Every finding on record at Mather Evanston, The

Based on interview and record review the facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis. This failure applies to all 22 residents within the skilled nursing unit of the facility. Findings include: On 03/17/25 at 10:45 AM V2 (Assistant Director of Nursing) reported the facility does not currently have a Director of Nursing. On 03/19/25 at 10:38 AM V1 (Administrator) stated the skilled nursing team responsible for recruiting staff, and they have placed ads, and gone to schools but has been unsuccessful and hiring a Director of Nursing. , V1 stated the skilled nursing unit has had applicants without enough experience, and people filled the position but have not stayed. V1 stated V2 (Assistant Director of Nursing) is not comfortable with being in the Director of Nursing position. V1 stated all facility's need a nursing director and a person responsible for coordinating nursing services. The facility's staffing list provided during the survey does not include a Director of Nursing.

Based on interview and record review, the facility failed to ensure that all residents were offered the pneumococcal booster vaccine. This failure applied to four (R9, R11, R12, and R19) of five residents reviewed for vaccines on the total sample of 20. Findings include: R9 is a [AGE] year-old female with multiple diagnoses including but not limited to the following: COPD (Chronic Obstructive Pulmonary Disease), anxiety, dysphagia, and need for assistance with personal care. R11 is a [AGE] year-old male with multiple diagnoses including but not limited to the following: CVD (CardioVascular Disease), dementia, and dysphagia. R12 is a [AGE] year-old female with multiple diagnoses including but not limited to the following: CVD, dementia, and macular degeneration. R19 is an [AGE] year-old male with multiple diagnoses including but not limited to the following: AFib, CAD (Coronary Artery Disease), HTN (Hypertension), heart failure, dementia, and legal blindness. On 3/18/2025 at 1:57PM, V2 (Director of Nursing/Infection Preventionist) said residents should receive the pneumococcal vaccination booster every five years. V2 said when a resident is admitted I check to see if they have any historical history of the pneumococcal vaccine. If they do not, I will order the vaccination, however if they do, I do not order anything. V2 says we offer a vaccination clinic almost twice a year for the influenza and COVID+ vaccine, but not the pneumonia vaccine. Vaccination history shows R11 last received their pneumococcal vaccine on 8/13/2018, R9 on 4/7/2015, R12 on 10/8/2015, and R19 on 3/16/2018. It is to be noted that R9, R11, R12, and R19 all received their last pneumococcal vaccination >5 years ago and were not offered a booster shot. Facility policy titled Immunization Program with revision date of 05/2024 states in part but not limited to the following: For adults [AGE] years or older, if PPSV23 is administered, use shared clinical decision-making to decide whether to administer one dose of PCV20 at least 5 years after the last dose of PPSV23 dose.

Based on observations, interviews, and record reviews the facility failed to follow their care planning policies by not ensuring a residents baseline care plan included safety/fall interventions. This failure applies to one (R1) of four residents reviewed for accidents on the total sample of 20. Findings include: R1 is a [AGE] year-old female with a diagnoses history of Prosthetic Heart Valve, Chronic Diastolic Congestive Heart Failure, Presence of Artificial Hip Joint, Primary Osteoarthritis of Hip, Dizziness, and Lack of Coordination who was readmitted to the skilled nursing unit on 02/25/2025. On 03/17/25 at 10:57 AM R1 stated she fell a couple of weeks ago and fractured her pelvis. R1's current physician orders includes an active order effective 03/03/2025 for Fall Risk Assessment Weekly for four weeks every day shift every 7 day(s) for fall precautions management for 4 Weeks. R1's Admission Baseline Care Plan assessment dated [DATE] documents her vision is impaired, cognitively impaired, uses a walker, has a history of falls, her last fall was 2 months prior to admission which resulted in a fractured pelvis, she receives psychotropic, diuretic, and anticoagulant medications, and it does not include fall interventions. R1's current care plan does not include falls interventions and documents she sometimes has pain or feels weak and might require extensive assistance to transfers. R1's fall risk assessments dated 02/25/2025, 03/10/2025, and 03/17/2025 document she is at high risk for falls, and her fall risk assessment dated [DATE] documents she is at moderate risk for falls. On 03/19/25 at 11:37 AM V2 (Assistant Director of Nursing/Registered Nurse) stated R1 was admitted to the facility from assisted living on 02/25/2025 and did have falls while in assisted living. On 03/19/2025 at 1:19 PM V8 (Certified Nursing Assistant) stated she's always assigned to R1 when she works, and she thinks R1 might be a fall risk. V8 stated usually R1 doesn't get up on her own without assistance but sometimes when she arrives to work in the morning R1 is already dressed and in her chair. V8 stated R1 walks sometimes but tires easily and has an unsteady gait. V8 stated R1 hunches over and doesn't stand up straight. V8 stated R1 mostly walks in her room and doesn't like coming out of her room. V8 stated she assumes R1 is a fall risk but was never actually informed that she was. V8 stated she is normally notified of residents being a fall risk when they come in to the unit. On 03/19/2025 at 1:24 PM V9 (Certified Nursing Assistant) stated he wouldn't say R1 is a fall risk but he hasn't worked with her since she's come back to the skilled nursing unit. On 03/19/2025 at 1:25 PM V10 (Certified Nursing Assistant) stated she believes R1 is a fall risk and she uses a gait belt to raise R1 up and follows her to the bathroom. V10 stated other fall precautions for R1 include low bed with a mattress on one side of the bed and at times raising her bedrails to keep her sideways so she won't roll out of bed. On 03/19/2025 at 1:34 PM V11 (Certified Nursing Assistant) stated she works with R1 and tries to check on her every hour and assists her with ambulating. On 03/19/2025 at 1:37 PM Observed R1 lying in her room in her bed raised to knee height and not in the lowest position, with no mats on the floor and without bedrails raised. On 03/19/2025 at 2:07 PM V2 (Assistant Director of Nursing) stated R1 needs fall interventions including regular checks from Certified Nursing Assistants and nurses, call light within reach, proper footwear, her walker always within reach, reminders to call for assistance when needed especially when toileting, and bed in low position when in it. V2 stated the facility does not use bed rails for fall precautions. On 03/19/2025 at 3:07 PM V12 (Registered Nurse) stated she has 21 days to complete a comprehensive care plan which would have been Monday 03/17/2025. V12 stated she isn't sure what other information staff would use to identify fall interventions besides the baseline and comprehensive care plans. V12 stated R1's baseline care plan assessment provided to the surveyor is considered their baseline care plan. V12 stated the baseline care plan does include fall risk information and could not explain where the fall interventions were located in R1's baseline care plan assessment. On 03/20/2025 at 1:20 PM V1 (Administrator) reported R1 went to the hospital on March 1, 2025 after her readmission to Skilled Nursing unit on 02/25/2025 and returned from the hospital on 03/03/2025. V1 stated R1 fractured her hip in November of 2024 when she was a resident in the assisted living unit of the facility. The facility's Care Plan Policy received 03/18/2025 states: The goal of the baseline care plan is to provide an initial set of instructions needed to provide effective and person-centered care of the resident. An initial baseline personalized plan of care addresses the transfer information sent on admission and initial nursing assessment information. The baseline care plan should include the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care and the minimum healthcare information necessary to properly care for each resident immediately upon their admission. This may include but is not limited to resident-specific safety concerns to prevent injury and would identify needs for supervision, behavioral interventions, and assistance with activities of daily living as necessary.

Based on interview and record review, the facility failed to ensure effective fall interventions were in place and fall interventions were being followed, resulting in multiple falls. This failure applies to one (R2) of four residents reviewed for falls on the total sample of 20. Findings include: R2 is a [AGE] year-old female who originally admitted to the facility on [DATE] and continues to reside in the facility. R2 has multiple diagnoses including but not limited to the following: CHF, respiratory failure, Parkinson's disease, dementia, lack of coordination. Per facility fall log R2 had a fall on 11/26/2024, 1/15/2025, and 2/16/2025. It is to be noted that R2 experienced these three falls during transferring. R2's Progress Note dated 11/26/2024 states in part but not limited to the following: Observed R2 sitting on the floor in the room. V5 (Certified Nursing Assistant) said she was transferring R2 to the wheelchair when R2's legs buckled, and she was lowered to the floor. R2's Progress Note dated 1/15/2025 states in part but not limited to the following: V5 was transferring R2 from the wheelchair to the bed. V5 said that R2's knee gave out and R2 was lowered to the floor. Fall Risk Assessment Post Fall Evaluation dated 1/15/2025 states in part but not limited to the following: R2 will have two-person assistance during transfers. R2's Progress Note dated 2/16/2025 states in part but not limited to the following: V6 (Certified Nursing Assistant) stated while transferring R2, R2 was unable to support her weight and subsequently V6 had to slide R2 to the floor. Fall Risk Assessment Post Fall Evaluation dated 2/16/2025 states in part but not limited to the following: Any commonalities with previous falls: Had a fall prior with similar incident. It is to be noted that on 2/16/2025, V6 was the only staff present when transferring R2. On 3/19/2025 at 1:15PM, V6 was interviewed regarding R2's fall on 2/16/2025. V6 said I was providing assistance while toileting R2. I was helping R2 pull her pants up and when she was standing up, her knees buckled, and I brought her down to the floor. V6 said after the fall, the nurse on duty let me know that she required two-person assistance with transfers due to a fall prior to this. However, I was never made aware of this. At 2:25PM, V2 (Director of Nursing) was interviewed regarding R2's falls. V2 said R2's falls on 11/26/2024, 1/15/2025, and 2/16/2025 all happened during transferring. After 1/15/2025, we recommended that R2 have two-person assistance during transferring. However, on 2/16/25, V6 was not aware of this and transferred R2 with one person assistance. Facility Fall Prevention Protocol states in part but not limited to the following: This protocol outlines procedures for implementing fall precautions. Post Fall Actions: The resident's care plan is reviewed after a fall event and new interventions are considered.

Based on observation, interview and record review, the facility failed to follow their policy on dating opened food Items and discarding expired foods in the refrigerator for 23 of 24 residents that receive meals from the dining room. Findings include: On [DATE] at 10:30am during a tour of the dietary department V14 (Culinary Director/Executive Chef) observed with the surveyor in the refrigerator, Dill sauce with a use by date of [DATE], Vitamin D milk with a use by date of [DATE], Mozzarella Cheese with a use by date of [DATE]. Salad dressing open no date, Parmesan Cheese open no date, sliced meat open no date, liquid eggs open no date. On [DATE] at 11:00am, V14 said all expired foods should be discarded, and all open foods should have a date. Facility Policy: Food Storage and Refrigeration Management-Effective date: [DATE], Revised February 2022, Revised [DATE]e Purpose: This policy reviews the process for food storage and refrigeration management in the life plan communities. Process: 7. Store food in original container if the container is clean, dry, and intact. If necessary, repackage food in clean, date marked and labeled, airtight containers. 7.1 This also can be done after a package is opened. 2. Dispose of items that are beyond the expiration or use by date

Based on observation, interview, and record review, the facility failed to ensure that 2 of 2 residents (R1, R12) observed for contractures have hand splint/palm guard applied in the sample of 13. Findings include: 05/02/2023 10:28 AM, R12 observed sitting in her chair, left hand contracted with no splint in place. V18 (R12 family member) stated that sometimes soft splint is applied, but not today. On 5/02/2023 at 10:30 AM, V13 (Registered Nurse/RN) said that R12 should have the splint on to prevent further contracture. On 5/3/2023 at 1:08 PM, V16 (Physical Therapy Director) said that R1 should have their left palm guards on to prevent further contracture. R12 is an [AGE] year-old female with a diagnosis of not limited to rheumatoid arthritis, major depression, and polyarthritis. 05/02/23 11:00 AM R1 - Observed in her room sitting in her chair. R1 has a left-hand contracture with no splint in place. On 5/3/2023 at 1:08 PM, observed R1 in her room sitting in her chair with V16 (Physical Therapy Director). R1 has no left palm guard on. V16 said that R1 should have her left palm guards on to prevent further contracture. R1 is a 101-year female admitted on [DATE] with a diagnosis not limited to muscle weakness, rheumatoid arthritis, and generalized anxiety. Restorative Care Protocol Purpose: This protocol describes the restorative care program in Skilled Nursing (SN). Standards of Practice Philosophy and Goals of Restorative Nursing Program 2. Prevent contractures via range of motion (ROM) activity, and splints/braces

Based on observation, interview, and record review, the facility failed to implement its fall precautions protocol by failure to complete root cause analysis and update care plan after each fall incident occurrence to a resident who is at high risk for falls. This deficiency affects one (R18) of three residents in the sample of 13 reviewed for Fall prevention program. Findings include: On 5/2/23 at 10:10am, V10 (Registered Nurse/RN) said that R18 is on fall precaution. R18 ambulates with rolling walker and wheelchair. R18 is confused due to his dementia. V10 said that they don't have list of residents on fall precaution program. V10 said that V3 (Assistant Director of Nursing/ADON) has the list. On 5/2/23 at 1:48pm, observed R18 lying on bed, sleeping. His bed in not in the lowest position. Rolling walker at bed side. On 5/3/23 at 12:50pm, observed R18 with V3 (ADON), R18 sleeping on low bed. His low bed in the lowest position. On 5/4/23 at 11:25am, V3 (ADON) said that she is the Fall Coordinator. She said that they have fall prevention program, and R18 in on the list. V3 said that the floor nurse is the one who completes and updates the post fall investigation and care plan. V3 with QAPI (Quality Assurance and Performance Improvement) review the fall post fall investigation and update the care plan as needed. On 5/4/23 at 11:30am, review R18's medical records with V3 (ADON) and V5 (Clinical Manager). R18 is admitted on [DATE] with diagnoses listed in part but not limited to Repeated falls, Dementia. Admission fall assessment dated [DATE] indicated at high risk for fall. Care plan indicated that he has memory problem, impaired decision making and judgement. He has an ADL (Activity of Daily Living) self-care performance deficit related to Dementia. He requires one staff assistance to use toilet and transfer. He needs supervision to reposition/turn in bed. He is at risk for falls characterized by history of falls prior to admission and new environment. R18's Fall incident reports: 1)12/3/22 Unwitnessed fall, observed R18 lying supine on floor in his room. He sustained superficial bruise to left knee and complained of chest pain. He was sent to the hospital and admitted with diagnosis of chest pain and fall secondary to syncope. R18 returned on 12/5/22. V3 (ADON) said that she did not update R18's fall care plan after he came back from the hospital. 2) 1/9/23 Unwitnessed fall, observed sitting on the floor in his room. R18 said I got up to use the bathroom, missed the step and fell on my butt. V3 (ADON) said that they don't have documentation that they check R18 every hour as indicated in fall intervention to ensure safety. 3) 1/16/23 Unwitnessed fall, observed crawling on floor in his room. R18 said he wanted to get to the bathroom. Post fall investigation dated 1/16/23 indicated R18's bed should be at lowest position. 4) 1/18/23 Unwitnessed fall, observed R18 on the floor attempted to crawl to his walker to the bathroom. Fall care plan is not updated after the fall occurrence. 5) 4/21/23 Unwitnessed fall, observed R18 sitting on the floor with bilateral lower extremities extended. R8 said that he came from the bathroom and lost his balance going back to bed. No post fall investigation/root cause analysis done. On 5/4/23 at 11:58am, informed both V3 (ADON) and V5 (Clinical Manager) that Fall care plan was not updated after fall occurrence on 1/18/23. No post fall investigation/root cause analysis done on 4/21/23. All the unwitnessed fall from 1/9/23, 1/16/23, 1/18/23 and 4/21/23 are related to going to the bathroom, as verbalized by R18 in the incident report, but they were not addressed in fall care plan intervention. V5 said that R18's bed should be on the lowest position while on bed. Informed V5 that R18 was observed with V3 (ADON), lying on low bed, not in lowest position. On 5/4/23 at 12:30pm, informed both V1 (Administrator) and V2 (Director of Nursing/DON) of above concern. V2 said that the floor nurse is the one who completes the post-fall investigation/root cause analysis, then the Fall Coordinator with QAPI team will review and updates the care plan. Fall care plan should be updated after each fall occurrence to prevent future falls. On 5/4/23 at 1:40pm, V17 (Agency Nurse) said she does not know who the residents on fall precautions are. She searched the endorsement binder and nursing station but unable to find the list. On 5/4/23 at 1:58pm, review QAPI fall meeting report with V1 (Administrator). V1 said that the QAPI meeting minutes did not indicate the discussion of the root cause analysis/post fall investigation and formulation of new fall intervention to prevent future falls. V1 said that she will talk with fall QAPI team. Facility Fall precautions Protocol indicates: Purpose: This protocol outlines the procedures for implementing fall precautions across the continuum. Standard of practice: 1. Fall precautions are designed by the care venue's multidisciplinary team. These interventions may be discussed in the quality assessment performance (QAPI) team meeting, morning meetings, shift reports, post fall huddles and or care plan/service plan conferences. 3. Interventions are documented in the resident's care plan/service plan. Post fall actions: 6. The resident's care plan/service plan is reviewed after a fall event and new interventions considered as per assessment and the post fall review. 8. A root cause analysis may be completed for certain falls, per policy. Communication of fall risk and falls to IDT (interdisciplinary Team): 1. Communication of resident's fall risk and plan of care to the IDT is a step in the fall reduction process.

Based on interview and record review, the facility failed to treat a resident with dignity by refusing to provide the resident with water after the resident asked for a drink. This affected 1 of 3 residents (R1) reviewed for resident rights. Findings include: On 11/4/22 at 2:00pm, R1 stated that V3 (Certified Nurse Aide/CNA) would not give R1 water when R1 asked for assistance. On 11/4/22 at 1:15pm, V7 (nurse) stated that R1's mood is good. V7 denied R1 expressing any further concerns with care/staff since the incident. V7 stated that R1 needs assistance from staff with drinking fluids. On 11/4/22 at 1:40pm, V4 (nurse) stated that while doing rounds on the residents at 6:30am, V4 observed a cup on right side of body and resident was wet. V4 stated that when R1 was asked what happened, R1 stated that he asked V3 (CNA) for water and she would not give him water, so he tried to reach for himself and spilled on himself. R1 stated that V3 refused to give R1 water stating that it is not her job to give water to R1. V4 stated that V4 spoke with V3 regarding incident and informed V3 that all staff are responsible for the care of the residents and providing water to residents. V4 stated that V4 reported this incident to V1 (Administrator). V4 stated that R1 is back to usual self now. V4 stated that R1 has difficulty with holding cup and drinking water by himself, staff need to assist R1. V4 stated that when rounding on residents, he checks to make sure there is water at bedside. On 11/9/22 at 12:30pm, V5 (Certified Nurse Aide/CNA) stated that V5 was passing by R1's room and heard him calling out for water. V5 stated that she went into R1's room and ask what happened, stated that R1 informed her that he asked V3 (CNA) for water and V3 didn't give it to him. V5 stated that she provided R1 with water and then reported incident to nurse. Review of this facility's investigation dated 10/27/22, notes R1 stated that R1 asked V3 (CNA) for water, and V3 wouldn't give it to R1. R1 stated that V3 informed R1: I'm not here to give you water, I'm here to change you. R1 stated that R1 didn't want to say anything to anyone, but admits that he felt comfortable enough to tell staff at dinner on 10/27/22 because R1 felt V3 should not be working here if V3 doesn't want to provide care to residents. V3 was suspended immediately upon notification of allegation. V3 was interviewed regarding incident. V3 informed V1 that V3 went to R1's room to provide incontinence care, while doing so, V3 had headphones on listening to music. V3 stated that V3 didn't hear R1 ask for water because the music was possibly loud in her ear. This facility concluded: it was determined that V3 (CNA) failed to provide R1 with the required basic care needs as R1 requested. V3's actions were not in alignment with the facility's requirement to provide the basic care needs to the residents. V3 was terminated.

Based on observation, interview, and record review, the facility failed to follow the policy related to hand washing and use of gloves during food preparation and handling of ready to eat foods. This deficiency has the potential to affect the 23 residents residing in the facility receiving meals from the kitchen. Finding include: Resident Census and Conditions of Residents, dated 6/07/2022, documents 26 residents are currently residing in the facility. Out of the 26 residents, three residents are on pureed diet. According to V8 (Executive Chef), the facility uses commercially prepared frozen pureed food items. On 6/07/2022 at 11:15 AM during food preparation, V6 (Cook) was observed touching food items like pita breads, pepperoni slices, sliced mushrooms, and mozzarella cheese with gloved hands. There were no serving utensils used to get the ingredients from each containers. As he (V6) finished topping all the ingredients, he placed the prepared pizza inside the oven. Then he started preparing another set of pizza again, wearing the same gloves touching pepperoni slices. Then he removed his gloves and donned another pair of gloves without handwashing, and continued touching the sliced mushrooms and mozzarella cheese. He was also observed touching lettuce, sliced strawberries and pineapple; cheese; plates and bowls without changing gloves in between, as he prepared poppyseed fruit salad. V7 (Cook) was observed performing multiple tasks such as taking pickles directly from the container, getting plates and plate covers from the counter without changing gloves. V7 was preparing chicken salad. V6 was again observed taking pickles from the container from time to time, with gloved hands. Serving utensils or tongs were not used. V9 (Culinary Manager) stated, Gloves are changed in between tasks. If they touch food products or a container or a pan, anything that is not similar product, they have to change their gloves. V8 stated, Staff needs to change gloves or use a serving spoon if they are preparing and touching cheese and other high allergy food items such as sausage, pepperoni and chicken. They should also use a tong in getting food items from the cold table, not with gloved hands. Facility's policy titled Culinary Employee Health and Personal Hygiene revised date December 2021 documented in part but not limited to the following: Process: Grooming: 3. Wash hands (including under fingernails) and up to forearms vigorously and thoroughly with soap and warm water for a period of 20 seconds, following handwashing guidelines; Before putting on gloves to start a task that involves working with food. Between each task performed and before wearing disposable gloves. Attire: 3. Utilize gloves as follows. Gloves should be worn, or utensils used when serving food. Change disposable gloves between tasks, for example, opening a refrigerator door to place pan of prepared product is considered a new task. Wash hands before donning and after discarding gloves. Do not blow into gloves, roll gloves, or wash and reuse the gloves.

Based on observation, interview, and record review, the facility failed to ensure that a resident with skin irritation in the anal area was provided with incontinence care according to facility policy and plan of care. This deficiency affects one (R13) of one resident in the sample of 22 reviewed for bowel and bladder. Findings include: R13 is a [AGE] year-old female, readmitted in the facility on 11/23/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R13's care plan, dated 5/31/2022, regarding potential/actual impairment to skin integrity, documented: Interventions: Uses incontinence brief in bed. Staff to be aware that (R13) is incontinent of bowel and does not always know when she is soiled. Keep clean and dry as possible. If R13 refuses to be changed notify the registered nurse as she is prone to MASD (moisture associated skin damage). Apply moisture barrier cream and antifungal powder as ordered. Wound Evaluation note, dated 6/02/2022, documented: Moisture Associated. R13 was assessed as having MASD, identified on 5/12/2022. On 6/08/2022 at 11:39 AM, V5 (Certified Nurse Assistant, CNA) was asked regarding the last time R13's incontinence brief was checked and changed. V5 stated, She was changed this morning by the night shift. I came in at 7:00 AM, and I have not checked and changed her yet. She usually calls me. She has not called me yet. But I can check her now. Subsequently, V5 was observed providing incontinence care for R13. R13 has an indwelling urinary catheter in place, draining to a urine bag. R13's incontinence brief was soiled with dry bowel movement. V5 turned R13 to the left side, took some disposable wipes and started wiping the anal area. V5 took some disposable wipes again and cleaned the anal area, buttocks, sacrum and coccyx area. R13's groin and genital area were not observed to be cleansed, R13 stayed on the left side until incontinence care was finished. During cleansing of R13's lower back, it was observed that her anal area and surrounding skin around the coccyx were red. R13 stated, It hurts from time to time. According to V4 (Registered Nurse, RN) V4 was not aware of R13's redness on the anal area. V1 (Administrator) was interviewed regarding incontinence care for residents. V1 replied, Standard is to check and change residents at least every two hours and as needed. Facility's policy titled Perineal Care, dated 2006, documented in part but not limited to the following: Purpose: To cleanse the perineum To prevent infection and odor Procedure: 11. Female perineal care a. If resident is soiled with feces, place resident on side and clean perineum and rectal area. d. Turn resident on her back. e. Ask resident to separate her legs and flex knees. If she is unable to spread her legs and flex knees. The perineal area can be washed with the resident on the side with legs flexed. f. Use one gloved hand to stabilize and separate the labia, with other hand wash from front to back. Rinse and pat dry with towel.

Based on observation, interview and record review , the facility failed to follow its policy on documentation of narcotic /controlled substance drug reconciliation during shift change and after administration of medications. This deficiency affects one of two medication carts reviewed for medication carts-controlled substance medication reconciliation. Findings include: On 3/16/21 at 10:19am, Checked narcotic/controlled substance medication in 2nd floor skilled unit medication cart with V5, RN. Observed shift change accountable record for narcotics and keys on 3/16/21, 7-3 shift are missing initial. V5 stated that she forgot to sign it. The incoming (7-3 shift) and outgoing shift (11-7 shift) count the narcotics at the beginning and end of each shift and sign the narcotic record count. Count narcotic medications with V5, RN. Observed R18's [MEDICATION NAME] (1mg tablet by mouth every 4 hours as needed for anxiety or agitation C-IV) bingo card medication. Observed number left 3, but controlled drug receipt record/disposition form documented #4 left dated 3/15/21 1 tab given at 9pm. V5 stated it was given at 9 AM this morning, but V5 forgot to sign. Observed R1's [MEDICATION NAME] (0.5mg tablet ½ tab (0.25mg) by mouth every 6 hours as needed [DIAGNOSES REDACTED].#27 but controlled drug receipt record/disposition form documented #28 left dated 3/16/21 given at 12am. V5 stated she gave it today at 9am but V5 forgot to sign. On 3/16/21 at 10:36am, V2, Assistant Director of Nursing, informed of above observation and showed R1's and R18's narcotic medication bingo dispensing cards and controlled drug receipt record disposition forms. V2 stated that two nurses must count narcotics at the beginning and end of each shift, initialing the narcotic count record. The two nurses counting should be the incoming and outgoing nurses. Medication administrated must be documented into controlled drug receipt/record form after given. Facility's policy on Medication/Treatment Management revised date October 2020 indicated: Page 2: 6.6 Controlled substances are signed off on the medications/treatments record as well as the Controlled Substance Record/signature page. Page 5: 11. Schedule II controlled substances are stored in double-locked container, with a separate key for each lock. 11.2 A narcotic count is completed between the oncoming nurse and the off going nurse between each shift. Both staff members sign the narcotic count sheet indicating agreement with the narcotic count. 11.2.1 Discrepancies in the narcotic count should be reported to the DON in a timely manner. Facility's policy on Preparation and General Guidelines : Controlled Substances Procedures: D. Accurate accountability of the inventory of all controlled drug is maintained at all times. When a controlled substance is administered, the licensed nurse administering the medication immediately enters the following information on the Medication Administration Record [REDACTED]. 1) Date and time of administration ( MAR, Controlled Drug Receipt/Record Disposition Form) 2) Amount administered ( Controlled Drug Receipt/Record Disposition Form) 3) Remaining quantity ( Controlled Drug Receipt/Record Disposition Form) 4) Initials of the nurse administering the dose, completed after the medication is actually administered ( MAR, Controlled Drug Receipt/Record Disposition Form)

Based on observation, interview and record review, the facility failed to discard items after the use by date , failed to remove dented cans from available stock and failed to follow infection control practices during the preparation and serving of puree diets. This has the potential to affect all 29 residents receiving meals from the dietary department. Findings include: On [DATE] at approximately 10:15 AM, during the brief tour of the kitchen with V4 (Executive Chef), cooler #5 was observed to have several food with expired dates. A container with 5 New York strip steaks with use by date of [DATE], there was a second container with 3 New York strip steaks with use by date of [DATE]. There were 4 (5 lbs.) containers of chicken stock with use by date of [DATE]. One small container of salsa roja (red sauce) use by date [DATE]. One small container of cocktail sauce labeled use by [DATE]. One small container of hash butter labeled use by [DATE]. V4 stated that the container was labeled incorrectly, that the date should have been on the prepared date instead of on the use by date. V4 further stated, Food needs to be used by the use-by date One small container of black olives labeled prepared [DATE], no use by date noted on the container. V4 stated that the black olives can be in the cooler for up to a month after preparation. There were 5 (5 lbs.) containers of Broccoli soup with a use by date [DATE]. In cooler #4, there was a container with blue cheese labeled prepared [DATE] use by [DATE] V4 stated that the blue cheese can last up to one week in the refrigerator. But that food needs to be discarded by the use by date. There was one half gallon of apple cider labeled open date [DATE] use by [DATE]. During a tour of the kitchen, the following was observed stored in the Dry Storage area: 1 dented (6 lbs) jalapeno pepper can 1 dented (6 lbs) apple sauce can 1 dented (7 lbs) hot fudge sundae can V4 stated that dented cans should be stored in a designated area to be returned to the supplier and not on the shelf with other canned foods. On [DATE] at 10:55 AM, during pureed food preparation, V5 (kitchen supervisor) was observed to place three mixed vegetables of pureed portions into the blender. V5 was observed to have on gloves during this procedure; however, V5 stirred the mixed vegetable every time the blender stopped, and with the same gloved hand he was observed touching the knobs on the blender, to turn the machine on/off. When the pureed process was completed, V5 proceeded to serve the bowls using the same gloved hands. V5 then proceeded to puree the grilled chicken breasts, V5 stirred the chicken breasts with his gloved hand; and every time the blender stopped, V5 then proceeded to serve the grilled chicken breasts on the bowls using same gloved hand that he used to turn on/off the blender's knobs. V5 didn't change gloves or wash hands during the food prep process. On [DATE] at 11:10 AM, V6 (Registered Dietitian) stated, when asked if it was common practice for kitchen staff to use their gloved hands to stir food, It all depends where their hands have been previously, I prefer not to but we have a lot of old timer cooks. On [DATE] at 9:50 AM V5 stated that I should have not stuck my hand in the blender, I should have used a spatula. Facility's policy Receiving, Inventory and storage, effective (MONTH) (YEAR), states All products should be inspected for safety and quality and be dated upon receipt and when they are prepared. Use use-by dates on all food stored in refrigerators. Items in the refrigerators should be covered, labeled and dated. Any expired or outdated food products should be discarded. Dented or Bulging cans should be placed on Damaged Goods Shelf and returned for credit. Facility's policy Receiving Food and Supplies, undated states Only accept food of the quality and in the quantity ordered. If a can is dented, rusty, or damaged return to supplier. These cans are to be stored in a designated area. Facility's policy Hand Hygiene Revised (MONTH) (YEAR) states Glove use does not replace the need for hand hygiene.

Based on observation, interview and record review, the facility failed to follow professional standards of practice for administering nebulization treatment, for one of one resident (R2) in the total sample of 14, reviewed for nebulization treatment. Findings include: On 5/20/19 at 1:05pm during the medication pass with V7 (Registered Nurse), V7 failed to check R2's breath sounds before and after administering the nebulization treatment. R2 has a [DIAGNOSES REDACTED]. R2's physician order [REDACTED]. During observations on 5/20/19 at 2:25pm, V7 stated, after the nebulizer treatment you should check to see if the resident is breathing well, he has refused to allow auscultation of lungs in the past. The Facility's Policy Administration of Handheld Nebulizer Treatment (Dated (MONTH) 2019) documents in part, Assessment of breath sounds, pulse, and respiratory rate is completed before treatment and after treatment and documented in electronic medical record.

Based on observation, interview, and record review, the facility failed to dispose of expired medical supplies. This has the potential to affect all 26 residents currently residing in the facility. Findings include: On [DATE] at 9:45 am, V1 (Administrator) stated 26 residents currently reside in the facility. On [DATE] at 12:00 pm, V17 (Nurse) stated the facility currently has one emergency cart, which services all residents in the facility. This emergency cart contained the following items: two suction catheter trays, with the expiration date (MONTH) (YEAR); and one oxygen nasal cannula, with the expiration date (MONTH) (YEAR). V2 (Director of Nursing) stated [DATE] at 1:20 pm all expired medical supplies, such as suction trays and nasal cannulas that are past their expiration date should be discarded and replaced. Facility policy titled Equipment and Supplies Managementdated [DATE] reads expired supplies are discarded and replaced as needed.

Based on observation, interview, and record review, the facility failed to have regular, mechanical, and pureed diet recipes. This has the potential to affect all 26 residents in the facility. Findings include: On 4/23/18 at 11:05am, V15 (cook) was observed preparing mechanical ground pot roast and pureed pot roast with vegetables and broccolini. V15 was asked by surveyor for the recipes. V15 stated he did not have any recipes. V11 (executive chef) was asked for the recipe binder. V11 stated, We don't have a book of recipes. I was never told that I needed one. On 4/23/18 at 3:00pm, V1 (administrator) stated, Yes, the kitchen needs to have a recipe book. On 4/24/18 at 10:14am, during facility presentation, V11 stated, We have contacted our corporate office and they are starting to create recipes. Yesterday, we created recipes for 3 pureed dishes. Facility's policy titled Standardized Recipes documents the following: Process: Standardized recipes will be used for all products prepared and will note appropriate seasonings in order to assure acceptance from the residents. 1. Use standardized recipes provided with menu cycle. 3. Standardized recipes will be adjusted for therapeutic and consistency modifications. 4. The Dietary Manager will monitor and check routinely the cook's use of recipes. 7. Recipes note how to prepare the food items in order to preserve vitamins, taste, and appearance.

Based on observation, interview, and record review, the facility failed to have thermometers in refrigerators/coolers, log refrigerator/cooler and food temperatures on a log sheet, sanitize thermometers properly, label and date food items, cover garbage cans, wear hair nets and beard protectors, secure carbon [MEDICATION NAME] tanks, clean kitchen floor, take temperatures of pureed food items, and perform hand hygiene. This has the potential to affect all 26 residents in the facility. Findings include: On [DATE] at 11:30am, initial tour of the kitchen was done with V4 (sous chef). The following observations were made. Refrigerator 1 did not have a thermometer inside. On the temperature log sheet, there were missing temperatures for ,[DATE], ,[DATE], ,[DATE], and [DATE]. Refrigerator 2 did not have a thermometer inside. On the temperature log sheet, there were missing temperatures for ,[DATE], ,[DATE], ,[DATE], and ,[DATE]. Inside, there was a tray with sixteen (32 ounce) containers of salad dressing not labeled or dated. V4 stated, These salad dressings should be labeled and dated. I'm going to throw these out. In the morning, it's the cook's job to take temperatures of the refrigerator. I will in-service my staff. In refrigerator 3, there was no open date on the following bottles: 4 (lb, pounds) of grape jelly, 6lb cranberry sauce, 24 ounces chocolate syrup, and one package of butter balls. V4 stated, These should have all been dated with an open date. There was no lid on the garbage can by the coffee makers. On the table top, there was no label or date on a dispenser freshly made with lemonade. In the prep cooler, there was no open date for the following items: 5.2lb stir fry sauce, 1 gallon of barbeque sauce, two jar of (1 gallon) mayonnaise, 1 gallon chunks of bleu cheese dressing, 1 gallon of tartar sauce, 1 gallon poppy seed dressing, I gallon of thousand island dressing, and 1 gallon of raspberry vinaigrette. V4 stated that he did not know the open date of the jars and said he would throw them out. V4 stated all cans/jars should have open dates. The ice-cream cooler had no thermometer inside and the cartons of ice cream were not labeled or dated with an open date. There was no temperature log. V4 stated, I don't know where the thermometer is. I will get a new one. We never had a temperature log for this. I will start one. On the table, there were 6 bags of raisin bread loaves, 2 bags of buns, 5 bags of bread, 1 bag of muffins, and 1 bag of bagels with no open date. There was one garbage can with dirty cloth napkins that was not covered with a lid. V5 (dishwasher/utility worker) was not wearing a hair net. V6 (server) and V7 (server) were observed not wearing a hair net. The garbage can by the three compartment sink was not covered with a lid. In the dry storage room, there were two unsecured tanks of carbon [MEDICATION NAME] in the dry storage room. One was by the wall and the other was propping the door open. V4 stated, I've always seen these tanks here. If it's not secured, then it's a hazard. It can cause someone injury. It should be chained or secured. It should not be propping the door. Inside the dry storage room, there were the following rubber maid containers that were labeled with a dry erase marker and starting to fade: Barely--[DATE] Penne--[DATE] Egg Noodles--[DATE] Rigatoni--no date or label Wild Rice--[DATE] Oricchetti--[DATE] Cous Cous--[DATE] Orzo--[DATE] Jasmine rice--,[DATE] Brown Rice--[DATE] Arborico Rice--[DATE] Quinea--[DATE] Split peas--[DATE] Lentils--[DATE] Barely--[DATE] Palenta--not dated/labeled V4 stated, Those dates are not correct. We have filled those containers past those dates. I will inservice my staff to use all of the product before refilling it. V4 was asked for the temperature logs for breakfast, lunch or dinner. V4 stated, We definitely temp, but we don't log it. We don't have a binder where we log the temperatures. Is that something we should be doing? V8 (server) was not wearing a hair net. V9 (cook) was not wearing a hair net or beard cover. In the main prep kitchen, the following observations were made: In the dry bin canisters, there was bleached or unbleached flour with no dates. There was also a canister of Panko with no date. There was one dry bin canister of all purpose flour with a label that documents Prepared [DATE] and use by [DATE]. There was a dry bin canister of granulated sugar with a label that documents Prepared [DATE] and use by [DATE]. Refrigerator 1 was missing temperatures on ,[DATE] and ,[DATE] on the temperature log sheet. Refrigerator 2 was missing temperatures on ,[DATE] and ,[DATE]. Inside, there was a cake that was not covered. V10 (Baker/Assistant Pastry Chef) was preparing desserts and was observed to not be wearing a beard protector. V11 (Executive Chef) was asked by surveyor to test a sanitation bucket. The test strip read 50 ppm (parts per million) of Quat. V11 stated it should be 200 ppm. V12 (Server) and V13 (Server) were not wearing hair nets. V4 stated, All garbage cans should be covered with a lid when not in use. All staff entering the kitchen should be wearing hair nets or a beard protector if needed. In the second floor kitchenette at 12:30pm the following observations were made: The floor was dirty and filled with crumbs and other particles. V14 (server) was asked for her food temperature log. Log book documented mash potatoes were 90 degrees. There were no temperatures taken for the pureed peas and pureed chicken pasta. V14 stated, I normally don't take the temperatures of the pureed items. I thought they take it downstairs in the main kitchen. I didn't retake the temperature of the mash potatoes. Yes, the mash potatoes should be 135 degrees and over. On [DATE] at 11:05am, mechanical/puree observation was done with V15 (cook). V15 put on gloves. V15 cut cooked pot roast with a knife and put it in the blender. V15 blended it. Then, put the liquid in from the post roast. V15 took the temperature with a thermometer. Instead of using a spoon, V15 scooped out ground pot roast from the blender with the same gloved hands and put it in a bowel. V15 then proceeded to puree the pot roast with vegetable dish and broccolini dish. V15 did not change gloves or perform any hand hygiene throughout. V15 did not sanitize the thermometer with alcohol wipes. V16 (cook) did not have a hair net on. Sign on wall documents High temperature Eco-lab (Oasis 146 Multiquat Sanitizer) should be between ,[DATE]ppm. The two tanks of carbon [MEDICATION NAME] were still not fastened or chained to the wall in the dry storage room. V11 stated he will have maintenance look it. The label to the carbon [MEDICATION NAME] tanks documents the following: Non-Flammable. Caution: High Pressure Liquid and Gas. Can cause rapid suffocation. Can increase respiration and heart rate. (MONTH) cause frostbite. Avoid breathing gas. Store and use with adequate ventilation. V11 stated, I am the head of the kitchen. I am pretty new here. I didn't know we have to record food temperatures in a log sheet. I didn't know we have to put dates on the dry good foods. Facility's policy titled Personal Hygiene documents the following: 2. Hands must always be washed prior to beginning work. Hands must always be washed after smoking, using the restroom, or handling any unsanitary items. 5. Staff in the food preparation areas should wear a clean hat or other hair restraint. Hair must be appropriately restrained 5.1 Head covering must be clean. 5.2 Body hair that may be exposed (i.e., arms) must be covered. Uncovered, short (individual hairs are not longer than ,[DATE] in length), and well-groomed mustaches wound not pose a food safety hazard. Facility's policy titled Garbage and Trash Cans documents the following: Process: 1. All food waste must be placed in covered garbage and trash cans. Garbage cans can remain uncovered while in use. Facility's policy titled Food Temperatures documents the following: Process: Foods should be served at proper temperature to insure food safety and palatability. 1. Wash, rinse, and sanitize a dial face, metal probe-type thermometer with alcohol wipe. A practical range of 0 degrees-220 degrees F is recommended. Resanitize the thermometer after each use. 3. Record reading on Food Temperature Chart at beginning of meal service tray line. If temperatures do not meet acceptable serving temperatures, reheat the product or chill the product to the proper temperature. Facility's policy titled Receiving, Inventory and Storage documents 1. All products should be inspected for safety and quality and be dated upon receipt and when they are prepared. Use use-by-dates on all food stored in refrigerators. 1.1: Items in the refrigerator should be covered, labeled, and dated. This may not be needed if in original packaging and product is identified on the package. 1.2 Any expired or outdated food products should be discarded. 16. Dry Storage: 7. Any opened products should be placed in seamless plastic or glass containers with tight fitting lids and labeled and dated. A label may not be needed if in original packaging and product is identified on the package. 8. Remove food stored in bins from their original packaging. Label and date all storage containers or bins. Keep free of scoops. Lids need to be tight fitting and in good condition. Clean and sanitize outside food bins daily. Clean and sanitize insides of food bins when product is changed out or is outdated. Facility's policy titled Record of Refrigeration Temperatures documents: 1. An employee is designated to record refrigerator and freezer temperatures on the Refrigeration Temperature log. 2. Internal thermometers in both the refrigerator and freezer are to be in the warmest area of refrigerator or freezer. Record temperatures from the internal thermometers. Facility's policy titled Sanitizer Use Concentrations documents 3. Sanitation buckets must be established with appropriate sanitizing solution, i.e., generally for chlorine-based sanitizer, ,[DATE]ppm or quaternary solution, ,[DATE] ppm or 200 ppm depending on the product used and manufacturer guidelines. 5. Dietary should change these buckets at least 3 times a day and test with the appropriate litmus strips each time the solution is changed to assure accurate levels of sanitizer. Facility's policy titled Carbon [MEDICATION NAME] Management documents the following: Process: Carbon [MEDICATION NAME] is stored in designated store room. 1. Carbon [MEDICATION NAME] cylinders must be stored in racks with chains, sturdy portable carts, or approved stands.

Based on observation, interview, and record review, the facility failed to ensure oxygen delivery supplies were dated and stored in a sanitary manner. This has the potential to affect one of twelve sampled residents (R26) reviewed for oxygen equipment, as well as three residents (R4, R10, and R25) outside of the sample . Findings include: On 4-22-18 at 10:50 am, R25 was using oxygen at two liters per nasal cannula via a portable tank attached to the back of her specialty chair. Behind R25's chair was a concentrator, with a 500 ml (milliliter) bottle of sterile water attached to it. This bottle of sterile water was open to air at the end of the spout, and was not dated as to when it was opened for use. On 4-23-18 at 11:02 am, the spout on R25's sterile water bottle remained open to air at its end, and still was not dated as to when it was opened for use. On 4-22-18 at 11:05 am, R4 was seated in a recliner in her room. Across the room was R4's oxygen concentrator, with a nasal cannula and long extension tubing attached to it. This extension tubing was lying coiled up on the floor. On 4-22-18 at 1:42 pm, R26 was in bed, using oxygen at three liters per nasal cannula via a concentrator. The 500 ml sterile water bottle attached to R26's oxygen concentrator was not dated as to when it was opened for use. On 4-23-18 at 10:30 am, R10 was laying in bed, using oxygen at two liters per nasal cannula via concentrator. R10's nasal cannula was connected to a long extension tubing, which was lying coiled up on the floor. V2 (Director of Nursing) stated 4-23-18 at 1:15 pm oxygen nasal cannulas and extension tubing should be contained in a plastic bag when not in use, and not be kept on the floor. Bottles of sterile water used to humidify oxygen should be dated when opened. Facility policy titled Oxygen and Respiratory Therapy, Infection Control Measures indicates, in part Oxygen and respiratory therapy tubing should be kept off the floor. When oxygen and/or respiratory therapy mask or cannula or nebulizer equipment is not being used, it is store at bedside in a clean plastic bag. If tubing is disconnected from humidifier bottle, ports should be covered.

Based on observation, interview, and record review the facility failed to ensure that food sanitation practices were implemented and failed to properly store and label perishable food in the refrigerator in the kitchen area. This failure has the potential to affect all 22 residents in the facility. Findings Include: During initial tour of the kitchen on 5/4/16 at 10:00 am observed one plastic container with fruit syrup with use date by 4/1/16. E3 (Head Chef) stated on 5-4-16, at 10:00 am the container of syrup discarded April 1, 2016. Observed on 5-4-16 at 10:10 am in walk-in refrigerator 12 quarts of minestrone soup undated. E3 stated on 5-4-16 at 10:10am the minestrone soup was for the residents and should have been dated prior to being placed in the refrigerator. It could then be held for three (3) days prior to disposal. Observed on 5-4-16 at 10:15am three bags of shredded and three bags of cubed cheese opened and undated in the walk-in refrigerator. E4 (Dietary Manager) stated on 5-4-16 at 10:15 am that any time food is opened it should be dated, staff know to discard it after three days. E4 indicated they were unsure when the cheese was opened. Facility's Safe Food Handling, Flow of Food policy denotes many packed foods are marked with expiration dates. Check these dates regularly and use the food before the date shown. Proper Food Handling: Leftovers must be dated, labeled, cooled, properly covered and stored in refrigerator or freezer. Leftovers are to be labeled, dated and used within three days.

Based on observation, interview and record review, the facility failed to follow standards of infection control by failing to: perform hand washing per facility policy and sanitize blood glucose monitoring machines prior to/after use. These deficient practices affected two residents (R6, R9) in the sample and five residents (R11, R13, R14, R15, R16) in the supplemental sample reviewed for infection control. Findings include: On 3/31/15 at 12:50 PM, E9 (RN-Registered Nurse) entered R15's room to administer Deep Sea Nasal Spray 0.65%. E9 washed her hands for three seconds, gloved and administered the nasal spray. On 3/31/15 at 2:30 PM, R13 had a bowel movement and E12 (CNA-Certified Nurse Assistance) performed incontinence care. E12 cleaned some of the bowel movement, removed her gloves, washed her hands for five seconds and donned a new pair of gloves. E12 continued to clean R13 from more bowel movement. E12 used the same gloves to place a new incontinence brief on R13. E12's gloved hands came into contact with R13's pants and shirt. E12 removed her gloves and washed her hands for five seconds. During the Medication Pass task on 4/1/15 at 8:00 AM, E9 (RN) placed her bangs in a clip. E9 then prepared R11's Humalog insulin without performing hand hygiene. E9 then coughed into her left hand and continued to handle the syringe with R11's insulin medication. E9 did not perform hand hygiene. E9 entered R11's room and washed her hands for three seconds. On 4/1/15 at 8:20 AM, E4 (CNA) entered R6's room with a mechanical lift. E10 (RN) entered R6's room on 4/1/15 at 8:21 AM. E4 and E10 did not wash their hands prior to assisting R6. Both staff members donned gloves. When E4 removed her gloves, she washed her hands for five seconds. On 4/1/15 at 8:55 AM, E10 crushed R9's medications and did not perform hand hygiene prior to spoon feeding R9 his medications. On 4/1/15 at 9:50 AM, E9 (RN) crushed R16's medications. Prior to entering R16's room, E9 did not perform hand hygiene, applied gloves and then spoon fed R16 her medications. On 4/1/15 at 7:55 AM, E9 indicated that she was going to perform a blood glucose monitoring test on R11. E9 pulled a black zippered case out of her medication cart and indicated that R11 has her own machine. E9 did not sanitize the blood glucose machine prior to use. E9 entered the room and washed her hands for three seconds. After performing the blood glucose test on R11, E9 did not sanitize the machine. E9 placed the glucose monitoring machine back into the black zippered case and stored it away in her medication cart. On 4/2/15 at 8:37 AM, E9 prepared to perform a blood glucose test on R14. E9 did not sanitize the machine before use. E9 indicated that R14 does not have his own machine and that the machine was a house blood glucose monitoring machine. E9 indicated that this means it can be used on other residents. E9 entered R14's room to perform the test. E9 did not sanitize the blood glucose monitoring machine after use. E9 stored the machine away in the medication cart. On 4/1/15 at 2:30 PM, E3 (ADON-Assistant Director of Nursing) stated, "They should wash their hands for 20 seconds." On 4/2/15 at 8:55 AM, E3 stated, "We use (bleach) wipes. We clean them before and after we utilize them. We wipe the glucometers down and leave it for three minutes. We sanitize them even though the residents have their own machines. The staff is trained to sanitize glucometers before and after use. A facility policy dated April 1, 2013 and titled, "Hand Hygiene" documents: 4. Perform hand hygiene: Before having direct contact with patients, After contact with a patient's intact skin, After removing gloves, Before and after any invasive procedure, Before and after medication preparation and administration. 5. Guidelines for performing hand hygiene include but are not limited to: 5.2 When washing hands with soap and water: Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. A facility policy dated April 1, 2013 and titled, "Glucometer Quality Control Testing and Cleaning" documents: 4. The glucometer is disinfected after each use using (disinfectant wipe) or other approved cleaner noted in the manufacturer's guidelines.

Based on interview and record review, the facility failed to update the fall prevention care plan for one resident (R3) out of three residents reviewed for falls in the sample of 10. Findings include: A Fall incident report dated 2/4/15 noted the R3 was "found lying on the floor". A statement from R3 read "I stood up from my wheelchair to use the toilet and I fell ." No injury was documented. The post-fall intervention was for R3 to be evaluated by Physical Therapy for safe transferring. A Physical Therapy Progress and Discharge Summary" indicated R3 began therapy 2/3/15 and ended on 2/18/15 with the goal of "patient will safely transfer from bed to and from wheelchair increasing to minimal assistance (1-25% assist)". This goal was shown as "not met". The discharge summary indicated R3 requires "maximum assistance (76-99% assist)". The Analysis of Functional Outcome/Clinical Impression reads "Patient has shown plateau with progress. Will continue using the sit-to-stand during morning bed to wheelchair transfer to protect the patient and the staff. For toilet transfer, the patient will be minimum assist." R3's care plan was updated on 2/4/15 to indicate Activity staff should alert nursing staff if resident leaves an activity "as she might need to void". A prior care plan update was recorded from a fall incident (lowered to the floor) on 10/30/14 that read "Resident will have one to two person assist during transfers. PT (Physical Therapy) to evaluate for ability to transfer safely with staff." On 3/17/15, a Fall incident report noted R3 "was lowered to the floor during transfer. Resident's knees gave up during pivot. Lowered to the floor by CNA (certified nurse aide)." No injury was assessed. No new intervention was noted on R3's Fall incident report. R3's care plan was updated on 3/17/15 to read "reinforced to staff on duty to call for assistance especially during transfer." No update was made from 2/18/15 to 3/17/15 or as of 4/2/15 indicating the recommendation from PT to use a sit-to-stand lift. On 4/1/15 at 11:40 AM, R3 stated staff sometimes use the sit-to-stand lift for her transfers, but not frequently. R3 stated the lift is less painful on her back, but "seems like a hassle for staff." R3 scored 12 out of 15 on the Brief Interview of Mental Status dated 12/26/14. On 4/2/15 at 10:50 AM, E2 (Director of Nursing) provided copies of R3's care plans, including the Fall care plan. E2 acknowledged R3's care plans made no mention of using the sit-to-stand transfer. E2 stated that she is responsible to update care plans and should get information from E8 (Restorative Nurse) regarding recommendations made by PT when the resident is discharged from skilled PT. On 4/2/15 at 12:30 PM, E1 (Administrator) stated a care conference was recently held with R3's daughter to discuss her physical decline. E1 stated she feels the staff should be using the sit-to-stand lift. The facility policy, Fall Precautions Protocol, dated 2.13, reads in relevant part: "Fall Reduction Interventions 2.2 Any interventions that are selected for a resident's plan of care/service plan should be documented in the care plan/service plan." Addendum #1, Reducing Extrinsic Risk Factors includes "individualize equipment specific to resident needs." The Fall Precautions Protocol also includes "Post Fall Actions 7. The resident's care plan/service plan is reviewed after every fall event and new interventions added as per assessment and the post fall review." "Communication of Falls 1. Communication of resident's fall risk to staff is a step in the fall reduction process. Once a resident's risk has been assessed and the individualized interventions have been planned to decrease the resident's risk, this information should be made known to all staff. Methods for providing information on individual resident's risk include: Written in the care plan/service plan; Oral during reports and team conferences; Visual cues to alert all staff, including staff as well as housekeeping, laundry, maintenance and clerical staff."