Every finding on record at Maple Leaf Health Care Center

Based on observation, interview, and record review, it was determined that the facility failed to ensure that expired medications were removed from use for 1 of 4 medication carts observed. (Resident identifier is #38). Findings include:Observation on 3/2/26 of the 3rd floor medication cart #7 with Staff A (Licensed Practical Nurse) revealed Resident #38's opened Lispro insulin pen an Insulin Lispro pen with an open date of 1/30/26 and an expiration date of 2/27/26. Interview on 3/2/26 at approximately 8:15 a.m. with Staff A confirmed the above. Review on 3/2/26 of manufacturer's instructions for Humalog (insulin lispro), dated 01/2026, revealed: when stored at room temperature, Humalog U-100 . can only be used for a total of 28 days, including both not in-use (unopened) and in-use (opened) storage time. Review on 3/2/26 of facility policy titled Medication Storage, reviewed 10/5/2025, revealed: 4 .Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on record review and interview, the facility failed to correctly code Minimum Data Set (MDS) assessments for 3 of 22 residents reviewed for MDS assessments in a final sample of 22 residents (Resident Identifiers #5, #44 and #64).Findings include: Resident #5 Review on 3/3/26 of Resident #5's Quarterly MDS with the Assessment Reference Date (ARD) of 12/17/25 revealed Section N0415E Anticoagulant was coded as is taking during the 7 day look back period. Review on 3/3/26 of Resident #5's physician order revealed that Resident #5 was not receiving anticoagulant medication between 12/11/26 and 12/17/26. Interview on 3/3/26 at approximately 1:15 p.m. with Staff B (MDS Coordinator) confirmed that Resident #5's quarterly MDS dated [DATE] was miscoded. Resident #44 Review on 3/3/26 of Resident #44's annual MDS assessment, with an ARD date of 12/3/25, revealed that section I-Active Diagnoses indicated that resident #44 had a diagnosis of PTSD (Post Traumatic Stress Disorder). Review on 3/3/26 of Resident #44's medical record revealed no documentation of a diagnosis of PTSD. Interview on 3/3/26 at approximately 2:35 p.m. with Staff B (MDS Coordinator) confirmed the above findings. Resident #64 Review on 3/3/26 of Resident #64's annual MDS with the Assessment Reference Date (ARD) of 12/24/25 revealed Section N0415E Anticoagulant was coded as is taking during the 7 day look back period. Review on 3/3/26 of Resident #64's medications for 12/18/25 through 12/24/25 revealed no anticoagulants were ordered. Interview on 3/3/26 at approximately 1:15 p.m. with Staff B confirmed the above findings.

Based on observation and interview, it was determined that the facility failed to ensure that residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good personal hygiene for 2 of 2 residents reviewed for ADL in a final sample of 22 residents (Resident Identifiers are #54 and #73). Findings include: Resident #54 Interview on 1/22/25 at 9:10 a.m. with Resident #54 revealed that he/she did not get showers on a regular basis and he/she would like to have showers weekly as scheduled. Observation on 1/22/25 at approximately 9:10 a.m. of Resident #54 revealed him/her lying in bed. His/her hair was uncombed and appeared greasy. Observation on 1/23/25 at approximately 9:45 a.m. of Resident #54 revealed him/her lying in bed. His/her hair was uncombed and appeared greasy. Review on 1/24/25 of shower schedule for Resident #54 revealed that Resident #54 is scheduled for showers on Mondays, 7-3 shift. Review on 1/24/25 of Resident #54's shower documentation for baths and showers from 11/18/24 through 1/18/25 (9 weeks) revealed that Resident #54 received one shower on 1/4/25. Further review revealed no documentation that Resident #54 had refused any showers. Interview on 1/24/25 at 12:15 p.m. with Staff B (Director of Nursing) confirmed the above findings for Resident #54. Resident #73 Observation on 1/22/25 at 10:30 a.m. of Resident #73 revealed he/she was in their room in bed and sitting upright in pajamas. Resident #73's hair was unkept, messy, and matted. Interview on 1/22/25 at 10:31 a.m. with Resident #73 revealed that he/she did not consistently receive weekly baths or showers and he/she would like to shower weekly. Observation 1/23/25 at 8:15 a.m. of Resident #73 revealed he/she was in their room lying in bed in pajamas. Resident #73's hair was unkept, messy, and matted. Observation on 1/24/25 at 10:30 a.m. of Resident #73 revealed he/she was in their room lying in bed in pajamas. Resident #73's hair was unkept, messy, and matted. Review on 1/24/25 of Resident #73's shower schedule revealed they were scheduled to receive a shower on Fridays in the morning. Review on 1/24/25 of Resident #73's shower documentation for baths and showers from 11/18/24 to 1/23/25 (9 weeks) revealed showers were marked as competed on 11/23/24, 12/9/24, 12/13/24, and 1/18/25 (4 times). Further review revealed that there was no documentation that Resident #73 had refused showers any time during the period reviewed. Review on 1/24/25 of Resident #73's care plan for ADL care, dated 10/21/24 revealed that Resident #73 required minimum to moderate assist with washing, dressing, grooming, and assistance with bath/showers. Interview on 1/24/25 at approximately 2:31 p.m. with Staff B confirmed the above findings for Resident #73. Review on 1/24/25 of the facility's policy Activities of Daily Living - Bathing Residents, revised 9/2022, revealed: .General Guidelines: 6. Bathing of choice will be offered at least weekly, on a schedule of their choice .Documentation: 1. The date and time the shower/tub was performed .Reporting . 1. Notify the supervisor if the resident refuses the shower/tub bath for further intervention . 3 . Report other information in accordance with facility policy and professional standards of practice . 48515

Based on observation, interview, and record review, it was determined that the facility failed to implement infection control policies and procedures for 1 of 3 residents reviewed for Transmission Based Precautions (TBP) (Resident identifier #63) and for 1 of 2 residents observed for wound care (Resident identifier #10) in a final sample of 22 residents. Findings include: Resident #63 Observation on 1/22/25 at approximately 8:40 a.m. revealed a sign posted outside resident's room for Isolation Droplet/Contact Precautions. The sign identified the Personal Protective Equipment (PPE) to use for Droplet/Contact Precautions was an isolation gown, N95 respirator, eye protection, and gloves. Observation 1/22/25 at approximately 8:45 a.m. of Staff C (Licensed Nurses Assistant) revealed that he/she entered Resident #63's room while wearing an isolation gown, an N95 respirator, and gloves. Staff C was not wearing eye protection. Staff C proceeded to remove the isolation gown and gloves when exiting the resident's room but did not remove his/her N95 respirator. Staff C proceeded across the hallway into the dining area where multiple residents and staff were located. Interview on 1/22/25 at approximately 8:50 a.m. with Staff C confirmed the above findings. Interview on 1/22/25 at approximately 2:00 p.m. with Resident #63 revealed that not all staff wear eye protection while providing care. Interview 1/23/25 at approximately 1:15 p.m. with Staff E (Infection Preventionist) confirmed it is the facility policy that staff entering a resident's room with droplet precautions would wear an isolation gown, N95 respirator, eye protection, and gloves. Staff E further revealed it is facility policy that staff would remove all PPE when exiting a resident's room with droplet precautions. Review on 1/24/25 of Resident #63's Preventive Health Care Report dated 1/17/25 revealed that Resident #63 tested positive for COVID-19 on 1/17/25. Review 1/24/25 of Resident #63's physician orders revealed an order for Droplet Precautions-COVID positive dated 1/17/25 at 10:50 p.m. Review on 1/24/25 of the facility's policy; Transmission Based Precautions dated 9/1/2022 revealed, .3. When transmission- based precautions are implemented, the infection Preventionist (or designees): a. clearly identifies the type of precautions, .and the personal protective equipment(PPE) that must be used .d. determines the appropriate notifications on the room entrance door .(1) The signage informs the staff of the type of CDC precaution(s), instructions for use of PPE . (https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html) 43002 Resident #10 Review on 1/23/25 of Resident #10's physician's order dated 12/30/24 revealed a treatment order for a Stage 3 pressure injury to the coccyx, clean with normal saline, lightly pack with collagen powder and cover with a border foam dressing daily. Observation on 1/23/25 at 1:47 p.m. of Staff F (Licensed Practical Nurse) providing wound care to Resident #10 revealed Staff F placed the wound care dressing supplies directly on the Resident's bedside table without cleaning the area or placing a clean field [covering the table with a clean disposable cloth to place the wound care items on to reduce the risk of of transmission of microorganisms]. Staff F removed the dirty dressing, removed their gloves and donned new gloves without sanitizing their hands. Staff F proceeded to clean the wound with normal saline, apply the collagen powder and apply the clean dressing. Interview on 1/23/25 at 2:28 p.m. with Staff F confirmed that he/she did not clean the bedside table or place a clean field on the bedside table for the dressing supplies during wound care. Staff F confirmed that he/she did not wash or sanitize their hands between glove change. Interview on 1/24/25 at 1:30 p.m. with Staff B (Director of Nursing) revealed that it is facility policy that staff would sanitize their hands between the dirty and clean parts of wound care and would use a clean field to place the dressing supplies on as per their policy. Review on 1/24/25 of the facility's policy titled Wound Care dated 9/1/22 revealed, .1. Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field . 4 remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. 6. Put on gloves . Review on 1/24/25 of the facility's policy Hand Hygiene dated 9/1/22 revealed, .7. Use and alcohol-based hand rub .or .soap . and water for the following situations . h. Before moving from a contaminated body site to a clean body site during resident care .k. After handling used dressings . m. After removing gloves .

Based on observation, interview and record review, it was determined that the facility failed to ensure that medications and biologicals were stored in locked compartments in 1 of 2 medication rooms observed. (Second Floor Medication Room.) Findings include: Observation on 1/22/25 at 10:32 a.m. of the Second Floor Medication Room revealed the door was unlocked and there was no staff in the medication room. Further observation of the Second Floor Medication Room revealed that there were resident's and house stock medications stored in open shelves. There was no staff outside the room or visible in the area. Additionally, there were several residents sitting right outside the medication room. Interview on 1/22/25 at approximately 10:33 a.m. with Staff B (Director of Nursing) confirmed that the medication room was unlocked. Review on 1/23/25 of the facility's policy Medication Storage dated 9/1/22 revealed, .The facility stores all drugs and biologicals in a safe, secure, and orderly manner . 1. Drugs and biologicals used in the facility are stored in locked compartments . 6. Compartments (including . rooms .) containing drugs and biologicals are locked when not in use .

Based on record review and interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the residents' status for 2 of 2 residents in a final sample of 22 residents (Resident Identifiers are #38 and #107). Findings include: Resident #38 Review on 1/23/25 of Resident #38's medical record revealed a smoking assessment dated [DATE], which indicated that the resident was a smoker. Review on 1/23/25 of Resident #38's comprehensive assessment, dated 6/19/24, section J1300, did not indicate tobacco use. Interview on 1/24/25 at 9:50 a.m. with Staff A (MDS Coordinator) confirmed that Resident #38 was an active smoker and section J1300 of the comprehensive assessment should have indicated tobacco use. Resident #107 Review on 1/24/25 of Resident #107's medical record revealed that Resident #107 had a planned discharge home on 1/6/2025. Review on 1/24/25 of Resident #107's Discharge MDS, dated [DATE], section A2105, revealed that resident #107 had discharged to a short-term general hospital. Interview on 1/24/25 at 10:15 a.m. with Staff A confirmed that Resident #107 discharged home as planned and did not discharge to a short-term general hospital.

Based on observation, interview, and record review, it was determined that the facility failed to properly labeled medications in 1 of 4 carts observed (Third Floor Medication Cart #5). Findings include: Observation on 1/23/24 at approximately 9:15 a.m. of the third floor medication cart #5 revealed an open Levemir insulin flex pen without a patient identifier and a liquid suspension in a bottle with a label that had peeled off making it illegible. Interview on 1/23/24 with Staff A (Licensed Practical Nurse) confrmed the above findings. Staff A was working on the cart and he/she stated they had not used the above medications that day. Review on 1/24/24 of the facility's policy titled Storage of Medications, revised 7/15/23, revealed .Patient medications are stored with identifying factors such as name and/or room number . Review of [NAME], [NAME] A., and [NAME] [NAME]. Fundamentals of Nursing. 7th edition. St. Louis, Missouri: Mosby Elsevier, 2009. Chapter 35 Page 707, revealed .Never prepare medications from unmarked containers or containers with illegible labels .

Based on observation, interview, and record review, it was determined that the facility failed to ensure that hand hygiene and recommendations for Transmission Based Precautions (TBP) were followed per Center for Disease Control and Prevention (CDC) guidelines for 3 of 5 residents observed for TBP (Resident identifiers are #16, #457 and #459). Findings include: Standard: Review on 1/25/23 of the CDC's website titled, Isolation Precautions, review date of 7/22/19, retrieved from: https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html, revealed .Summary of Recommendations .Hand Hygiene .Perform hand hygiene in the following clinical situations: .After contact with a patient's intact skin (e.g., when taking a pulse or blood pressure or lifting a patient) .After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient .After removing gloves .Wash hands with non-antimicrobial soap and water or with antimicrobial soap and water if contact with spores (e.g., C. difficile [Clostridioides difficile] or Bacillus anthracis) is likely to have occurred. The physical action of washing and rinsing hands under such circumstances is recommended because alcohols, chlorhexidine, iodophors, and other antiseptic agents have poor activity against spores .Contact precautions .Change protective attire and perform hand hygiene between contact with patients in the same room, regardless of whether one or both patients are on Contact Precautions .Use of personal protective equipment .Gloves . Wear gloves whenever touching the patient's intact skin or surfaces and articles in close proximity to the patient (e.g., medical equipment, bed rails). Don gloves upon entry into the room or cubicle .Wear a gown whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the patient. Don gown upon entry into the room or cubicle. Remove gown and observe hand hygiene before leaving the patient-care environment .After gown removal, ensure that clothing and skin do not contact potentially contaminated environmental surfaces that could result in possible transfer of microorganism to other patients or environmental surfaces . Resident #16 Review on 1/26/23 of Resident #16's active physician orders revealed an order for contact precautions for diagnoses of Methicillin-Resistant Staphylococcus Aureus (MRSA) wounds with a start date of 12/31/22. Review on 1/26/23 of Resident's electronic medical record revealed that the MRSA is on Resident #16's right lower extremity. Observation on 1/26/23 at approximately 8:00 a.m. at Resident #16's room revealed a contact precautions sign and Personal Protective Equipment (PPE) precaution cart outside of the resident room, next to the door. Staff A (Licensed Practical Nurse (LPN)) was wearing a surgical mask, goggles, and donned PPE (gown and gloves) then entered Resident #16's room to administer Resident #16's medications. Further observation revealed that Staff A doffed the gown and gloves and proceeded to the medication cart and prepped another resident's medication without performing hand hygiene. Interview on 1/26/23 at approximately 8:20 a.m. with Staff A confirmed above observation. Resident #457 Review on 1/25/23 of Resident #457's electronic medical record revealed that Resident #457 was admitted to the facility on [DATE] with a diagnoses of Clostridioides difficile (C-diff). Resident #457 was receiving Vancomycin (antibiotic) medication and was placed on contact precautions. Review on 1/25/23 of Resident #457's active physician orders revealed an order for contact precautions for a diagnoses of C-diff with a start date of 1/21/23. Observation on 1/25/23 at approximately 10:00 a.m. at Resident #457's room revealed a contact precautions sign and a PPE precaution cart outside Resident #457's room. Further observation revealed that Resident #457's male visitor had a surgical mask and no other PPE sitting within less than 3 feet of Resident #457. Observation on 1/25/23 at between 11:58 a.m. to 12:15 p.m. at Resident #457's room revealed that Resident #457's female visitor was in Resident #457's room with no gloves and gown. Resident #457's female visitor was observed sitting in a chair next to Resident #457. Resident #457's female visitor was also observed fixing Resident #457's bed. Resident #457's female visitor closed Resident #457's door then a couple minutes later opened the door. Further observation revealed that Resident #457's commode had no lid with a white plastic bag over the commode with soft brown and liquid substance, stool-like. Further observation revealed Staff D (LPN) going into Resident #457's room with no gown and gloves, administered medications to Resident #457. Staff D touched Resident #457's side table, throwing away the medication cup and empty cup that Resident #457's touched and went out of Resident #457's room without performing hand hygiene. Interview on 1/25/23 at approximately 12:00 p.m. with Resident #457 and Resident #457's female visitor confirmed the above observation in Resident #457's room. Resident #457 stated that they had closed the door as he/she was using the commode to have a bowel movement. Resident #457's female visitor stated that he/she wanted to fix Resident #457's bed and that he/she did not need to wear a gown and glove as he/she was just visiting Resident #457. Resident #459 Observation on 1/25/23 at approximately 11:35 a.m. at Resident #459's room revealed that Resident #459 had a contact precautions sign and a PPE precaution cart outside Resident #459's room, next to the door. Observation also revealed that Staff B (Housekeeper) was in Resident #459's room wearing goggles, mask, gloves and no gown. Staff B was cleaning resident's room and side table, Staff B was within 3 feet of Resident #459. Further observation revealed that Staff B proceeded to go outside of Resident #459's room without performing hand hygiene then touching the housekeeper's cart and then went to the housekeeper room. Interview on 1/25/23 at approximately 11:36 a.m. with Resident #459 confirmed the above observation in Resident #459's room. Review on 1/25/23 of Resident #459's active physician's order revealed an order for contact precautions for the diagnoses of C-diff with start date of 1/14/23. Interview on 1/27/23 at 8:15 a.m. with Staff C (Director of Nursing) revealed that staff should perform hand washing with soap and water for hand hygiene for resident's with contact precautions related to C-diff. Interview on 1/27/23 at approximately 8:27 a.m. with Staff B revealed that he/she would use hand sanitizer after doffing PPE and going out a resident room with a contact precautions sign for C-diff.

Based on observation, interview, and record review, it was determined that the facility failed to ensure the removal of expired medication (insulin) according to manufacturer's instructions for 1 out of 4 medication carts (Second Floor North Cart) observed. (Resident identifiers are #16 and #34) Findings include: Observation on [DATE] at 3:02 p.m. of the Second Floor North Cart revealed the following; -A vial of [MEDICATION(S)] (novolog) insulin 100 units for Resident #16 that was dated opened on [DATE] and to discard after 28 days; -A vial of [MEDICATION(S)] R insulin 100 units for Resident #34 that was dated opened on [DATE] with no discard date noted. Interview on [DATE] at 3:02 p.m. with Staff A (Licensed Practical Nurse) confirmed the above findings. Interview on [DATE] at 3:02 p.m. with Staff B (Director of Nursing) confirmed that the [MEDICATION(S)] insulin should have been discarded 28 days after opening ([DATE]), and 31 days after opening for the [MEDICATION(S)] R insulin ([DATE]). Review on [DATE] of Resident #16's Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on [DATE] of the manufacturer's instructions for insulin [MEDICATION(S)] revealed .After vials have been opened . Throw away all opened insulin [MEDICATION(S)] vials after 28 days, even if they still have insulin left in them . Review on [DATE] of Resident #34's Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on [DATE] of the manufacturer's instructions for [MEDICATION(S)] R insulin revealed .16.2 Storage and Handling . Table 3. Storage Conditions and Expiration Dates for [MEDICATION(S)] R . In-Use (Opened) Refrigerated or Room Temperature 31 days . Review on [DATE] of the facility's policy titled Disposal of Medications dated ,d+[DATE] revealed . 4. Mediations . shall be destroyed by the nursing center as outlined below 7. Outdated medications, contaminated or deteriorated medications . shall be destroyed according to the above policy .

Based on interview, observation and facility policy review, it was determined that the facility failed to follow acceptable professional principles of labeling and/or storing drugs and biologicals for 3 out of 4 medication carts and 1 out of 1 medication storage room observed. (Resident identifiers #30, #42, #49, #50, #56 and #69.) Findings include: Observation on [DATE] at approximately 8:35 a.m. of 3rd floor south east medication cart with Staff A (Registered Nurse) revealed an opened bottle of OTC (over the counter) Acidophilus ([MEDICATION NAME]) in the medication cart. Review on [DATE] of OTC bottle revealed a storage instruction to refrigerate after opening. Interview on [DATE] at approximately 8:35 a.m. with Staff A confirms the above findings. Resident #56 Observation on [DATE] at approximately 8:54 a.m. of 3rd floor north east medication cart with Staff B (Licensed Practical Nurse) revealed an opened bottle of OTC Acidophilus was noted to be in the medication cart. Review on [DATE] of OTC bottle revealed a storage instruction to refrigerate after opening. Interview on [DATE] with Staff B confirmed the above findings. Staff B revealed that Resident #56 had a current daily order for Acidophilus. Resident #49 Observation on [DATE] at approximately 8:54 a.m. of 3rd floor north east medication cart with Staff B revealed Resident #49's open bottle of [MEDICATION NAME] (antipsychotic) ER (extended release) 150 mg (milligrams) in drawer of cart. Review on [DATE] of [MEDICATION NAME] ER 150 mg bottle revealed the pharmacy label to read: fill date [DATE] and use by date [DATE]. Interview on [DATE] with Staff B confirmed the above findings and that Resident #49 had a current order for [MEDICATION NAME] ER 150 mg at bedtime. Interview on [DATE] at approximately 9:05 a.m. with Staff C (3rd floor Unit Manager) stated the expectation for checking for expired medication is done by the night nurse and monthly by the person who orders supplies. Resident #42 Observation on [DATE] at approximately 2:25 p.m. of 2nd floor northwest medication cart with Staff D (Medication Nursing Assistant) revealed Resident #42's [MEDICATION NAME] pen in the medication cart that did not include prescribed dose or open expiration date. Black magic marker was used to label resident name on cap. Manufacturer expiration on pen was ,[DATE]. Interview on [DATE] at approximately 2:30 p.m. with Staff D confirmed the above findings. Resident #30 Observation on [DATE] at approximately 2:25 p.m. of 2nd floor northwest medication cart with Staff D revealed Resident #30's vial of [MEDICATION NAME] R 100 units/ml (milliliters) to have no open expiration date. Interview on [DATE] at approximately 2:30 p.m. with Staff D confirmed above findings. Review of [MEDICATION NAME] R Manufacturers instructions revealed medicaiton can be stored up to 31 days after openning. Resident #69 Observation on [DATE] at approximately 2:25 p.m. of 2nd floor northwest medication cart with Staff D revealed Resident #69's Breo Ellipta ,[DATE] mcg (micrograms) inhaler in medication cart with no open expiration date on device or packaging. Manufacturers' packaging and label states discard 6 weeks after opening moisture protective foil tray Interview on [DATE] at approximately 2:30 p.m. with Staff D confirmed above findings. Resident #50 Observation on [DATE] at approximately 9:30 a.m. of 3rd floor medication storage room refrigerator with Staff D noted an open vial of Resident #50's Insulin [MEDICATION NAME] 100 units/ml (milliliters). Observation on [DATE] at approximately 9:30 a.m. of Resident #50 Insulin [MEDICATION NAME] vial indicated an open date on vial of [DATE]. A pharmacy label on vial reads discard 28 days after opening. Interview on [DATE] at approximately 9:30 a.m. with Staff D verified the above findings. Review on [DATE] of facility policy labeled 3.7 Medications and Medication Labels Procedure .1. Each prescription medication will be labeled to include: a. Resident's name b. Specific Directions for use, including route of administration c. medication name .d. strength of medication .e. Prescriber's name f. Date medication dispensed g. Quantity dispensed h. Expiration or end-of-use date .2. Multi-dose vials shall be labeled to assure product integrity, considering manufacturers' specification .document the date opened on multi-dose vials on the attached auxiliary label.

Based on observation, interview and manufacturer's instruction, it was determined that the facility failed to follow professional standards of care for 1 resident out of 6 residents observed during medication administration. (Resident identifier is #12.) Findings include: Professional reference: Potter, Patricia A and Perry, Anne Griffin . Essentials for Nursing Practice. 9th Edition St. Louis Missouri: Elsevier, 2019. Page 431-Subcutaneous Injections .Priming involves pointing the open needle up to the air, dialing one or two units (see package directions) on the pen and then pressing the plunger fully with the thumb relatedly until a drop appears. This clears the needle of air and ensures a full dose is ready . Resident #12 Observation on 1/28/21 at approximately 11:55 a.m. of Staff E (Licensed Practical Nurse) administering medications to Resident #12 revealed Staff E prepared [MEDICATION NAME] to administer 8 units of insulin by turning dial to 8 units. During administration of insulin to right thigh, Staff E depressed [MEDICATION NAME] Flex Pen button for approximately 2 seconds then removed it from the thigh. Interview on 1/28/21 at approximately 11:57 a.m. with Staff E revealed that when asked about process for insulin pen administration, Staff E stated you turn dial to units ordered and inject by pressing button on pen to administer. When asked if there was any additional steps before administering insulin Staff E responded No. When asked if there was a specific length of time to depress the insulin pen button with administration, Staff E stated you just hold until you hear a click and the dial goes to zero. Interview on 1/28/21 at approximately 12:05 p.m. with Staff B (Licensed Practical Nurse) when asked about the process for administering insulin with an insulin pen, Staff B stated you would prime with 2 units and then add the ordered amount of insulin, you would administer by pushing button down. When asked if there was a specific amount of time to depress button down Staff B stated until dial gets to zero. Interview on 1/28/21 at approximately 12:20 p.m. with Staff A (Registered Nurse) revealed when asked about the process for administering insulin with an insulin pen, Staff A stated you would prime with 2-3 units then add amount ordered. When asked how long to depress the button when administering with an insulin pen, Staff A stated hold until the number goes to zero. Review of Manufacturers instructions for Use of [MEDICATION NAME] , page 8 .Giving air shot before injection. Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: E. Turn the dose selector to select 2 units .G. Keep needle pointing upwards press the push button .A drop of insulin should appear at the needle tip .Giving the injection .J. Keep the needle in the skin for at least 6 seconds, and keep the push button pressed all the way in until the needle has been pulled out from the skin. This will make sure the full dose has been given.

Based on observation, interview and policy and procedure review, the facility failed to follow the Centers for Disease Control and Prevention (CDC) guidelines for universal masking during the COVID-19 pandemic in multiple areas throughout the building. Findings include: Observation on 7/14/20 at approximately 11:30 a.m. at the front entrance of the facility revealed Staff A (Cook) in the lobby with a surgical mask placed below their nose. Staff B (Receptionist) was located approximately 4-5 feet from Staff A. Interview on 7/14/20 at approximately 11:45 a.m. with Staff I (Director of Nurses) and Staff K (Infection Control Preventionist) revealed that surgical masks should be covering staff member's nose and mouth. Observation on 7/14/20 at approximately 12:10 p.m. on the 3rd Floor nursing unit revealed Staff C (Restorative Nurse) at the nurses station on the phone with surgical mask placed below their nose. Interview on 7/14/20 at approximately 12:10 p.m. with Staff I confirmed the above finding. Observation on 7/14/20 at approximately 12:15 p.m. on the 3rd floor nursing unit revealed Staff D (Medical Records) walking in the hallway on the unit with a surgical mask placed below their nose. Staff I approached Staff D as Staff D entered the stairwell and reminded Staff D that the surgical mask needs to cover their nose. Observation on 7/14/20 at approximately 12:20 p.m. in the laundry room revealed Staff E's (Laundry Aide) surgical mask was placed below their nose. Observation on 7/14/20 at approximately 12:25 p.m. in the kitchen revealed Staff F's (Cook) surgical mask was placed below their chin. Approximately 3-4 feet from Staff F was Staff G (Dietary Aide) whose surgical mask was placed below their nose. Staff I reminded Staff F and Staff G that surgical masks needed to cover both their nose and mouth. Staff A was also observed with surgical mask placed below nose. Observation on 7/14/20 at approximately 12:30 p.m. of the business office revealed 2 staff members in the office. Staff H (Business Office Manager) was not wearing a mask. Staff I reminded Staff H that a surgical mask is required in the office if another staff member was present. Review on 7/15/20 of the facility policies and procedures revealed a policy to ensure preparedness in the event of a Coronavirus (COVID-19) outbreak, dated 3/5/20, that said the facility would referred to following CDC guidelines for COVID-19. Further review of facility policies revealed a policy titled Screening Partners/Visitors during COVID-19, dated 6/5/20, that states Upon entering the center all partners/visitors will wash their hands and then apply a mask. Staff I was unable to provide other policies that were specific to universal masking during COVID. Review on 7/16/20 of the CDC website titled, Preparing for COVID-19 in Nursing Homes, updated June 25,2020 revealed the following (retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html): Core Practices, Implement Source Control Measures, HCP (Health Care Personnel) should wear a facemask at all times while they are in the facility. Further review of the website revealed that the CDC defines HCP as the following: HCP include, but are not limited to, emergency medical service personnel, nurses, nursing assistants, physicians, technicians, therapists, phlebotomists, pharmacists, feeding assistants, students and trainees, contractual HCP not employed by the healthcare facility, and persons not directly involved in patient care but who could be exposed to infectious agents that can be transmitted in the healthcare setting (e.g., clerical, dietary, environmental services, laundry, security, engineering and facilities management, administrative, billing, and volunteer personnel).

Based on observation, interview, and record review, it was determined that the facility failed establish and follow written policies and procedures for standard and transmission-based precautions and when and how isolations should be used for a resident for 4 of 4 residents observed on precautions. (Resident identifiers are #18, #53, #99, #205.) Findings include: Resident #18 Observation on 4/30/19 at 9:40 a.m. revealed a precaution sign outside of room [ROOM NUMBER]. Interview on 4/30/19 at approximately 9:45 a.m. with Staff B (Unit Manager) revealed that Resident #18 in room [ROOM NUMBER] was on precautions for [MEDICAL CONDITION]. Observation on 4/30/19 at 10:20 a.m. revealed a staff changing Resident #18's bed with gown hanging off of the staff's shoulders. Observation on 4/30/19 at 10:50 a.m. revealed housekeeping cleaning room and mopping floor around Resident #18's bed not wearing a gown or gloves. Observation on 4/30/19 at 1:50 p.m. revealed two Licensed Nursing Assistants (LNA) in Resident #18's room not wearing a gown or gloves. Staff C (LNA) removed the garbage bag from the trash container that contained used gowns and took it down the hallway to the soiled utility room. Observation on 5/1/19 at 8:30 a.m. revealed staff went to deliver food to Resident #18. Staff put food on top of the precaution cart in the hallway and put on a mask and brought the tray into Resident #18 who was in bed. Review on 5/3/19 of Resident #18's care plan dated 4/29/19 revealed that the resident is on contact precautions. Review on 5/3/19 of Resident #18's physician orders [REDACTED]. Interview 5/3/19 at 12:50 p.m. with Staff D (Infection Preventionist) revealed that for some residents on contact precautions, staff only need wear gloves and gowns during direct care, that residents can attend activities and dining and some residents would need to stay in their room and require staff to wear gloves and gowns whenever they enter the resident's room. Staff D revealed the differences in procedure is not reflected in facility policy, on signs, or in the resident's care plan. Staff D revealed that a mask is not a recommendation for contact precautions but is available for use if staff want to wear one. Resident #99 Interview on 4/30/19 at approximately 8:55 a.m. with Staff B (Registered Nurse) revealed that there is a question of bed bugs in Resident #99's room, and the room has been treated for [REDACTED]. Observation on 4/30/19 at 10:22 a.m. of this room revealed there is a precaution cabinet outside the room with PPE (personal protective equipment), but there is no precautions signage or Stop/see Nurse signage at the room entrance. Interview on 4/30/19 at approximately 9:15 a.m. with Staff I (clinical) revealed that instruction was to wear gown and gloves to go into the room. Observation on 4/30/19 at 10:50 a.m. revealed a visitor, without donning any personal protective equipment (PPE), walked into the room and spoke with Resident #99, then carried 2 framed pictures, one at a time, out of the room into the hallway, showing them to people in the hall, then returning the pictures to the room. Interview on 4/30/19 at approximately noon with Staff B revealed gown and gloves indicated when contacting linens/residents, the room was treated for [REDACTED]. Interview on 5/3/19 in the afternoon with Staff G (Director of Nursing) revealed the bed bugs were for Resident #99, they found a couple live bed bugs that Staff G thinks may have come in with Resident #99, he has one treatment to go. Interview on 5/3/19 at 2:04 p.m. with Staff J (clinical) confirmed Resident #99 has one treatment to go. Observation on 5/3/19 at approximately 12:43 p.m. revealed there was a Stop signage at the doorway to Resident #99''s room, there was still a PPE cabinet outside the room but no precaution sign on the PPE cabinet. Resident #205 Interview on 4/30/19 at approximately 8:55 a.m. with Staff B (Registered Nurse) revealed that Resident #205 is on precautions for [MEDICAL CONDITION]. Observation on 4/30/19 at 11:12 a.m. revealed a precaution cabinet outside of Resident #205's room with Contact Precautions signage and a Stop sign at the doorway. Staff K (clinical) was observed at this time in the room near the doorway without PPE on. Staff K exited the room and interview at that time with Staff K revealed Staff K had a mask on as they were only talking to the resident, and they had just removed it, Staff K related gloves are only needed if touching/doing care, if entering the room and only talking just need a mask. Observation on 4/30/19 until 11:24 a.m. revealed, after Staff K exited the room, a visitor was observed in the room with Resident #205, the resident was not visualized as they were behind a pulled curtain. The visitor came into view, and was observed wearing a mask and gloves but no gown. The visitor was touching things in the room including a grasping tool. Interview on 4/30/19 at approximately noon with Staff B revealed that for Resident #205, one should wear gown and gloves when contacting linens, the resident; and a mask is not needed in the room. Interview on 5/1/19 at approximately 1:54 p.m. with the resident's daughter revealed Resident #205 is presently on precautions for [DIAGNOSES REDACTED] ([MEDICAL CONDITION]); after staff finish care the staff discard their gown/gloves in the trash then remove the liner and replace it; after the resident uses the bedside commode the staff puts the contents in a bag and removes it. Observation of the room at time of this interview revealed the bathroom in the room is located on the roommate's side of the room, by the room entrance. There is only one sink in the room which is not in the bathroom but is in the room itself, again on the roommate's side. Resident #205's bed is at the far side of the room, by the window, separated from the roommate by a pulled curtain. There is a portable commode located between Resident #205's bed and the window wall, and the waste basket, which has a plastic liner, is also adjacent to the window wall. Record review on 5/2/19 at 9:22 a.m. of Resident #205's Discharge Summary for Date of Service 4/15/19 reveals Metabolic [MEDICAL CONDITION] due to [DIAGNOSES REDACTED] and secondary active [DIAGNOSES REDACTED]. Record review on 5/2/19 at 12:27 p.m. of the Admission Minimum Data Set assessment dated [DATE] revealed that that Resident #205 has frequent incontinence of urine and bowel, and Section I codes [DIAGNOSES REDACTED]. Interview on 5/3/19 at 9:37 a.m. with Staff B revealed Staff usually have bags with them that they put their PPE into when they are done, and then take the bag out of the room; similarly after commode use, the liner with waste is taken out of the room to the dirty utility. Record review on 5/3/19 at 12:24 p.m. of Resident #205's physician's orders [REDACTED]. Record review of the facility's [DIAGNOSES REDACTED]icile-Contact Precautions sheet, provided on survey, and dated 5/1/18, reveals, in part, that gloves are to be used When giving direct care. Also, The use of gowns when giving direct care will depend on site of infection and residents sign & symptoms. Resident #53 Observation on 4/30/19 at approximately 9:30 a.m. of Resident #53 revealed Resident #53 was sitting in a common area of the 3rd floor wing. There was a precautions cart and a sign identifying that the purpose for the cart was Droplet Precautions. The cart was located outside of a room that had four resident occupants. Staff was queried as to whom the precautions were for, the staff identified Resident #53 who was sitting in the common area. At the same time that the observation was taking place, a member of the Laundry staff delivered laundry items to the room in question. Laundry staff did not don Personal Protection Equipment prior to entering the room. Interview on 4/30/19 at 10:15 with Staff H (3rd floor Unit Manager) revealed that Resident #53 had Upper Respiratory Infection (URI) symptoms. Resident #53 was given an influenza test that resulted negative. Observations that occured at 9:30 a.m. were revealed to Staff H. Staff H responded that the concerns would be addressed. Interview on 5/3/19 at 12:10 PM with Staff D (Infection Preventionist) and Staff G, Registered Nurse, revealed that facility staff is empowered to initiate precautions if it is suspected by staff that infection prevention is needed. Staff D revealed that Resident #53 was suspected of requiring droplet precautions and that unit staff were finding it difficult to keep a mask on her or monitoring Resident #53's movements in the hallway.

Based on observation, interview, review of physicians orders, manufacturers instructions and it was determined that the facility failed to follow physicians orders for 1 out of 4 residents observed during medication administration and 1 of 3 residents reviewed for pain in a final sample of 23. (Resident identifier is #17 and #57.) Findings include: Potter, [NAME] A., and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Resident #57 Observation on 5/1/19 at approximately 8:20 a.m. with Staff A, Licensed Practical Nurse (LPN) during medication pass with Resident #57 revealed that Resident #57 had a [MEDICATION NAME] adhered to the lower back dated 4/30. Review on 5/1/19 of Resident #57's physicians orders revealed the following: (pronoun omitted) [MEDICATION NAME] 4% adhesive patch. Apply 1 patch topically to low back (remove after 8 hours). Apply 8 a.m. and remove 4 p.m. Interview on 5/1/19 at approximately 8:25 a.m. with Staff A revealed that the [MEDICATION NAME] should have been removed at 4:00 p.m. on 4/30. Review on 5/2/19 of the manufacturer's instructions for (pronoun omitted) [MEDICATION NAME] 4% adhesive patch revealed: . Directions . Remove patch from the skin at most 8-hour application Resident #17 Review on 5/3/19 of Resident #17's physician orders [REDACTED]. Review on 5/3/19 of Resident #17's Medication Administration Record [REDACTED]. Interview on 5/3/19 at 12:48 p.m. with Staff B (Unit Manager) confirmed the it was not documented that Resident #17's patch was removed on 4/10/19 and 4/24/19.

Based on observation, record review and interview, the facility failed to implement an infection prevention practice to prevent the potential transmission of influenza for 1 out of 2 residents who received nasal swabs for influenza during the standard survey. (Resident identifier is #61.) Findings include: Observation on 3/14/18 at approximately 10:00 a.m. of Resident #61 revealed that Resident #61 was short of breath and had frequent coughing. Review on 3/15/18 of Resident #61's nurses notes, dated 3/14/18, revealed that Resident #61 .complained of 'not feeling well' .non prod (non productive) cough .had a temperature of 100.2. Review on 3/15/18 of Resident #61's Physician Telephone Orders, dated 3/14/18, revealed an order for [REDACTED].>Review on 3/15/18 of Resident #61's nurses notes, dated 3/14/18, revealed a note which documented .Flu Swab A & B collected. Observation on 3/15/18 at approximately 3:00 p.m. of Resident #61's room revealed that there was nothing indicating that Resident #61 was placed on precautions. Interview on 3/15/18 at approximately 3:00 p.m. with Staff A (Registered Nurse, Unit Manager) confirmed that Resident #61 had not been placed on precautions. Review on 3/16/18 of the facility's Infection Control Manual, dated 12-98, revised 10-1-08, revealed that In addition to Standard Precautions, use Droplet Precautions, or the equivalent, for a patient known or suspected to be infected with microorganisms transmitted by droplets .that can be generated by the patient during coughing, sneezing, talking, or the performance of procedures . Interview on 3/16/18 at approximately 12:00 p.m. with Staff B (Licensed Practical Nurse, Infection Control) confirmed that Resident #61 should have been placed on Droplet Precautions when Resident #61 was suspected of having influenza.

Based on record review, staff interview, and Policy/Procedure review, it was determined the facility failed to follow the Professional standards of practice for documenting the effectiveness of PRN (as needed) [MEDICATION NAME] for 1 resident in a survey sample size of 15. Review on 12/4/15 of the facility Medication Administration Policy in #4 Medications and Treatments, section b PRN medications: [REDACTED]. Record notes on the PRN record or in the Nurses Notes if prn records are not used c Psychoactive medications: [REDACTED]. Reference for the professional standard of practice is: Potter-Perry, 2009, Review of the Fundamentals of Nursing, Patricia Anne Griffin Perry, Mosby, St. Louis, Missouri, 2009, 7th Edition, revealed the following, Chapter 26, pg.387, Nurses need to indicate all assessments, interventions, client responses, instructions, and referrals in the medical record. Record review on 12/4/15 of the October and November Medication Administration Record [REDACTED]. On twenty occcasionsns there was no documentation as to how the medication affected the resident. During interview with Staff B, RN on the afternoon of 12/2/15 about the absent documentation. Staff B had no answer for the missing documenttion.

Based on medical record review and interview, it was determined that the facility failed to follow professional standards of care for checking physician orders [REDACTED]. (Resident identifiers are #11 and #19.) Findings include: The Potter-Perry, 2009, Review of "Fundamentals of Nursing," Patricia A. Potter and Anne Griffin Perry, Mosby, St. Louis, Missouri, 2009, 7th Edition, revealed the following, Chapter 23 Legal Implications in Nursing Practice, on page 336- Physicians' Orders states, "The physician is responsible for directing medical treatment. Nurses follow physician's order [REDACTED]. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary..." Maple Leaf Health Care Medication Validation Policy and Procedure with an update date of 10/15/12: "It is the Policy of Maple Leaf Health Care Center to Validate medication and treatment orders every month and PRN (as needed), as well as new telephone orders are received from physicians throughout the month and PRN. There will be a double check performed by Licensed Nurses." Resident #11 Review on 2/11/15 of Resident #11's medical record revealed "physician's orders [REDACTED]. These orders also revealed two nurses' signatures present indicating medication review was completed on the following: 11/22/14 and 11/26/14, 12/24/14 and 12/26/14, 1/23/15 and 1/28/15. Interview on 2/12/15 at 9:00 a.m. with Staff A (Director of Nurses) reviewed the above conflicting order. Staff A confirmed that the double check system had not caught this conflicting order. Staff A and review of the facility's policy confirmed that Resident #11 would be considered a full code until a DNR had been established in the event that she had coded. Resident #19 Closed record review revealed apparent duplicate orders for [MEDICATION NAME] 50 mg on January 2015 physician's orders [REDACTED]. One order instructs [MEDICATION NAME] ER 50 mg one tab by mouth daily for hypertension -on days of ECT (electroconvulsive therapy), give [MEDICATION NAME] 50 mg with sips of water @6AM. This order could be misinterpreted to mean give a second dose of [MEDICATION NAME] on days of ECT. In addition, there is a separate additional order, dated 1/22/15, that instructs [MEDICATION NAME] 50 mg by mouth daily; and this latter order does not identify if the medication is [MEDICATION NAME] or [MEDICATION NAME]. Review of Patricia A. Potter and Anne Griffin Perry, "Fundamentals of Nursing", 7th Edition, St. Louis, Missouri: Mosby Elsevier, 2009, reveals on page 336: Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary.

Based on medical record review and interview, it was determined that the facility failed to ensure that during physician visits "Physician's Orders" were reviewed by the physician before signing them for 1 resident in a survey sample of 22. (Resident identifier is #11.) Findings include: Review on 2/11/15 of Resident #11's physician telephone order dated 10/22/14 revealed resident was "DNR (Do Not Resuscitate)." Review of Resident #11's "P-DNR (Portable Do Not Attempt Resuscitation)" order revealed it was signed on 10/22/14. Review of Resident #11's "Physician's Orders" dated 12/1/14 through 12/31/14 and 2/1/15 through 2/28/15 revealed an order to the left the physician's signature that stated the following: "Code Status: Full Code-location of wrist band: wheelchair-check placement daily on 7-3." These orders also revealed below the physician's signature the following order: "DO NOT RESUSCITATE." These "Physician's Orders" were signed on 12/12/14 and 2/10/15. Interview on 2/12/15 at 9:00 a.m. with Staff A (Director of Nurses) reviewed the above information. Staff A confirmed that the physician had signed these orders and had not made a clarifying order to correct these two conflicting orders. Staff A and review of the facility's policy confirmed that Resident #11 would be considered a full code until a DNR had been established in the event that she had coded.

Based on medical record review and interview, it was determined that the facility failed to maintain a complete and accurate medical record for 1 resident in a survey sample of 22. (Resident identifier is #11.) Findings include: Review on 2/11/15 of Resident # 11's medical record revealed "Medication Administration Record" dated 12/1/14 through 12/31/14, 1/1/15 through 1/31/15 and 2/1/15 through 2/10/15 having the following order: "Code Status: Full Code-Location of Wrist Band: Wheelchair-Check Placement Daily on 7-3." For these time periods, nurses had signed off that this had been done. Review of Resident #11's "P-DNR (Portable Do Not Attempt Resuscitation)" order revealed the resident had been DNR (Do Not Resuscitate) status since 10/22/14. Observation on 2/11/15 at 10:10 a.m. with Staff B (nurse) of Resident #11's wheelchair revealed there was not a full code wrist band present on the chair. When Resident #11's wrist was checked by Staff B, Resident #11 was wearing a red wrist band which Staff B confirmed was for DNR status. Interview on 2/12/15 at 9:00 a.m. with Staff A (Director of Nurses) reviewed the above information. Staff A confirmed that Resident #11 had been a DNR status since 10/22/14. Staff A also confirmed that nurses should not be signing off they have checked the wrist band if they have not. Staff A explained that the nurses have received training regarding this.

Based on observations during a Medication Administration Pass, review of the MAR (Medication Administration Record), Review of the Facility's list of stated Medication Pass Times, and review of a nursing standard for medication administration, the Facility failed to ensure that all medications were administered within professional nursing guidelines for medication administration for 4 of 27 residents on one half of the second floor of this Facility. (Resident identifiers are: #23, #24, #26, and #27.) Findings include: Review of the Facility Medication Pass Times reveals that the medication pass times for the facility are: 8:00 a.m., 9:00 a.m., 11:30 a.m., 2:00 p.m., 4:00 p.m., 8:00 p.m. and 12:00 midnight, if necessary for antibiotic (administration). Review of the text Fundamentals of Nursing, 7th edition, edited by Potter and Perry, copyright 2009 by Mosby/Elsevier, St Louis, MO in Chapter 35, Medication Administration, page 708 at the subheading entitled Right Time reveals the following; "The prescriber often gives specific instructions about when to administer a medication ...Give all routinely ordered medications within 60 minutes of the times ordered (30 minutes before or after the prescribed time)." During the observation of a medication pass, 2/20/14, performed by Staff A, RN it was noted that 24 medications for 4 different residents were given later than the times ordered in the MAR. Resident #23. Resident #23 had 3 medications due to be administered at 8:00 a.m., one which was ordered for 1 time per day, one which was ordered for 2 times per day and one which was ordered for 3 times per day. It was observed that all these medications ordered as due at 8:00 a.m. were not administered until approximately 9:05 a.m.. Resident #24. Resident #24 had 10 medications due to be administered at 8:00 a.m., 7 which were ordered for 1 time per day and three that were ordered for 2 times per day. It was observed that these medications ordered as due at 8:00 a.m. were not administered until approximately 9:19 a.m.. Resident #26. Resident #26 had eye drops ordered to be instilled at 8:00 a.m. that were not administered until approximately 9:55 a.m.. Resident #27. Resident #27 had 10 medications due to be administered at 9:00 a.m., 6 were ordered for 1 time per day, 3 were ordered for 2 times per day and 1 was ordered for 4 times per day. It was observed that these medications ordered as due at 9:00 a.m. were not administered until approximately 10:28 a.m..