NUMBER] a way to sanitize his hands prior to eating his lunch. The lunch was sloppy joes, which was a ready-to-eat food On 9/29/2020 beginning at 12:12 p.m. through 12:35 p.m. lunch meal pass was observed on 2 North (yellow zone hall). CNA #4 and the director of nursing (DON) were observed delivering trays to residents in five rooms without offering any hand hygiene to the residents prior to eating their meals. The residents in four of the five rooms received the main entrée which was sloppy joe sandwiches, considered a ready-to-eat food. On 9/29/2020 at 4:00 p.m. certified nurse aide (CNA #6) exited room [ROOM NUMBER] wearing her full PPE (gown, gloves) walked down the hallway and went into the dirty utility room. She exited the room thirty seconds later without her gown and gloves. The entire hallway was under isolation precautions requiring full PPE usage according to the facility's COVID-19 outbreak precautions. Although there were no COVID-19 positive residents on the hallway, the facility was under the direction of their local county health department guidance for precautionary guidelines during an active COVID-19 outbreak. The CNA was interviewed immediately following the observation. She said that she had received training regarding the proper use of PPE and that she should have removed her PPE inside the room prior to exiting the room. The COVID-19 positive red hall was observed on 9/29/2020 from 4:45 p.m. to 6:30 p.m. CNA #5 was observed at 5:48 p.m. She applied some ABHR to her hands and rubbed them for five seconds, then began flapping her hands to finish drying them. At 5:50 p.m., she again rubbed ABHR into her hands for five seconds, then waved her hands around to dry them. At 5:53 p.m., the CNA practiced hand hygiene with ABHR for 10 seconds before donning gloves. On 9/29/2020 at 4:38 p.m. housekeeper (HSK #1) was observed preparing to enter an isolation room. She did not sanitize her hands with the hand sanitizer available on the isolation cart. She donned her disposable gown and then donned her gloves and entered the resident room. She first took a clean rag that was soaking in a bleach solution and wiped down the resident's over bed table. She then took another clean rag (without doffing her gloves or sanitizing hands) and started wiping down the inside of the sink, sink counter, and the surfaces of the sink drawers and handles and nearby dresser. She then moved to wiping down the closet door and handle. She then took another clean rag, without doffing her gloves and wiped the door handle of the bathroom, the hand rail and then ended with the toilet. She exited the bathroom, did not change her gloves or sanitize her hands and with the same gloves took the toilet bowl brush and went in and cleaned the inside of the toilet. She exited the bathroom, did not doff her gloves or sanitize her hands and then began to sweep the floor in the room, then went to the bathroom and swept the bathroom floor and out of the room towards the doorway. She did not doff her gloves or sanitize her hands and with the same gloves took a clean mop sponge and moped the bathroom floor. She exited the bathroom and discarded the mop sponge, did not doff her gloves or sanitize her hands, took a clean mop sponge and mopped the inner room floor. HSK #1 was interviewed immediately following the observation. She said that she donned her PPE and sanitized her hands before entering a room to clean. She said she sanitized her hands before and after exiting a room and that she washed her hands with soap and water after every third room. She said she had received training on how to properly use PPE and that she would sanitize her hands with alcohol based hand rub (ABHR) for ten seconds. She said she changed gloves in between rooms or if they were damaged or soiled. On 9/29/2020 at 5:35 p.m., certified nurse aide (CNA) #8 was observed coming out of room [ROOM NUMBER] on the COVID-19 positive red hall still donned in her gown. She removed her gown in the hall between the resident's room instead of the room the staff were working in. On 9/29/2020 at 6:04 p.m., CNA #3 was observed entering the COVID-19 Red Unit to start her shift. She did not have any type of mask donned when she entered the unit. She proceeded to sign in on the screening forms with no PPE at all donned. Registered nurse (RN) #3, who was working as the COVID-19 unit manager asked CNA #3 to don a mask and CNA #3 said she had thrown her N95 mask away. Two or three minutes passed before CNA #3 donned a surgical mask to go down to the staff room to get another N95 mask. All PPE required to work on a COVID-19 positive unit were stored outside the door CNA #3 had just entered in order to work on the COVID-19 Red Unit. On 9/29/2020 at 6:20 p.m., CNA #3 was observed passing a third room tray on the COVID-19 red hall without offering hand hygiene to the resident. During this observation, no other staff member was observed offering hand hygiene to this resident prior to the resident eating his meal. IV. Administrative interviews The nursing home administrator (NHA) was interviewed on 9/30/2020 at 10:15 a.m. She said CNA #3 had just returned from a COVID-19 quarantine after she tested positive for COVID-19 and thought 9/29/2020 was the CNA's second shift working in the facility after recovering from COVID-19, but it was probably the first time she had worked on the COVID-19 positive red hall. The NHA said, to her knowledge, there had been no refresher training provided by the director of nursing (DON) for staff who had recently returned back to work from their COVID-19 quarantine. She said the facility would look at adding a refresher training to staff dedicated to the COVID-19 positive unit prior to them returning to work after recovering from COVID-19 themselves. The director of nursing (DON) was interviewed on 9/30/2020 at 10:55 a.m. She said that in both the Red and Yellow zones staff were required to donn PPE before entering a room to assist residents. She said in the Red, COVID-19 positive wing staff are to donn PPE before entering the wing. She said that staff are to perform hand hygiene with ABHR any time they come in contact with high touched surfaces, residents and when coming in and out of the building. She said gloves must be changed in between tasks and hands should be sanitized appropriately in between glove changes. She said in relation to staff hand hygiene practices throughout the building, staff better be doing it. She said she expected staff to practice hand hygiene anytime they touched a resident, touched anything like a surface area, their glasses or goggles, after toileting and before and after the staff ate. She said, I have gone over hand hygiene, I can't tell you how many times with 100% of the staff. It's not rocket science. She said the proper way to practice hand hygiene with ABHR was to apply the ABHR and rub with friction for at least 20 seconds. She said staff should cover all areas of their hands, including the backs and wrists. She said if staff did not sanitize for at least 20 seconds, they should do another squirt because what they did was not sufficient. She said staff should rub the ABHR into their hands until thoroughly dry and it was not okay for staff to air dry or flap their hands because you had to do the rubbing motion to get the germs off. She said staff should always sanitize their hands prior to putting a fresh pair of gloves on. She said her personal observations of the COVID-19 positive red unit had been conducted through the small window on the fire doors which led into the red unit and were located in the transition area between the main part of the facility and the COVID positive red hall. She said she had not entered the COVID-19 positive hall since the outbreak, as the facility was trying to preserve the DON as the last resort to enter the Red Unit. She said she thought CNA #3 had worked on the COVID-19 unit since she recently returned from her quarantine. She said it was her expectation for staff working in the facility and especially on the COVID-19 unit to don all required PPE prior to entering a resident's room and doff the same PPE before exiting the room. She said if staff were hanging out in the hallway, the staff should be in full PPE because you just don't know. She said, in relation to the observation of CNA #3, the CNA had been educated about PPE and she was aware which halls were designated yellow and red. She said the CNA had to walk right by the necessary PPE required for the unit. She said she was disappointed in CNA #3's performance. She said it would not be a bad practice to have some kind of notebook and retraining prior to staff recently returning to work from COVID-19 prior to working again She said all staff had been sent staff education via computer and cell phones during the outbreak and the education and information had been provided to them. She said it was her expectation for all staff to offer residents a method to practice hand hygiene prior to eating their meals. She said the facility had been engaging in this practice prior to COVID-19. She said the facility had done several in-services on the topic, as well as auditing and conducting return demonstrations. She said the facility had tried having one staff member providing hand hygiene and another staff member offering the resident their tray, but because of all the PPE donning and doffing, it delayed room tray delivery. She said the staff should proceed into the resident's rooms prior to meal service and offer hand hygiene to ensure it was getting done. She said the facility was doing the best they could with what they had. She said she did not know if all residents had ABHR in their rooms. The director of housekeeping (DOH) was interviewed on 9/30/2020 at 12:07 p.m. She said that housekeeping staff are to apply proper PPE and sanitize their hands before and after cleaning rooms and that gloves should be changed in between different items and cleaning tasks inside a room. The NHA was again interviewed on 9/30/2020 at 12:58 p.m. She said all staff entering the COVID-19 positive Red Unit must don all appropriate PPE prior to entering the unit. She said the facility had conducted resident hand hygiene audits and the facility had a number of different hand hygiene options to offer the residents. She said the residents were encouraged to wash their hands with soap and water on their own, if able. She said they were encouraged to use ABHR, staff could assist them with Purell wipes, using visual cues to mirror what the residents were expected to do or provide the residents who were confined to their beds with a warm rag for their hands. She said the facility typically provided the Purell wipes to the residents, as that was what staff were used to doing when residents were still going down to the dining room. She said the facility would be working with the staff to take hand hygiene products into the resident's room with them when they were actually serving the meal. She said ABHR were not allowed in resident's rooms prior to COVID-19, but due to the outbreak, every resident room should have some type of hand sanitizer located within it. She said she would expect any associate to practice hand hygiene before and after every task and after touching any surface. She said the process included using an ample amount of ABHR on their hands, using friction, and covering all surfaces of their hands for approximately 20 seconds or until their hands are dry. V. Status of COVID-19 in the facility The nursing home administrator was interviewed on 9/28/2020 at 2:00 p.m. She reported the resident census was 63 and there were 15 residents positive for COVID-19. She said these residents were on the Red COVID-19 isolation unit. She said they had not had any positive cases of COVID-19 in their building for 191 days. She said the outbreak occurred on 9/16/2020. She said the remaining areas (hallways on first and second floor) of the facility were designated as Yellow zones which meant that full PPE was required each time a resident room was entered for resident care. She said this was per the direction of their local health department. She said the most recent county positivity rate (9/23/2020) was 3.2 percent.

Based on record review and staff interviews, the facility failed to ensure for one (#2) of three residents received treatment and care in accordance with professional standards of practice out of 22 sample residents. Specifically, the facility failed to ensure medications were received in a timely manner according to the admission orders [REDACTED] Findings include: I. Policy and procedure The Medication Shortages/Unavailable Medications policy, revised 1/13, was provided by the director of nursing (DON) on 7/18/19 at 5:37 p.m. It read in pertinent part, If a medication shortage is discovered during normal pharmacy hours. Facility nurse should call pharmacy to determine the status of the order. If the medication is not available in the emergency medication supply, facility staff should notify pharmacy and arrange for an emergency delivery. II. Resident #2 A.Resident status Resident #2, under the age 65, admitted on [DATE] and was discharged to home 5/30/19. The (MONTH) 2019 computerized physician orders [REDACTED]. The 5/30/19 minimum data set (MDS) documented the resident had no cognitive assessment was conducted Resident #2 was coded to be given antibiotic medication seven days a week. She received special treatment for [REDACTED]. A. Record review The 5/24/19 baseline care plan documented the resident had cutaneous abscess of left upper limb, difficulty in walking, fusion of spine, cervical region, other chronic pain, and asthma. The intervention included was to take medications as ordered. A review of the (MONTH) 2019 MAR indicated [REDACTED] Resident missed the following amount of dosages for each medication: -[MEDICATION NAME] missed three doses totallying 3750mg/750ml, [MEDICATION NAME] missed 450mg, [MEDICATION NAME] missed one 500-50mcg dose. 1.[MEDICATION NAME] The (MONTH) 2019 CPO documented the resident had an order for [REDACTED]. According to the 5/24/19 at 8:30 p.m. progress note, the nurse revealed that Resident #2 [MEDICATION NAME] 1250 mg/250mL in 0.9% sodium chloride, to be given every 12 hours was not available in the facility from pharmacy. -The pharmacy delivery sheets on 5/25/19, at 4:11 a.m. revealed facility received [MEDICATION NAME] (HCL) one-gram vial. The facility lab results for 5/26/19, [MEDICATION NAME] trough documentation said to target trough concentration of five to fifteen UG (microgram)/ml recommended. Trough concentration of up to 20 ug/ml documented severe infections where drug penetration may be compromised. The trough documentation highlighted results were 17.0ug/ml, and they were high. According to the 5/27/19, at 12:38 p.m. progress note, the nurse documented [MEDICATION NAME] trough drawn yesterday, orders faxed to pharmacy, and pharmacist called and added no changes to the [MEDICATION NAME] dosage. According to the 5/27/19, at 8:46 p.m. progress note, the nurse documented [MEDICATION NAME] received late from pharmacy and medication retimed and not started this shift until 9:30 p.m. A telephone order written on 5/27/19 revealed continue same dosage of IV [MEDICATION NAME]. Check [MEDICATION NAME] trough 5/28/19, before 6:00 p.m. dose from contracted pharmacist. There were no other TO orders documented. TO written on 5/27/19 documented continue same dosage of IV [MEDICATION NAME]. Check [MEDICATION NAME] trough 5/28/19, before 6:00 p.m. dose from contracted pharmacist. There were no other TO orders documented. -The pharmacy delivery sheets on 5/27/19, at 8:45 p.m. revealed facility received [MEDICATION NAME] (HCL) one-gram vial. The facility lab results for 5/28/19, revealed [MEDICATION NAME] trough 20.8 ug/ml results were high. The target trough 5-15 UG (microgram)/ml recommended. A Trough concentration of up to 20 ug/ml documented severe infections where drug penetration may be compromised. According to the 5/29/19, at 4:40 a.m. progress note, the nurse documented [MEDICATION NAME] was held by the evening nurse, stat trough not received until after 3:00 a.m. New trough ordered for 5/31/19, at 8:30 p.m. -The resident did not receive dosage on 5/24/19, 5/27/19, and 5/28/19 [MEDICATION NAME] 1250mg/250ml in 0.9% sodium chloride. There was no documentation of the pharmacy or the doctor holding the antibiotic. -The pharmacy delivery sheets on 5/29/19, at 3:14 p.m. revealed facility received [MEDICATION NAME] (HCL) one-gram vial. 2.[MEDICATION NAME] The (MONTH) 2019 CPO documented the resident had an order for [REDACTED]. According to the 5/25/19, at 1:58 a.m. progress note, the nurse revealed that Resident #2 [MEDICATION NAME] capsule 300mg give 450mg. Medication was not available in the facility from the pharmacy. -The resident did not receive [MEDICATION NAME] capsule 300mg on 5/24/19. The facility lab results for 5/26/19, [MEDICATION NAME] serum for mood stabilizer documented that range should be in the 0.60-1.20 percentile. The highlighted results were documented low for the resident with a range of 0.50 percentile. -The pharmacy delivery sheets on 5/24/19, at 10:00 p.m. revealed facility received two [MEDICATION NAME] 150 mg capsule. 3.[MEDICATION NAME] The (MONTH) 2019 CPO documented the resident had an order for [REDACTED]. The order was written on 5/24/19, at 11:20 a.m. According to the 5/25/19, at 1:00 a.m. progress note, the nurse revealed that Resident#2 [MEDICATION NAME] diskus aerosol powder breath, activated 500-50 microgram (mcg) dose was not available in the facility from pharmacy. -The resident did not receive [MEDICATION NAME] diskus aerosol powder breath activated 500-50 mcg dose on 5/24/19 and 5/25/19. 4. Pharmacy delivery information A review of the documentation revealed the following: -The pharmacy delivery information schedule for Monday thru Friday states: If medication order received, by 2:30 a.m. it will be delivered by 5:00 a.m. If ordered by 9:30 a.m. it will be delivered by 12:00 p.m. if ordered by 4:30 p.m. it will be delivered by 7:00 p.m., and if ordered by 9:30 p.m. it will be delivered by 12:00 a.m. -The pharmacy delivery information schedule for Saturday states: If medication order received by 2:30 a.m. it will be delivered by 5:00 a.m., if ordered by 10:30 a.m. it will be delivered by 1:00 p.m. if ordered by 4:30 p.m. it will be delivered by 7:00 p.m. -The pharmacy delivery information schedule for Sunday states: If order received by 2:30 a.m. it will be delivered by 5:00 a.m., if ordered by 4:30 a.m. it will be delivered by 7:00 p.m. II. Staff interviews The licensed practical nurse trainer (LPNT) #2 was interviewed on 7/18/19, at 3:04 p.m. LPNT#2 said, nurses would not typically document orders given verbally. She said the policy for pharmacy orders was a four to six hour turnaround time. She said the facility was dependent on pharmacy run times. She said if medication was ordered before three 'o'clock p.m. then they would receive the medication within the four turnaround time. The director of nursing (DON) was interviewed on 7/18/19, at approximately 3:04 p.m. She said medications should be ordered in a timely manner. She said nursing staff should follow doctors' orders. She said if we did not start the orders the day the resident was admitted then we should get the doctor permission that we can wait until the next day. She said she could not acknowledge that they had doctors' permission to hold medications for Resident #2. She acknowledge there were missed doses in the MARS and Resident #2 should have been given mediations. She said, The physician should be called to do the medication reconciliation and if there was a change in the order. She said there was no document to support whether physician was contacted or not. She said if the physician says to give them medication then we give the medication on the date it was ordered. She said there was no documentation to support the medications were given and confirmed this. She said Resident #2 medication should have been given the day they were ordered. She said, A [MEDICATION NAME] trough was conducted 5/26/19 and 5/28/19, however, she said she only knew about the (MONTH) 31 trough. She acknowledged that the order was unclear on what to do. She said the first trough was high. She said the results were initially high and got higher. She said she did not think it was documented and she believed that she talked to the doctor and it was not documented but can not say for sure. She acknowledged that Resident #2 missed three doses but was only aware of one, and did acknowledge there were three undocumented spots in the MARS. She said all of the administration issues were noted and nurses should have gotten permission. She said we should be proactive in managing and issue with pharmacy. She said the medications were missed because of the [MEDICATION NAME] troughs. She said it is unclear why it was missed. She said her nurses probably at the time did not give medications because of the trough but were unclear on why they did not. She said she could not prove if they contacted doctor. Contract pharmacy account manager (CPAM) was interviewed on 7/23/19, at 1:30 p.m. She said the facility emergency kit would hold medications that pharmacy pre-stocked to be used in case of an emergency. She said, Pharmacy can do emergency delivery of medication based upon the list of medication in the emergency kit. Contract pharmacist supervisor (CPS) was interviewed on 7/18/19, at 4:05 p.m. He said the delivery time to this facility was Monday thru Friday 5:00 a.m., 7:00 p.m. and 12:00 a.m. He said medications leave pharmacy site at these times, and confirmed the times. He said stat (immediately) time was if they had emergency kits but we will always check if facility had medications. He said if they truly do not have it in house then we will get that to them through, customer service. He said, Were not too far from that facility since we are in (name of city), without traffic the drive time would be about 30 minutes. He said turnaround time, if facility ordered something at 4:30 p.m. Monday thru Friday would depend on courier as they may have several facilities. He said pharmacy was not allowed to change time of medications it would have to come from physician to change time. He said pharmacy communicate with physician related to any medication changes. If there are any changes that we required we need document faxed copy sent to us. If the nurse has a TO and there are changes, nursing would have to put in electronic order to make changes. He said we do not have the final say on medication changes but physician has final decision. He said He saw no delays of medications at the facility in the last four months: nothing out of the ordinary except regular questions about a medication that they would want to talk to a provider - nothing specific at facility. He said a conversation on clarification for any of Resident #2 drug interactions was not delivered to pharmacy. He said, If serious enough then filling system will include if facility has concern about drug allergy then contract pharmacy would recommend discussing with provider and reconcile ways to minimize reactions. He said if facility were to reach out to us then we would defer to provider. He said pharmacist consultant could tell facility to not use it. He said facility used electronic prescribing system and facility received [MEDICATION NAME] at 2:08 p.m. delivered at 10:00 p.m. He said on [MEDICATION NAME] do not have on electronic system. He said it was delivered 4:11 a.m. on 5/25/19. He stated, I would be curious to look at time. He said [MEDICATION NAME], and [MEDICATION NAME] doses were missed. He said, A delayed antibiotic had the potential to lead to further infection and worsening symptoms. He said, delayed [MEDICATION NAME] could cause worsening symptoms especially used for [MEDICAL CONDITION] or [MEDICAL CONDITION].

Based on observations, interviews and record review the facility failed to ensure for two (#3 and #11) of two dependent residents out of 22 sample residents who were unable to carry out activities of daily living services to maintain grooming, and personal hygiene. Specifically, the facility failed to ensure showers were provided consistently according to Residents #3 and #11 care plan and preferences. Findings include: I. Policy and procedure The Tub baths and Showers policy, revised 6/19, was provided by the director of nursing (DON) on 7/18/19 at 5:37 p.m. It read in pertinent part, Tub baths or showers will be scheduled at least two times per week based on resident preferences. Staff will encourage residents to complete a minimum of one tub bath, shower, or bed bath per week. The Activities of Daily Living (ADLs), revised 12/18, was provided by the(DON) on 7/18/19 at 5:37 p.m. It read in pertinent part, The resident will receive assistance as needed to complete activities of daily living (ADLs). Any change in the ability to perform ADLs will be documented and reported to the licensed nurse. II. Resident #3 A. Resident status Resident #3, less than 70 admitted [DATE] and readmitted [DATE]. The (MONTH) 2019, computerized physician orders [REDACTED]. The 5/8/19 minimum data set (MDS) documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. He was completely dependent on staff for bathing. The resident was always incontinent of both bladder and bowel. The resident's preference revealed important for receive showers on Tuesday and Friday. B. Observations and resident interview On 7/17/19 at 12:25 p.m., Resident #3 was observed in electric wheelchair going down the hall. His face was oily and dirty in appearance. He had multiple dry brown stains on his shirt and his pants. The resident said he was very uncomfortable as he had not received showers for ten or eleven days in a row when he had requested them. He said staff also said they were too busy to give him a shower. He said he refused a couple of times because of how late staff came to give him a shower. See record review below C. Record review The 2/25/19 care plan documented the resident has an ADL self-care performance deficit related to immobility due to traumatic [MEDICAL CONDITION]. Some interventions were bathing- check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. The resident is totally dependent on one staff to provide shower twice a week and as necessary. -Resident #3 was not getting his showers, as documented in his plan of care, as mentioned in his interview above. Point of care (P[NAME]) documentation for clinical information that CNAs use for ADL care.The following information was documented: -Resident #3 received a shower on 6/5/19 at 9:59 p.m. -Resident #3 next shower was on 6/11/19 at 9:59 p.m. seven days later. -Resident #3 received a shower on 6/14/19 at 8:59 p.m. -Resident #3 next shower was on 6/22/19 at 8:52 p.m. eight days later. -Resident #3 received a shower on 7/1/19 at 9:33 p.m. -Resident #3 next shower was on 7/7/19 at 9:21 p.m. six days later. -Resident #3 received a shower on 7/7/19 at 9:20 p.m. -Resident #3 next shower was on 7/16/19 at 9:35 p.m. nine days later. D. Ongoing shower concerns (Name of facility) grievance and concern documentation for Resident #3 revealed the following information: On the 5/22/19, grievance and concern documentation it revealed Resident #11 reported that he had not received a shower in eight days. The resident said he went previously ten days without a shower. The director of nursing (DON) documented that no showers were charted for eight days. Documented as follow-up, shower schedule to reflect evenings and to (name of staff) to perform daily accountability. On the 7/11/19, grievance and concern documentation. The documentation revealed Resident #11 reported that he had not received a shower in over a week again. The director of nursing (DON) follow-up documented, hiring new staff, scheduling to cover holes, remains unhappy. III. Resident #11 A. Resident status Resident #11, less than 60 admitted [DATE] and readmitted [DATE]. The (MONTH) 2019, computerized physician orders [REDACTED]. The 4/24/19 minimum data set (MDS) documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required total assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. He was completely dependent on staff for bathing. The resident was always incontinent of both bladder and bowel. The resident's preference important to receive showers on Wednesday and Saturday. B. Observations and resident interview On 7/17/19 at 12:35 p.m., Resident #11 was observed in wheelchair going to the dining hall. He had stains on the front of his shirt and pants. The resident said he was very uncomfortable and was not receiving showers for ten or eleven days in a row when he requested them. He said he brought the issues of not receiving showers up in resident council as well. C. Record review The 4/24/19 care plan documented, the resident was a risk for ADL self-care performance deficit related to disease process. Some interventions were the resident was dependent on one staff to provide showers twice a week and as necessary. The resident is totally dependent on one staff for personal hygiene. Point of care (P[NAME])activities of daily living (ADL) bathing for Resident #11. The following information was documented: -Resident #11 received a shower on 5/31/19 at 7:49 p.m. -Resident #11 next shower was on 6/7/19 at 9:12 p.m. seven days later. -Resident #11 received a shower on 6/11/19 at 7:28 p.m. -Resident #11 next shower was on 6/21/19 at 7:24 p.m. ten days later. -Resident #11 received a shower on 6/21/19 at 7:24 p.m. -Resident #11 next shower was on 6/28/19 at 9:17 p.m. seven days later. D. Ongoing shower concerns (Facility name) grievance and concern documentation for Resident #11 the following information: On the 5/16/19, grievance and concern document. Resident #3 reported that he wanted showers that were more frequent. The DON follow-up documented showers were often late due to staffing. Onboarding new CNAs (certified nurse aides), agency CNAs to maintain staffing. Reviewing shower schedule. On the 5/7/19, grievance and concern document. A frequent visitor reported concerns with showers were not completed. The DON follow-up documented several showers were not completed timely. The DON documented that she identified a system disconnect in charting, and shower days were unclear to staff. IV. Staff interview CNA#2 was interviewed on 7/23/19 at 10:20 a.m. She said if residents were scheduled to receive a shower. She would identify it by looking at the shower sheet provided to cnas to know who to ask for showers. She said if residents refused, she would attempt to ask three times then go communicate with nursing staff about it. She said there was no place on her sheet to document the three refusals or attempts made to ge the resident to take a shower. She said she would not put that information in P[NAME] system until the end of her shift. She confirmed that she did not document all three refusals. She said she did not know if staff approached residents again to take showers later. She said she did not know if Residents #3 and #11 received showers regularly. CNA #3 was interviewed on 7/23/19 at 10:26 a.m. She said for residents needing showers she would identify them from her daily shower sheet. She said if a resident refused a shower, she would attempt several times and communicate with nursing staff letting them know. She said there was a shower book that would be used to see if residents missed showers. She confirmed she never looked in it to see if Residents #3 and #11 had not received showers. She also said she never looked to see if nursing documented residents missing showers. She said she did not know if Residents #3 and #11 received showers regularly. Licensed Practical Nurse/Unit Nurse (LPNUN) was interviewed on 7/23/19 at 10:24 a.m. She said nursing staff would go to residents who refused showers and have a different person attempt to give a shower. She said she did not know if staff gave showers to residents after their first refusal at late nights. She said she did not know if Residents #3 and #11 received showers regularly. She confirmed her nursing staff did not put progress notes in system for shower refusals. She said the therapy department will sometimes help out with showers, however, she said the therapy department sometimes do not tell them if they give residents showers. Director of Rehabilitation Services (DRS) was interviewed on 7/23/19 at 5:05 p.m. She said occupational therapy (OT) and physical therapy (PT) only shower residents occasionally on their therapy schedule. She said after looking at her records that Resident #3 and Resident #11 were not on her therapy shower schedule and did not receive showers from her department. She said if they were on the schedule the showers given to residents would be documented on therapy documentation. The frequent visitor was interviewed on 7/18/19 at 3:50 p.m. She said she talked to several residents and the facility about residents not receiving their showers in the previous weeks. She said the DON said she would handle the issue and put plans in place to correct the system breakdown. The director of nursing (DON) was interviewed on 7/23/19 at 5:40 p.m. She revealed there was a system issue with showers being given to residents. She said she was still working on correcting the system to get staff to ensure residents were given shower. She acknowledged she expected shower reports to be documented and that there was no shower book to be used to document missed showers. She said her expectations would be for residents to receive showers when they wanted them and according to their preferences.

Based on interview, and record review the facility failed to identify, report, investigate, and protect a vulnerable resident after an allegation of misappropriation of property was made for one (#7) of three vulnerable residents reviewed for misappropriation of property, out of 22 sample residents. Specifically, the facility failed to: -Identify, and report Resident #7's allegation her diamond ring and $10.00 Timex watch were stolen; which she made to certified nurse aide (CNA) #4; -Investigate Resident #7's allegation; and, -Protect Resident #7's property and facility residents ' property from misappropriation and implement measures to help prevent potential misappropriation of her and facility residents ' property. Findings include: I. Facility policy The Protection of the Residents: Reducing the Threat of Abuse & Neglect policy, undated, provided by the executive director (ED) on 7/23/19 at 8:00 a.m., it identified: -Each resident had the right to be free from misappropriation of resident property from staff. -It was the policy and practice of the facility that all residents would be protected from all types of misappropriation of property. -The facility was to identify and correct situations when misappropriation of resident property was most likely to occur; to include assuring the staff assigned had the knowledge of the individual resident's need. -The facility was to report the allegation of misappropriation of resident property, investigate the allegation, and prevent further potential for the allegation to occur during the investigation process. II. Reference The National Consumer Voice for Quality Long-Term Care, Fact Sheet: Abuse, Neglect, Exploitation, and Misappropriation of Property, (YEAR), https://theconsumervoice.org/uploads/files/long-term-care-recipient/abuse-fact-sheet-18.pdf, (7/29/19): -Federal law gave each nursing home resident the right to be free from misappropriation of property. -To help prevent further suffering by any resident, it was important for a facility to believe a resident when they said they experienced misappropriation of property, and to: investigate and address it. III. Resident #7 A. Resident status Resident #7, was under age 90, was admitted on [DATE] and readmitted on [DATE]. The (MONTH) 2019 computerized physician orders [REDACTED]. According to the quarterly 5/8/19 minimum data set (MDS) assessment she had severe cognitive deficits with a brief interview for mental status (BIMS) score of six out of 15. B. Resident interview Resident #7 agreed to be interviewed while she was in the dining room. She planned to go to sleep after she ate. She had no watch or rings on. During the entire interview she easily understood all the questions asked of her, her answers were appropriate for all questions asked, her answers were direct and to the point, and all her answers were provided without hesitation. Her words were clearly formed, and her sentences were properly structured. She spoke in complete, well-formed sentences, and she was easily understood during the entire interview. Resident #7 was interviewed on 7/18/19 at 12:56 p.m. She said she lost a diamond ring and a watch. She said she told the certified nurse aides (CNAs), a few weeks ago, and they said they reported the items lost for her. As of today, she had not received facility any follow-up. She said, one of the CNAs she told about her stolen ring and watch was working today; this CNA agreed with her and told her she too thought her ring and watch were stolen. She said, it was a $10:00 Timex watch and a ring with three diamonds on it that was stolen; she kept them in her room on top of her chest of drawers. She said, it bothered her to not have them, she really wanted to have them back, and wanted to know what happened to them (it was at this time the expression on her face changed from concern to sadness as evidenced when her eyes watered a little bit and she grabbed the arm of the surveyor as she expressed her feelings about wanting her ring and watch back). C. Record review Review of the (MONTH) 2019 and (MONTH) 2019 progress notes, reflected there was no documentation of Resident #7's allegation of misappropriation of property to the CNA. Review of the documented facility grievances involving Resident #7 for the last six months, provided by the ED on 7/18/19 at 2:30 p.m., revealed there were no documented grievances involving misappropriation of property. Review of Resident #7's face sheet, provided by the ED on 7/23/19 at 8:00 a.m., reflected she had two responsible parties (RPs), RP #1 and RP #2. D. Responsible party interview The responsible party (RP) #2 was interviewed on 7/29/19 at 2:47 p.m. He said he lived out of state and the facility called him when there were concerns which involved Resident #7. The facility did not call him about a stolen ring or watch involving Resident #7. He did not visit her in (MONTH) 2019 or (MONTH) 2019. He said, Resident #7 talked on the phone when she asked the facility to call him. She could hold a conversation with him and could express her concerns to him. She understood what he said and he understood what she said, when they spoke. He said, she did not tell him about a missing ring or watch. He said, he and RP #1 gave her jewelry. He also said, Resident #7 had personal property missing in the past (he did not specify what type of property) and he did not know if it was stolen or missing. RP #1 was interviewed on 7/29/19 at 3:15 p.m. He said he lived out of state, and the facility called him or RP #2 when there were concerns which involved Resident #7. The facility and the sheriff called him a couple of weeks ago to tell him about Resident #7's missing ring and watch; he did not know about them being missing prior to their phone call. A police report was filed regarding the missing items. That was the first time the facility called to notify him about the ring and watch being missing. Although Resident #7 had not told him about the missing a ring or watch she probably told the facility about the stolen items because she could speak her concerns to others. He visited Resident #7 the weekend after the facility called him (a few weeks ago); and before that he had not visited her since (MONTH) 2019. He spoke to her on the phone infrequently; less than RP #2. He said, she did not tell him about a missing ring or watch when they talked on the phone. During his recent visit with her she told him about a ring and watch that was missing, and because she was upset about it he tried not to talk too much about it with her beyond her saying they were missing. He said, she told him she could not find her ring and watch, she was concerned about them being missing. He bought her watches every time he visited her; he bought her a $10:00 watch from the store outside of the facility before this visit. He was not familiar with the diamond ring she told him about. She had a lot of costume jewelry and she had some valuables at the facility; the facility also took her to shop at the store outside of the facility. She was not wearing a watch when he recently visited her. She did not like to wear watches, she would not wear the ones he bought her; she just liked to look at them and her rings. E. Staff interviews CNA #4 was interviewed on 7/18/19 at 5:14 p.m. She said Resident #7 told her, two weeks ago, she had been missing a ring and a watch and thought a former CNA #5 had stolen it. She (CNA #4) told her she (CNA #4) did not think former CNA #5 would have stolen it. CNA #4 said she did not help Resident #7 look for her ring and watch, and did not tell anyone about what the resident had reported to her because she forgot to tell anyone. In addition, she said Resident #7 had a lot of jewelry in her room, it was hard for her (CNA #4) or anyone to know what jewelry she could be missing; another reason why she did not help her look for the ring and the watch. She said, iIf a resident said they felt their property was stolen or missing the facility process was to tell the nurse who would fill out a form for the missing items. She said she did not know anything about the form because only the nurses filled out the forms for missing items; the forms were located by the nurses ' station and available to all staff. She said, from this point on, if Resident #7 told her she had missing or stolen jewelry she (CNA #4) would tell the nurse. The licensed practical nurse (LPN) #2 was interviewed on 7/18/19 at 5:37 p.m. She said the process for when a resident reported their personal items missing or stolen was to fill out a concern form and give it to the executive director (ED). Concern forms were located at the nurses ' stations and by the director of nursing office; accessible to all staff. Any staff, resident, or family member could fill out concern forms. The social services assistant (SSA) was interviewed on 7/18/19 at 5:31 p.m. She said she was involved in grievances that involved missing jewelry. She said, staff were to immediately fill out the ' Help Us to Serve You Better ' form for allegations of missing resident property. She said, if the allegation involved missing jewelry (other valuables) or stolen items, staff were to give the form to her, immediately notify the ED, then immediately help the resident search for it. Any staff member could fill out the form; the forms were accessible to all staff. The facility would replace or reimburse whatever resident property was lost or stolen. The facility used inventory sheets to document what personal items each resident had from admission, were kept in the residents ' charts, and were to be updated when other items were added to their personal property; any staff member could inventory her items for her for security reasons. The facility resolved grievances in no more than 48 hours. She said, CNA #4 had not turned in a form to her regarding Resident #7's missing ring or watch; she should have notified her about the missing ring and watch. Resident #7 had a lot of costume jewelry in her room which she purchased at the facility's country store; she loved to shop there. F. Executive director interview The ED was interviewed on 7/18/19 at 5:32 p.m. He said staff were to notify him about missing or stolen items, fill out the ' Help Us to Serve You Better ' form, and help the resident search for the missing or stolen items. If they were not found the facility was to check the resident's inventory sheet to see if they were listed on it; the facility would reimburse or replace the missing or stolen items. The ' Help Us to Serve You Better ' forms were located outside of the director of nursing office and department heads could get the forms; they were accessible to all staff. He said, he was not told about Resident #7's allegation her ring and watch were stolen. He said, the facility response to her allegation was to follow a grievance process: immediately talk to Resident #7 and begin searching for her ring and watch. He would call the RP to see if he knew about the ring and the watch. Typically the facility encouraged families to take valuables home. The facility was to resolve grievances within 72 hours or sooner. CNA #4 should have followed the grievance process. The ED did not say he planned to do an investigation of misappropriation of propertyResident #7 reported to CNA #4 two weeks prior to today. The ED was interviewed a second time, on 7/18/19 at 6:05 p.m. When asked again what the facility process was for Resident #7's reported allegation to CNA #4 that a former male CNA stole her ring and watch he said the facility would submit an electronic report of her allegation into the electronic portal system of reporting within the two-hour window it had. The facility response included to try to validate the allegation today by immediately: interviewing her, helping her to search for the ring and watch, contacting the responsible party (RP) in an effort to locate her ring and watch. The facility would still investigate her allegation of misappropriation of property even if she had a care plan which identified she had a history of [REDACTED]. He identified Resident #7's allegation of misappropriation of property was first reported to him when the survey team reported it to him at 5:30 p.m. today. He suspended CNA #4 today due to her failure to report Resident #7's allegation of misappropriation to him which prevented him from investigating it. IV. Follow-up A. Review According to the Consumer Voice, Abuse, Neglect, Exploitation, and Misappropriation of Property in Nursing Homes: What You Need to Know, (YEAR), https://theconsumervoice.org/uploads/files/issues/ANE_Prezi_Script-_FINAL_-_2018.pdf, (8/1/19) defined misappropriation of property as: The deliberate misplacement, or wrongful, temporary, or permanent use a resident's belongings without the resident's consent. Resident #7 did not consent to anyone having or using her ring or watch, as evidenced by her interview in which she stated very clearly: It bothered her to not have them, she really wanted to have them back, and wanted to know what happened to them; and then she became tearful when she made those statements. The allegation she reported to CNA #4 that CNA #5 stole her property (ring and watch) indicated she did not give consent to anyone to have or use her ring or watch; which by definition constituted misappropriation. RP #1 said in his interview it bothered Resident #7 to talk about her missing ring and watch during his recent visit with her. As a result of Resident #7's allegation to CNA #4, two weeks prior to 7/18/19, it warranted the facility's need to identify, report, investigate her allegation as misappropriation of property, and to implement measures to protect not only her property, but the property of all of its residents; as a result of her allegation. The facility did not file a grievance for Resident #7. She stated in an interview the staff told her they reported her missing ring and watch allegation and she did not receive follow-up from the facility about it. The facility did not provide the survey team with a documented grievance of misappropriation of property involving Resident #7's allegation her ring and watch were stolen when a request was made for six months of grievances which involved Resident #7. The facility was aware Resident #7 kept a lot of costume jewelry in her room as evidenced by the SSA and CNA #4 interviews; they both stated she had a lot of costume jewelry. The facility was aware she purchased some of the costume jewelry in the facility's country store as evidenced by the SSA interview; she stated Resident #7 bought jewelry from the facility's country store. The facility response was on 7/22/19 it concluded, through its investigation of Resident #7's allegation of misappropriation which the facility had not started until 7/18/19, that Resident #7's property was not lost or stolen because it was in her room. The facility did not implement its facility property which addressed how it would: identify, protect, report, investigate all allegations of misappropriation of property, and put measures in place to prevent it from happening, after Resident #7 reported it to CNA #4 two weeks prior to 7/18/19. The facility did not take action on Resident #7's allegation until after a state surveyor notified the ED of her allegation of misappropriation of property on 7/18/19; which was two weeks after Resident #7 had already reported it to CNA #4 and was waiting for facility follow up. Despite the facility's awareness that Resident #7 had a lot of jewelry and purchased it in the facility's country store, the facility failed to: implement its policy on misappropriation of resident property, follow the state and federal regulations which required it to protect her property from the risk of misappropriation, implement measures to prevent it from happening (the facility did not have documentation to show it put protective measures in place for Resident #7's jewelry and other residents ' property), report and investigate any allegation of misappropriation of property. The facility failed to identify misappropriation of Resident #7's property and immediately report it to the ED; CNA #4 said in her interview that she did not report Resident #7's allegation (from two weeks prior to 7/18/19; when she was interviewed by a state surveyor) to anyone, did not help her look for it, did not file a grievance for her, and told Resident #7 that CNA #5 did not steal her property. During the abbreviated survey investigation, there was no documentation: which identified CNA #4 reported Resident #7's allegation of misappropriation of property when Resident #7 reported it to her which was two weeks prior to 7/18/19. There was no documentation the ED conducted an investigation regarding Resident #7's allegation of misappropriation of property when Resident #7 reported it to CNA #4. B. Record review A request, submitted to the ED on 7/18/19 at 5:30 p.m., was made for Resident #7's inventory sheet of her belongings (per the interview of the SSA). The facility did not provide a documented inventory sheet of Resident #7's belongings during the survey nor after the exit from the survey. The 7/22/19 progress note, provided by the ED on 7/23/19 at 8:00 a.m., reflected the SSA spoke to Resident #7 about securing her belongings so they would not get misplaced, she offered: a lock box, to have her valuables locked in the nurses ' cart or business office; Resident #7 declined and was happy her watch was found. There were no further concerns documented. According to the 7/18/19 ' Help Us to Serve You Better Concern & Comment Form ' , provided by the ED on 7/23/19 at 8:00 a.m., it reflected (the following documentation was not dated nor timed): -It identified a concern, for Resident #7, which involved a diamond ring with three diamonds on it and a $10.00 Timex watch, which was to be investigated and followed up by SSA. -SSA documented she called RP #1 who said the diamond ring and Timex watch did not sound familiar. -SSA documented she interviewed Resident #7 who said she was missing diamonds; someone stole her diamonds. -SSA documented she (SSA) picked up a ring on her dresser that had clear stones in it and that Resident #7 stated that was the one stolen. -SSA documented, that on 7/19/19, Resident #7 was wearing her lost watch and stated that she found it. -SSA documented the plan or outcome of the grievance was cautious and optimistic. The Abuse/Adverse Event Investigation Packet, provided by the ED on 7/23/19 at 8:00 a.m., reflected the facility did not begin an investigation of Resident #7's allegation her property (ring and watch) was stolen by CNA #5 until 7/18/19. The facility did not document the date and time on the investigation packet when Resident #7 initially reported her allegation to the facility, via CNA #4, two weeks prior to 7/18/19; which CNA #4 revealed when she was interviewed on 7/18/19 during the abbreviated survey investigation. The facility did not initiate an investigation when Resident #7 reported her allegation to CNA #4 due to CNA #4 did not immediately report her allegation to the ED; which CNA #4 revealed when she was interviewed on 7/18/19 during the abbreviated survey investigation and said she did not report her allegation to anyone but instead told her CNA #5 did not do it. The facility documented the date and time it was notified of Resident #7's allegation was on 7/18/19 at 5:30 p.m. (the date and time the ED was notified during the abbreviated survey investigation; which the ED revealed when he was interviewed on 7/18/19 and said he was not notified by the facility of her allegation). The facility planned to monitor the monitor the ' Help Us to Serve You Better Concern & Comment ' forms for missing items during its quality assessment performance improvement (QAPI) meetings; a plan which was presented for review after the ED was notified, on 7/18/19 of Resident #7's allegation by a state surveyor. Resident #7 was interviewed for the first time, by the facility, about her allegation on 7/18/19; which was the first time the RP, police, and the health department were notified of it. The Misappropriation of Property Occurrence Report, provided by the ED on 7/23/19 at 8:00 a.m., it reflected Resident #7's allegation her property (ring and watch) was stolen by CNA #5 was not reported until 7/18/19. The facility did not document the date and time, on the report, when Resident #7 initially reported her allegation to the facility, via CNA #4. CNA #4 said in her interview on 7/18/19, Resident #7 reported it to her two weeks prior to 7/18/19. The facility did not initiate a report when Resident #7 reported her allegation to CNA #4 due to CNA #4 did not immediately report her allegation to the ED. The facility presented documentation that it educated CNA #4, and other staff, on mandatory reporting of misappropriation of property, and offered Resident #7 a way to store her property more securely; documentation which was presented for review after the ED was notified, on 7/18/19 of Resident #7's allegation by a state surveyor. A 7/18/19 typed document on the topic of reporting, provided by the ED on 7/23/19 at 8:00 a.m., which was presented for review after the ED was notified on 7/18/19 of Resident #7's allegation by a state surveyor, revealed the facility: must follow its grievance policy, report lost or stolen items regardless of a resident's cognition to ensure the complaint was investigated thoroughly, was a mandatory reporter, and was to report to the State within two hours if there was a complaint of misappropriation of property.

Based on record review, and staff interviews, the facility failed to conduct and document a facility-wide assessment to determine and identify what resources are necessary to care for its residents appropriately during both day-to-day operations and emergencies. Specifically, the facility failed to develop a facility assessment to include specifics about the current resident population resident on the long term side of the facility. Cross reference F-726 failure to provide required behavior training to all facility staff timely. Findings include: I. Record review The facility assessment was last revised on 10/16/18. The executive director (ED) and director of nursing (DON) were listed on the facility assessment. The facility assessment failed to: -Identify the acuity levels of the resident population on all units; and -Identify wandering resident population and ensure staff were trained regarding this population. II. Staff interviews The ED and DON were interviewed on 3/26/19 at 5:13 p.m. The DON said they have staffed accordingly to the acuity level of the residents with two CNAs on each hallway. The ED acknowledged the assessment was not accurate because it did not include long-term care residents and only addressed the rehabilitation population of the facility. He said he was in charge of updating the facility assessment they planned to adjust the assessment on their next review in their next quality assurance performance improvement meeting which occurred monthly. III. Follow-up No further documentation was provided by the facility during the survey or after to indicate the facility assessment had been updated or completed for the current residents, and their specific population, residing in the facility.

Based on interviews and record review, the facility failed to provide adequate training and assess competencies for adequate provision of care and services to the behavioral health population, as determined by the facility assessment. Specifically, the facility failed to provide required behavior training to all facility staff timely. Findings include: Cross reference F-838 failure to develop a facility assessment to include specifics about the resident population, and F-758 failure to track target behaviors and non-pharmalogical interventions for a routine and as needed (PRN) [MEDICAL CONDITION]. I. Record review The in-service education revised 11/28/16 revealed the facility had training requirements to be implemented upon hire and annually which included training for dementia management; however, this training was not completed until it was brought to the facilities attention during survey (see below). Review of a facility incident dated 9/4/18 revealed there was a resident to resident altercation. The facility stated they would provide dementia management training to two staff members who were present during the altercation to ensure the safety of the residents. -The facility was unable to provide documentation of the training until during survey on 3/24/19. Furthermore the facility stated they would conduct a pop quiz on dementia management; however, they were unable to provide this documentation. The facility assessment revised on 10/16/18, was provided by the executive director (ED) on 3/21/19 at 7:30 p.m. It revealed, the facility number of beds was 120, and its average daily census was 81. -The assessment revealed under the description of acuity levels, it was documented as not applicable for residents with behavioral symptoms and cognitive performance. The resident census and conditions of resident's form was provided by the NHA on 3/20/19 at 2:00 p.m. The form revealed the facility had a census of 71 residents, 43 residents (60%) had dementia, 24 residents (33%) had documented psychiatric diagnosis (excluding dementia and depression), and 33 residents (46%) had documented signs and symptoms of depression. Review of the facilities computer based training revealed all staff did not complete their yearly dementia care training which was initiated in (MONTH) (YEAR). Twelve employees had not completed the training during the survey; and eight out of the 12 were direct care staff. Review of agency staff training revealed one of three certified nurse aides (CNAs) did not receive dementia care training prior to there employment at the facility. II. Staff interviews Licensed practical nurse (LPN) #4 was interviewed on 3/21/19 at 2:55 p.m. She said the facility relied on a computer based training system to ensure staff were completing their required training. She said the dementia care training was automatically initiated in their system and staff were required to complete it on their own. This program has to be monitored by an individual, it will not prompt you if staff members are not trained in a specific area or education. Currently the facility was at 87% and after six staff members completed the training that day they would be at 91% compliance. She had no response as to who was responsible for ensuring all staff completed their required training, but no one had been monitored previously to ensure this was done. The staff development coordinator (SDC) was interviewed on 3/25/19 at 12:28 p.m. She said she had been working as the SDC since (MONTH) of (YEAR). She said the facility started a performance improvement plan for ensuring staff completed their required training as she would be responsible in her new role. III. Facility follow-up The SDC provided documentation on 3/25/19 at 12:28 p.m. ensuring the facility staff and agency CNA received dementia care training. During Survey 100% of the staff had completed the training.

Based on observations, record review and interviews, the facility failed to effectively follow an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection. Specifically, failed to provide residents with an opportunity to wash or sanitize their hands before meals in one of two dining rooms. Findings include: I. Professional reference The Centers for Disease Control and Prevention (2019) Hand Hygiene in Healthcare Settings, retrieved from: https://www.cdc.gov/handhygiene/patients/index.html. It read in pertinent part; Clean Hands Count for Patients As a patient in a healthcare setting, you are at risk of getting an infection while you are being treated for [REDACTED]. Your hands can spread germs too, so protect yourself by cleaning your hands often. When should you clean your hands? Before preparing or eating food Before touching your eyes, nose, or mouth Before and after changing wound dressings or bandages After using the restroom After blowing your nose, coughing, or sneezing After touching hospital surfaces such as bed rails, bedside tables, doorknobs, remote controls, or the phone. II. Facility policy and procedure The Hand Hygiene for Residents policy, revised 8/10/18, was provided by the regional director of clinical services (RDCS) on 3/26/19 at 11:29 a.m. It read in pertinent part; -Handwashing/hand hygiene is generally considered the most important single procedure for preventing infections. -Staff will encourage and assist the resident as needed to ensure proper hand hygiene through handwashing or use of alcohol-based hand rub. Alcohol-based hand rubs, or hand sanitizers, may be used when hands are not visibly soiled. -Hand hygiene should be offered/performed prior to handling and/or consumption of food or drink and after coughing and sneezing. III. Resident and family interview Resident #31, alert and oriented, was interviewed on 3/25/19 at 11:10 a.m. She said resided on the second floor and ate her meals in the dining room on her floor. She said she ambulated with a walker to get to the dining room. She said she was not offered an opportunity to wash or sanitize her hands before eating her meal. She said the only place she could wash her hands was in her room. She said she would prefer to have a way for the staff to assist the residents with hand hygiene that wander around and touch her and other residents ' plates, utensils, and cups on the tables. Resident #16 ' s family member was interviewed on 3/25/19 at 2:09 p.m. He said his wife resided at the facility on the second floor and needed assistance with care due to her dementia. He said he often assisted his wife with her meals in her room and in the dining room. He said his wife was not offered hand hygiene by the staff before eating her meals. IV. Observation and record review The second floor dining room located on the unit was where 27 residents ate their meals. The meals offered on 3/20/19 were beef fajitas served in a flour tortilla and spaghetti served with garlic toast. The always available menu offered daily included deli sandwich, grilled cheese sandwich and hamburger plate. The lunch meal service the main dining room was observed on 3/20/19 from 11:49 a.m. to 12:47 p.m. Numerous residents entered the dining room without staff assistance. Several residents ambulated to the dining room , other residents propelled their wheelchairs with their hands and some were assisted in their wheelchair by staff into the dining room. Residents were not offered hand hygiene when entering the dining room or previously to their meal being served. -At 12:20 p.m. Resident #26 was sitting in a chair at the table. She was coughing multiple times and had fluid coming from her nose past her mouth. A certified nurse aide (CNA) offered the resident more milk and did not offer to wipe her nose and assist her with hand hygiene from coughing. The resident was eating a sandwich with the liquid from her nose hitting it. At 12:31 p.m. the minimum data set coordinator (MDSC) donned gloves, helped her wipe her nose and hands with a wet wipe. She doffed her gloves and used alcohol-based hand rub and cued her for the remaining of the meal. -At 12:38 p.m. multiple residents were observed eating with their hands garlic toast, beef fajita served in tortillas, sandwiches with chips and hamburgers. The meal offered on 3/21/19 was fried chicken with a biscuit and frosted cupcake for dessert. The lunch meal service the main dining room was observed on 3/21/19 from 12:15 p.m. to 1:15 p.m. Numerous residents entered the dining room without staff assistance. Several residents ambulated to the dining room, other residents propelled their wheelchairs with their hands and some were assisted in their wheelchair by staff into the dining room. Residents were not offered hand hygiene when entering the dining room or previously to their meal being served. -At 12:36 p.m. multiple residents were observed eating with their hands fried chicken, sandwiches with chips, hamburgers and frosted cupcakes. The meal offered on 3/25/19 was spaghetti served with garlic toast, chili dog on a bun and eclair for dessert. The lunch meal service the main dining room was observed on 3/21/19 from 11:51 p.m. to 12:46 p.m. Numerous residents entered the dining room without staff assistance. Several residents ambulated to the dining room, other residents propelled their wheelchairs with their hands and some were assisted in their wheelchair by staff into the dining room. Residents were not offered hand hygiene when entering the dining room or previously to their meal being served. -At 12:44 p.m. multiple residents were observed eating with their hands chili dogs served in a bun, tater tots, sandwiches with chips, garlic toast and eclairs. V. Staff interviews The registered dietitian (RD) was interviewed on 3/25/19 at 6:04 p.m. She said that 27 residents at their meals in the dining room on the second floor. She said the residents should be offered hand hygiene before consuming their meals. She said many of the residents on second floor eat sandwiches or finger type foods and some wandered around the unit so their hand should be cleaned. The staff development coordinator (SDC), the infection control preventionist, was interviewed on 3/25/19 at 7:16 p.m. She said hand hygiene stations with sanitizing hand wipes were located outside of each dining room. She said the residents took the container of sanitizer wipes and bring them to their rooms or throwing the container in the trash. She said the facility had ordered two wellness stands that would hold the sanitizer wipes in place so the residents could only pull one wipe at a time from the container. She said in the meantime the staff had portable alcohol-based hand rub that they were to offer and assist the residents with it in order to provide clean hands before eating their meals. She said she was not aware that the staff on the second floor were not offering the alcohol-based hand rub based on the observations (see above) and she would in-service staff on providing the second floor residents a form of hand hygiene. VI. Facility follow-up response On 3/25/19 at 7:52 p.m. the SDC placed a cart with a container of sanitizer hand wipes outside of the dining room since she said the wellness stands were on back order and not be shipped until 4/4/19.

Based on observations, record review and interviews, the facility failed to ensure professional standards of practice were followed during medication administration and regarding change in conditions. Specifically the facility ' s nurses failed to: -Use proper technique while administering subcutaneous injection (SQ) for one (#72) of one out of eight sample residents during medication administration observation and; -Monitor, assess and document Resident #40 status after change in condition for one of one out of 29 sample residents. A. Improper needle safety Findings include: 1. Professional references According to Lippincott Manual of Nursing Practice, by Lippincott,[NAME] & Wilkins, 10th Edition (copyright 2014), page 116: Standards of Practice: Drawing up medication for injection: -without inverting the vial, insert the needle into the vial; -remove the needle from the vial; -cover the needle with the needle sheath. 2. Resident #72 status Resident #72, age 76, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 2/19/19 minimum data set (MDS) assessment revealed, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. She was identified as having [DIAGNOSES REDACTED]. 3. Observation On 3/21/19 at 7:45 a.m. licensed practical nurse (LPN) #2 was observed during medication pass. She prepared and administered 25 units of [MEDICATION NAME]SQ for Resident #72. LPN drew up the medication into a syringe, however, she did not cover the needle with the needle sheath (protective covering to protect from accidental needle sticks). Moreover, she walked across the hallway to the resident ' s room with the syringe in her hand with the exposed needle and administered the medication to the resident. 4. Record review The (MONTH) 2019 CPO included [MEDICATION NAME] solution inject 25 units SQ two times a day related to type 2 diabetes mellitus with [MEDICAL CONDITION]. 5. Staff interviews LPN #2 was interviewed on 3/21/19 at 7:55 a.m. She said she did not cover the needle with sheath, because she was under the impression that recapping needles were prohibited. She did not know the syringes were equipped with the safety lock, and the safety locks needed to be used after the needle was removed from the vial of medication. The director of nursing (DON) was interviewed on 3/21/19 at 8:33 a.m. She said LPN #2 did not follow proper procedure when administering insulin. She said they would provide education to the nurse right away. 6. Facility follow-up On 3/21/19 at 11:30 a.m. the DON provided a copy of the education acknowledgement form that was completed by the nurse regarding injectable medication administration. LPN#2 completed the form which showed her understanding and competency. B. Change in resident ' s condition 1. Facility policy and expectation TheChange in Resident ' s Condition and Alert Charting revised 3/07, was provided by DON on 3/26/19 at 9:37 a.m. It read: alert charting will be completed on residents who require more frequent monitoring, assessment, and follow-up on the regular basis related to certain clinical indicators .the charge nurse on shift will initiate alert charting when any condition develops that could require more frequent monitoring. Documentation will address general conditions to establish baseline data for use in the comprehensive assessment .vital signs will be monitored/documented every shift for 3 days .those are minimum requirements . 2. Resident #40 status Resident #40, age 95, was admitted on [DATE]. According to the (MONTH) 2019 CPOs, [DIAGNOSES REDACTED]. The 1/23/19 MDS assessment revealed, the resident had severe cognitive impairment with short and long-term memory problems. She required extensive assistance for bed mobility, transfers, grooming and toilet use and was incontinent of bowel and bladder. 3. Record review Electronic progress note written on 3/22/19 at 10:03 p.m., revealed Resident #40 at 7:00 p.m. demonstrated incident of hematuria (blood) when urinating. Specimen with very bloody urine was obtained and sent to the laboratory for testing STAT (urgent). The resident also had small amount of emesis without pain or discomfort. The registered nurse assessed the resident and obtained vital signs, which were at normal limit and notified the physician and the POA. There were no follow-up documentation in the medical record regarding Resident #40 ' s condition according to the facility expectations and professional standards of practice. 4. Staff interviews The DON was informed of the above findings on 3/26/19 at 9:05 a.m. She verified there were no follow-up notes documenting the residents condition and the nurses were responsible to monitor resident ' s status after a change in condition for the next 72 hours. The LPN #1, who worked over the weekend, and on Monday 3/25/18 was interviewed on 3/26/19 at 9:30 a.m. She said she was aware of the event on 3/22/10 with Resident #40, however, she did not follow-up on her condition. She said she should have observed Resident #40 ' s status/condition, obtained vital signs and documented it in the medical record. 5. Facility follow-up On 3/26/19 at 11:40 a.m., the DON provided a copy of the in-service that was provided to eight nurses regarding alert charting. She said all nursing staff will be reeducated as soon as possible. The DON provided a copy of the lab results which were communicated timely with the physician, her visit and comprehensive assessment from 3/25/19. The LPN #1 did a late entry progress note on 3/26/19 at 9:59 a.m., after the issue was communicated to the DON at 9:05 a.m.

Based on interview and record review, the facility failed to clarify a physician order [REDACTED]. Resident #7, who had a history of [REDACTED]. The resident's physician ordered [MEDICATION NAME] solution ([MEDICATION NAME] sulfate) 1 cc per hour. [MEDICATION NAME] sulfate solution comes in three different concentrations; as such, interviews revealed an order for [REDACTED].#7's order for [MEDICATION NAME] did not include this information and staff failed to clarify the order to determine the amount the physician intended the resident to receive. Resident #7, known to be sensitive to the narcotic [MEDICATION NAME], received two 20 mg doses of [MEDICATION NAME] in one hour. The resident became minimally unresponsive and was transferred to the hospital where she subsequently expired. The findings include: 1. Professional References a. Standards of Nursing Practice According to Perry and Potter, Clinical Nursing Skills and Techniques, 8th Edition 2014, Ch. 20, pp ,[DATE], nurses should adhere to the six rights of medication administration to prevent medication errors. Many medication errors are related to an inconsistency in ensuring the right medication, the right dose, the right patient, the right route, the right time, and the right documentation. b. [MEDICATION NAME] According to the Food and Drug Administration (FDA), [MEDICATION NAME] Prescribing Information, 2009, https://www.accessdata.fda.gov/drugsatfda_docs/label/,[DATE]s002lbl.pdf ([DATE]), [MEDICATION NAME] oral solution can be prescribed at three concentrations: -10 milligrams (mg) per 5 milliliter (mL) solution (2 mg/mL) -20 mg per 5 mL solution (4 mg/mL) -100 mg per 5 mL solution (20 mg/mL) 2. Facility expectations regarding medication administration a. Policy review The facility's Administration of Medications policy, provided by the nursing home administrator on [DATE], read in pertinent part: -Nursing professionals should be aware of the classification, action, correct dosage, and side effects of medication prior to administration. -A physician order [REDACTED]. b. Interview Physician (MD) #1 was interviewed on [DATE] at 3:04 p.m. He said in situations where multiple concentrations of a medication were available (see [MEDICATION NAME] sulfate above), staff need to clarify the concentration of the medication to ensure the appropriate dose is administered. Pharmacist #1 was interviewed on [DATE] at 3:42 p.m. She said the pharmacy offered three different concentrations of [MEDICATION NAME] sulfate oral solution: 2 mg/mL, 5 mg/mL, and 20 mg/mL. She said because of the different concentration of the solutions, the facility would need an order that included both the concentration and the volume to ensure the correct dosage of the medication. The director of nursing (DON) was interviewed on [DATE] at 4:30 p.m. She said prior to administering medications, nurses need to ensure the five rights of medication administration, including the correct dose. She said when there were multiple concentrations of an oral solution, the nurse needs to clarify the appropriate concentration to ensure the correct dose was ordered and administered. c. Observation A review of the facility's medication emergency kit (e-kit) indicated it contained two 30 mL vials of [MEDICATION NAME]/[MEDICATION NAME] sulfate oral solution at a concentration of 20 mg/mL. The e-kit also contained 2 1 mL vials of Naxolone (used to counteract overdoses of [MEDICATION NAME]). 3. Resident #7 a. Resident status Resident #7, age 75, was admitted to the facility initially on [DATE], and readmitted on [DATE] after a three day hospitalization for a [MEDICAL CONDITION]. According to the resident's computerized physician orders, [DIAGNOSES REDACTED]. According to the minimum data set assessment dated [DATE], the resident demonstrated moderate cognitive impairment with a brief interview for mental status of 12 out of 15. The resident did not display pain, but was noted to be on both scheduled and as needed pain medication. An admission nursing assessment dated [DATE], upon the resident's return from the hospital, documented resident #7 was alert and oriented and able to communicate her needs. Her blood pressure was ,[DATE], pulse was 98, and respirations were 18 breaths per minute. Her pulse oxygen was 92%. The resident's medical record established that she did not have an extensive history with narcotic pain medications. A review of the resident's pain assessments indicated the resident did not experience pain or receive pain medication prior to her hospitalization on [DATE]. A hospital discharge summary dated [DATE] indicated the resident had not been taking a narcotic pain medication prior to her hospital admission on [DATE]. However, while hospitalized , she was prescribed a narcotic, [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) ,[DATE] mg, for pain relief. A nutrition assessment dated [DATE] indicated the resident had been sensitive to the [MEDICATION NAME], exhibiting drowsiness. A nursing note written on [DATE] at 11:25 a.m. indicated that at 8:00 a.m. that morning the resident said she felt short of breath and congested. The resident's oxygen saturation was noted to be 76%, and the administration of her oxygen was increased from 3 to 4 liters per minute, then to 6 liters per minute. Her respirations became moist and rapid, and the note read MD #1 prescribed [MEDICATION NAME] ([MEDICATION NAME] sulfate) oral solution (for dyspnea - shortness of breath). The note was written by licensed practical nurse (LPN) #1. The note indicated multiple blood pressure values between ,[DATE] and ,[DATE], a heart rate of 130 beats a minute, and 30 respirations a minute, however, it was unclear whether these values were before or after the administration of [MEDICATION NAME]. b. Failure to clarify an order of [MEDICATION NAME] sulfate oral solution for resident #7 and evidence of the administration of high doses of the medication on [DATE]. According to the FDA (see above [MEDICATION NAME] Prescribing Information, 2009, https://www.accessdata.fda.gov/drugsatfda_docs/label/,[DATE]s002lbl.pdf ([DATE])), -Due to potential confusion between the different concentrations (of [MEDICATION NAME] sulfate) and between milligrams and milliliters, additional caution should be taken when administering [MEDICATION NAME] sulfate to avoid an accidental overdose and potentially death. -The recommended dosage for [MEDICATION NAME] sulfate is 10 to 20 mg every four hours. The 100 mg per 5 mL concentration (20mg/mL) should only be used for [MEDICATION NAME] tolerant patients, as it may cause fatal respiratory depression when administered to patients who are not tolerant to the depressant effects of opioids. -Additional caution should be taken in administering [MEDICATION NAME] to older adults and individuals with respiratory illnesses (including [MEDICAL CONDITION]) as even a moderate dose can decrease respiratory drive to the point of apnea (a temporary stop in breathing). Review of a telephone physician order [REDACTED]. The order did not state which concentration of [MEDICATION NAME] sulfate oral solution to administer. Record review revealed no follow up orders to clarify the concentration of the [MEDICATION NAME] sulfate oral solution. However, an e-kit notification message dated [DATE] indicated a 30 mL vial of [MEDICATION NAME] ([MEDICATION NAME] sulfate oral solution at a concentration of 20 mg/mL) was removed from the e-kit and the instructions written on the notification message read one cc every hour as needed, listing MD #1 as the prescribing physician. Although the concentration of the medication was not included in the instructions, review of the narcotics log indicated resident #7 received [MEDICATION NAME] from the e-kit and the dose written on the log indicated a 20 mg/mL dose, with one cc sublingually every hour as needed. The log indicated the resident was administered one cc administration (20 mg total dose) at 8:00 a.m. and a second dose (20 mg total dose) was administered at 9:00 a.m. Review of the e-kit and the resident's Medication Administration Record [REDACTED]. c. Documentation of resident #7's decline following the above administrations of [MEDICATION NAME] sulfate. Nursing notes revealed: -A note dated [DATE] at 1:12 p.m. read the resident was minimally responsive to stimuli. -Another note dated [DATE] at 2:34 p.m. read the resident was sent to the hospital. According to the facility's internal investigation dated [DATE], provided by the director of nursing (DON) on [DATE] at 4:28 p.m., the resident's blood pressure at the time of transfer was ,[DATE], her oxygen saturation did not register, and her pulse was thready. The resident's medical record did not contain an assessment by a registered nurse (RN) after the note written on [DATE] when the TPO was received and up to the time of the resident's transfer to the hospital. However, the facility's internal investigation provided by the facility for review contained retrospective interviews from licensed practical nurse (LPN) #1, registered nurses (RN) #2 and #3, and the social services director. -The investigation revealed the resident went into respiratory distress prior to 8:00 a.m. on [DATE]. A chest x-ray indicated results consistent with [MEDICAL CONDITION]. A nebulizer treatment had been administered without effect. At that time, the resident was awake and alert, and was able to decline to go to the hospital at that time. -The resident's charge nurse, LPN #1, obtained a physician's orders [REDACTED]. The LPN obtained the medication from the facility's e-kit and administered the [MEDICATION NAME]. -At approximately 8:30 a.m., the resident was no longer gasping for air, however, her breathing was shallow and labored, she was no longer verbally responsive, and her hands and legs were cold to the touch. -At approximately 2:15 p.m. the resident was transported to the hospital with the vital signs noted above. The investigation did not include documentation of the rationale for the administration of the second administration of [MEDICATION NAME], or documentation of follow up from a RN after the administration. 4. Interviews Physician (MD) #1, who was the resident's physician, was interviewed on [DATE] at 3:42 p.m. He said the facility usually used [MEDICATION NAME] for pain relief in terminally ill residents on hospice, however, this had not been the case for Resident #7. He confirmed the resident was not terminal and said the [MEDICATION NAME] had been prescribed to alleviate shortness of breath. Regarding the dosage, he said he was unsure how many milligrams he had intended to prescribe, but that the documentation should be present in the order. He said if it was not present, the nursing staff needed to clarify the order. Registered nurse (RN) #1 was interviewed on [DATE] at 5:43 p.m. She said she had worked with the resident for a long time, and was familiar with her. She said although the resident had [MEDICAL CONDITION], she did not often have breathing difficulties. She said on [DATE], she had arrived at the building and the resident was in respiratory distress. She said the facility had administered the [MEDICATION NAME] to attempt to relieve the shortness of breath. The DON was interviewed on [DATE] at 4:30 p.m. -She said the resident had received multiple medications on [DATE] in an attempt to relieve her shortness of breath, including 80 mg of [MEDICATION NAME], .5 mg of [MEDICATION NAME], and a nebulizer treatment in addition to the 40 mg of [MEDICATION NAME]. She confirmed the combination of medications, especially the [MEDICATION NAME], could have led to a side effect of respiratory depression. -She said after the resident's death, the facility had conducted the internal investigation (see above) which included interviews not present in the medical record. They had concluded that additional safeguards were needed to monitor side effects with narcotic medications but had not identified the need for further clarification on the order for the resident's [MEDICATION NAME], despite her statement that when there were multiple concentrations of an oral solution, the nurse needs to clarify the appropriate concentration to ensure the correct dose was ordered and administered, as well as MD #1's statement that an order which lacked information on the number of milligrams to administer should be clarified. The DON confirmed there was not documentation of an assessment by a registered nurse prior to the administration of the [MEDICATION NAME] in the resident's medical record, but said an RN assessment had been conducted as demonstrated by the investigation (see above). The DON confirmed the resident's condition required an RN assessment. The DON said neither RN #2 nor #3 was available for an interview and LPN #1 was not scheduled to work. 5. Facility follow-up Following the conclusion of the investigation into the resident's passing, the facility implemented a process improvement plan for pain management. The plan included an audit of residents receiving narcotic pain medications to ensure appropriate doses and parameters were in place, and included reductions in a number of pain medications. However, the plan did not identify the need for clarification of physician orders [REDACTED]. The director of nursing (DON) and nursing home administrator (NHA) were interviewed on [DATE]. Both confirmed the need for clarification in the dosage of [MEDICATION NAME] had not been identified or addressed by the performance improvement plan. The facility presented no information that staff had received education since the [DATE] incident about the precautions in administering [MEDICATION NAME] sulfate. See FDA reference above.

Based on observation, record review, and interview, the facility failed to ensure three of 36 sample residents (#74, #3, and #111) received the care and services necessary to promote urinary continence and to prevent urinary complications. Specifically: -The facility failed to ensure resident #74 and #3's catheters were removed as soon as the catheters were not clinically warranted. Resident #74 was hospitalized prior to her admission to the facility on [DATE], and was catheterized during her hospital stay. an order written [REDACTED]. D/C (discontinue) with Foley; work on bladder training at SNF (skilled nursing facility)." As of 6/12/13, the resident still had the catheter in place, without a valid medical justification for its continued use. The resident experienced pain, infections, and reduced freedom of mobility because of the catheter. -The facility failed to ensure resident #111's urinary incontinence was assessed and monitored. The findings include: A. Facility policy The facility's undated Indwelling Catheters policy included the following protocols: "-Intent: An indwelling catheter shall not be used unless there is valid justification. An indwelling catheter for which continued use is not justified medically shall be discontinued as soon as warranted clinically... -Procedures: Conduct a careful examination and review of the resident's history and physical for factors that may contribute to either urinary incontinence or [MEDICAL CONDITION] a comprehensive assessment that addresses those factors that predispose the resident to the development of urinary incontinence and/or the use of an indwelling urinary catheter. -A comprehensive assessment should include: a. the risks and benefits of an indwelling catheter; b. identification of reversible and irreversible conditions that cause incontinence; c. factors supporting medical justification for the initiation of, and continuing need for catheter use; d. the potential for removal of the catheter; and e. consideration of complications resulting from the use of an indwelling catheter such as symptom of blockage with associated bypassing of urine, expulsion of the catheter, pain, discomfort, and bleeding. The comprehensive assessment also should include a review of the RAI (resident assessment indicators), the history and physical, and other information, such as physician orders, progress notes, nurses' notes...and the resident's response to catheter/continence services... The nursing staff should: a. provide appropriate justification for the use of the catheter; b. identify previous attempts made (and the results of the attempt) to remove a catheter; and c. identify a history of UTIs (if present) and interventions to try to prevent recurrence... Care plans must address...potential psychosocial complications of catheterization such as social withdrawal, embarrassment, humiliation, isolation, or resignation; include a component to inform the resident and representative about the risks and benefits of catheter use...The care plan must...provide assessments of the indwelling catheter, and remove the catheter when it is no longer needed..." B. Resident Failures 1. Resident #74 Resident #74 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the most current MDS (minimum data set) assessment, dated 3/20/13, the resident was cognitively intact, with a BIMS (brief interview for mental status) score of 13 out of 15, and required extensive assistance for all activities of daily living. a. Record Review 1) Pre-Admission hospitalization Prior to admission to the facility, the resident had been admitted to the hospital on [DATE]. In a hospital report, dated 4/10/12, the physician wrote the following: "....Two days after admission, the patient developed marked abdominal distention and had CT scan of the abdomen that showed evidence of distal small bowel obstruction, thought to be secondary to adhesions. She was also noted to have [MEDICAL CONDITION] with a distended bladder and mild bilateral hydro[DIAGNOSES REDACTED]. She was treated with decompression of the bowel with [MEDICAL CONDITION] tube and she also had a Foley catheter inserted to keep the bladder drained...the patient says she feels quite a bit better than when she came in...She has been having bowel movements..." an order written [REDACTED]. D/C (discontinue) with Foley; work on bladder training at SNF (skilled nursing facility)." In response to this order, a nurse wrote, "Pt unable to void after Foley D/C'd. Pt requesting more time to try...PA (physician assistant) notified and orders received to replace Foley." 2) Admission History and Physical The resident's initial history and physical (H & P) report, completed by the facility physician and dated 4/13/12, included the following documentation: "...with [MEDICAL CONDITION] on admit with bilateral hydro[DIAGNOSES REDACTED] secondary to retention; Foley placed but when attempted to d/c again (yesterday) retained approximately 1000 cc urine so replaced; add [MEDICATION NAME] 0.4 mg at HS (bedtime) and attempt Foley d/c in 10 - 14 days; may need urology f/u (follow-up)..." However, there was no documented evidence in the resident's record that an attempt to discontinue the resident's catheter was made after 10 - 14 days after admission to the facility or at any time until 6/10/13 (during survey). 3) Assessments/Care Plan The resident's record contained just one Urinary Incontinence Assessment, and it was undated and unsigned. The Assessment included the following instructions: "To be completed within 7 days after admission for incontinent residents. Thereafter, complete quarterly as determined by the Assessment for Bowel and Bladder Training." The Assessment included a section pertaining to catheter use, and the following information was elicited: current use of a catheter; the specific type, size, date inserted, and the length of time required; medical [DIAGNOSES REDACTED]. The "yes" box was checked for use of catheter, but the rest of the section was not filled out. The resident's record did not contain a comprehensive assessment pertaining to a careful examination and review of the history and physical, progress notes, nurses' notes, or the resident's response to the use of a catheter. There was no indication in the record as to which discipline - therapy or nursing - was responsible for the review of the resident's urinary continence status. The resident's Urinary care plan, initiated on 5/10/12 and last updated on 3/27/13, included the following Problem, Goals, and Approaches: - Problem: "(Resident) has an indwelling urinary catheter - Diagnosis: [REDACTED]. - Goals: "(Resident) will be free of complications related to f/c (Foley catheter) over the next quarter." - Approaches: "Provide f/c and pericare every shift and prn (as needed); output every shift; monitor urine for cloudiness, color and/or unusual odor; monitor for sx (symptoms) of UTI (urinary tract infection) such as LBP (low back pain), dysuria, burning; ..monitor for pain/dysuria;...monitor for adverse reactions." The care plan did not address assessments of the catheter or the potential psychosocial complications of catheterization. The resident's record did not contain evidence the resident and representative were informed of the risks and benefits of catheter use. 4) Nurses Notes The resident's record included the following Nurses Notes, beginning September 2012, that related to catheter use and complications: - 9/5/12 - "Resident c/o (complains of) bladder pain, unable to get comfortable. Requesting present Foley catheter be removed. Resident says, "This tube hurt a lot tonight...Current Foley removed ...reinserted a number #16 Fr. Foley catheter..." - 9/13/12 - "UTI ABX (antibiotics))...urine cloudy, dark amber. Foley patent...aware of temp (100.4)..." - 9/13/12 - "Resident is on charting for a UTI with organism of E-coli...Urine is dark amber with mucous shreds "white-like" odor is strong but not foul. Resident's Foley catheter is patent..." - 9/17/12 - "Continues with ABX for UTI. Urine in Foley catheter clearing. Pain well controlled with routine and PRN [MEDICATION NAME].." - 3/4/13 - "Resident with foul mucous at catheter insertion site. Noted confusion today. Orders received for [MEDICATION NAME] BID x 7 days. First dose to be administered this evening." - 3/8/13 - "Resident is on ABX for UTI...Resident is c/o bladder pain/tube pain periodically sharp and intense...Wants to lie very very still to see if that helps..." - 3/9/13 -9:17 am - "Continues with ABX for UTI...c/o intermittent pain in bladder area but states frequency and intensity of pain resolving...." - 3/9/13 - "Remains with ABX for UTI...Foley catheter with leakage and purulent drainage at insertion site. Catheter changed...." - 3/10/13 - "Continues with ABX for UTI...States increased comfort since catheter changed yesterday." - 3/28/13 (Social Service note) - "Care conference was held on 3/27/13 with IDT (interdisciplinary team) and MDPOA (medical durable power of attorney). MDPOA's concern is with (resident's painful bladder spasms...Resident is resistant to going to a urologist...Staff will continue to monitor bladder spasms, level of pain, and encourage a urology consult." A telephone order, dated 2/7/13, read "...change cath prior to UA (urinalysis) - urology consult for suprapubic cath, bladder spasms." (physician progress notes [REDACTED].) - 5/16/13 - "Resident on ABX for UTI..." - 5/18/13 - "Resident continues with ABX for UTI...pain controlled with routine and PRN [MEDICATION NAME]." - 6/1/13 - "Late entry for 6/1/13, 4:45. It was brought to this nurse's attention that resident's urine is a dark red in Foley bag...No clots present...Resident's pain is controlled by scheduled pain medication..." 5) physician progress notes [REDACTED]. - 1/10/13 - "Pt c/o bladder spasm from Foley catheter last week. Nurse also reports leaking of catheter. New larger gauge Foley placed Monday 1/7/13...Bladder spasms resolved with larger gauge Foley..." - 3/11/13 -Chronic UTI: "Catheter changed again on 3/10/13, only [MEDICATION NAME] 10 days. Reviewed medications and patient is not on cranberry tabs. Start 2 tabs daily, in hope of changing acidity of bladder and decrease mucous and sediment in bladder and catheter." physician progress notes [REDACTED]. 6) The resident's chart included a Catheter Justification form, with reviews dated 4/12/12, 7/18/12, 11/6/12, 1/14/13, and 5/22/13. The form had a section to complete, answering the "primary reason continued use of indwelling catheter is unavoidable at the time of this review." The following was written on the form: 4/12/12 - "1000 cc retained" 7/18/12 - "failed reduction" 11/6/12 - "failed reduction" 1/14/13 - "retention" 5/22/13 - "[MEDICAL CONDITION]" b. Observations During an initial interview with resident #74 in her room on 6/5/13 at 12:30 p.m., the resident explained that she did not participate in group activities because she preferred to stay in her room. She did not elaborate as to the reason she consistently declined group activities. During intermittent observations of the resident on 6/5/13, 6/6/13, 6/10/13, 6/11/13, and 6/12/13 (various times in the morning, noon and early evening), the resident was observed to spend most of the day on her bed, awake. c. Interviews 1) Staff interviews On 6/10/13 at 3:15 pm, the director of nursing (DON) was interviewed. -The DON explained that when the physician wrote the recommendation to attempt a trial discontinuation of the resident's Foley in 10 to 14 days back in April 2012, a TO (telephone order) was never written. The DON acknowledged that the nursing staff should have reviewed the H & P and clarified the order with the physician. -The DON explained that attempts to remove the resident's catheter were not made on any of review dates listed on the Catheter Justification form (see above reviews on 4/12/12, 7/18/12, 11/6/12, 1/14/13 and 5/22/13). The DON said when the nurses wrote "failed reduction" on the form, it was in reference to the initial attempt tried at the hospital on [DATE], before the resident was admitted to the facility. d. Action taken during survey On 6/11/13 at 8:55 a.m., the physician wrote an order to "D/C Foley after lunch today." The physician was interviewed on 6/11/13 at 9:05 am. The physician related that she had spoken to the resident earlier that morning, and that she was "surprised (the resident) was very willing to take out the Foley." The physician ascertained this could be because the resident was more alert and would have more freedom of mobility. The physician verbalized that without a Foley, there is less discomfort and improved quality of life. The physician confirmed that the [DIAGNOSES REDACTED]. When asked why an attempt to remove the catheter was not made back in April 2012, the physician responded she did not know. 2) Resident interview On 6/12/13 at 10:30 am, resident #74 was awake, lying in bed. The resident was asked how she felt about having her Foley catheter removed. The resident quickly answered, "Wonderful!" When asked in what ways it would be wonderful, the resident stated, "It's a pain to have it attached." The resident went on to explain that a family member was planning to take her on an outing "in a couple of weeks," and it would be nice to not have the catheter at that time. 2) Resident #3 Record Review Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]., dysthymic disorder, [MEDICAL CONDITION], urinary incontinence, uterine prolapse, dementia without behavioral disturbance, [MEDICAL CONDITION] of native arteries of the extremities, [MEDICAL CONDITIONS] reflux, [MEDICATION NAME] degeneration and [MEDICAL CONDITION] - stage III. During Stage I, staff interview it was disclosed that the resident had an indwelling Foley Catheter. The reason given for use of the Foley Catheter was the presence of a non-healing pressure ulcer. The Minimum Data Set ((MDS) dated [DATE] identified Resident #3 as having adequate hearing, clear speech, was able to make herself understood, was able to understand others and had adequate vision with corrective lenses. The MDS indicated there was no presence of behavioral symptoms. Functionally, Resident #3 required extensive physical assistance of two persons for bed mobility, transfers and toileting. For eating and personal hygiene the resident required extensive physical assistance of one person. The resident was documented to be frequently incontinent of bladder and always incontinent of bowel. The resident was 64 inches in height (5' 4") and weighed 136 pounds. The MDS documented the presence of a stage II pressure ulcer that dated from 1/16/13. There was no stage 3 or 4 pressure ulcers or unstageable ulcers present. A Physician Telephone Order (TO) dated 5/14/13 ordered "Foley #16 F (French) 30 ml balloon insert today, P (after) Q (every/each) month change. Foley output 11-7, 7-3, 3-11. Total Foley care Q (every/each) shift. Change Foley bag Q 14 days. An undated TO ordered UA for suspective (sic) UTI. CBC (Complete Blood Count) and BMP (Basic Metabolic Panel) STAT. A TO dated 6/3/13 ordered 1) [MEDICATION NAME] 100 mg ER Z12H x 7/days for UTI; 2) Cranberry 450 mg bid for UTI [MEDICATION NAME]. A TO dated 6/7/13 showed the following order (in pertinent part), May reinsert catheter with 22 French cath with 30 ml balloon. A Physician's Progress Note (PPN) dated 6/3/13 documented treatment of [REDACTED]. A wound note dated 5/2/13 documented in pertinent part, Stage II to sacrum and measures 0.3 x 0.2 (cm). Wound note dated 5/8/13 documented in pertinent part, Stage II to sacrum and measures 0.3 x 0.2 (cm). Wound note dated 5/15/13 documented in pertinent part, stage II smaller. New orders to place Foley cath to promote wound healing. Wound slightly smaller this week and measures 0.2 x 0.2 100% of granulation tissue. An assessment for Bowel and Bladder Training dated 5/7/13 assigned a score of "0" for the criteria "condition of skin on genital/perineal. "0" indicated "no redness". The total score assigned was "16", an indication that the resident was a poor candidate for scheduling or retraining. Predisposing factors checked included impaired mobility, impaired fluid intake, [MEDICAL CONDITIONS] UTI. A pressure Ulcer Risk assessment dated [DATE] checked as predisposing medical conditions: [MEDICAL CONDITIONS] or other dementia. Risk factors checked included Urinary or bowel incontinence and pain that effects movement or mood. A Catheter Justification Worksheet dated 5/17/13 documented the presence of an indwelling catheter, 16 Fr (French) 30 cc. A non-healing pressure ulcer was documented. The primary reason for continued use of indwelling catheter was given as "non healing pressure sore" and the reason for continued use of the indwelling catheter was said to be unavoidable at the time of this review. A care plan for Break in Skin Integrity, potential for, dated 4/24/13 documented the resident as being at risk for impaired skin integrity secondary to decreased mobility, incontinence of bowel and bladder, fluid deficit, [MEDICAL CONDITION] to lower extremities, dementia, ASA (aspirin), and antidepressant use. Interventions included in pertinent part, weekly skin assessment; Clean and dry skin after each incontinent episode; standard pressure relieving mattress and w/c cushion; refer to wound nurse as appropriate; encourage adequate nutrition and hydration deemed appropriate by MD. Staff Interview An interview was conducted on 6/12/13 at approximately 3:05 p.m. with a Licensed Practical Nurse (LPN #2) LPN #2 said Resident #3 has a Foley (indwelling catheter) because of a pressure ulcer. The pressure ulcer is now pin size so it (the catheter) will come out soon. The pressure ulcer was never more than a stage II. During an interview with the Director of Nursing (DON) on 6/12/13 at approximately 4:15 p.m. the DON said "I was aware" that stage II pressure ulcers were not justification for an indwelling catheter. The DON said it was not his expectation that a catheter be placed to promote healing of a stage II pressure ulcer. 3. Resident #111, [AGE] years old, was admitted on [DATE] with [DIAGNOSES REDACTED]. MDS Data The Minimum Data Set (MDS) for re-admission, dated 3/12/13, Section H - Bladder and Bowel, documented that resident was frequently incontinent (seven or more episodes of urinary incontinence, but at least one episode of continent voiding) during the seven-day look-back period. The documented assessment remained the same for the 14-day (3/19/13) and 30-day (4/2/13) MDS. Care Plan The Care Plan for Incontinency, which was not dated, included the following: Problem: Due to s/p (status [REDACTED]. Goals: (Resident) will be free of complications related to incontinency over the next 90 days Approaches: Wash and dry skin after each incontinent episode cleansing front to back, apply protective ointment, provide incontinence pad to assure dignity, provide call light within reach, check and change protocol. (Resident) is not a good candidate for bladder retraining (see bladder assessment), bladder assessment on admission, quarterly and PRN (as needed) and monitor skin for breakdown. Record Review Resident's chart was reviewed and there was no documented bladder assessment found, nor any documentation supporting the care plan approach that resident was not a good candidate for bladder retraining. Staff Interviews On 6/10/13 at 1:33 p.m. the two MDS coordinators (designated as A and B) were interviewed. B stated that resident is due for his next MDS and is on the schedule. A stated that she gathers the information for the MDS from data from the CNAs, staff and family interviews. B said that once an issue is identified it's discussed with the interdisciplinary team, then they look into starting a bowel or bladder assessment and training program. MDSC A added that there's an observation period of the resident to see what type of program he or she would benefit from. Both MDSC were asked why there was no bladder training or toileting program for resident. B replied that he had been in and out of the hospital many times and they were waiting for him to be completely stable before initiating anything. A stated that the observation period is 72 hours, then depending on what is found out from that, a program is initiated for that. B stated that it had not been done for this resident because he was on Medicare and was not medically stable, but there was no documentation to this effect, although it had been discussed. They both agreed that in the six-month period under discussion, there should have been an evaluation done, and there should have been some documentation why it was not done sooner. The Director of Nursing was interviewed on 6/1/13 at 1130 a.m. and stated that he thought resident had been assessed for bladder training. He agreed that sometime in the past several months this should have occurred and that a voiding trial or check and change should have been done. He stated that he would provide a copy of the urinary incontinence assessment showing that resident was not a candidate for bladder retraining, but it had not been received by survey's end.