Every finding on record at Mayflower Healthcare Center

Based on observation, interview, and record review, the facility failed to conduct medication self-administration assessment to ensure safety for 1 of 1 residents reviewed for self-administration of medications, of a total sample of 28 residents, (#42). Findings: Resident #42 was admitted to the facility on [DATE] with diagnoses which included encounter for surgical aftercare following surgery on the digestive system, Parkinson's Disease, anemia, major depressive disorder, generalized anxiety disorder, presence of left artificial hip joint and dementia. Review of the Minimum Data Set annual assessment with assessment reference date of 12/11/24 revealed resident # 42 had a Brief Interview for Mental Status score of 15 out of 15 which indicated she was cognitively intact. On 2/17/25 at 12:58 PM, resident #42 was observed in her wheelchair watching television with her bedside tray table directly in front of her. Towards the right side of the tray table a small red pill was observed on a white tissue that had times written on it. When asked about the times written on the tissue, she explained that it was written down so that she could be reminded of when to take her eye vitamin. Resident #42 mentioned her daughter bought the vitamins for her because the eye doctor told her it was okay to take them and that they were very expensive. She stated the nurses knew she had been taking the medication on her own twice daily. A review of resident #42's medical record indicated no physician orders for eye vitamins or self administration of medication, no care plan for self-administration of medication and no assessments completed for resident #42 regarding self-administration of medications. On 2/17/25 at 2:07 PM, the assigned nurse Registered Nurse (RN) A observed and verified the red pill on a piece of tissue on resident #42's tray table in her room. With the resident's permission, RN A then retrieved the bottle of pills from an uncovered white plastic container on the resident's tray table and confirmed the pill bottle was labeled PreserVision AREDS 2. Resident #42 explained she had been taking it a long time and it was very expensive. RN A told the resident she was not allowed to have the medication at the bedside and assured her that the facility had medications in stock which could be provided. On 2/18/25 at approximately 10:00 AM, resident #42 stated she was not aware she could not take her own medication. She explained she did not know of any assessments which should be completed by nurses prior to her self-administering medication. She said that the nurse took the medication from her, and they would administer it. On 2/19/25 at 10:06 AM, assigned Certified Nursing Assistant (CNA) B said she had seen the medication on the resident's tray table previously and confirmed the resident had marked the times on the tissue to remind herself when to take it. CNA B stated she thought the residents were allowed to have over the counter medications at their bedside but now understood why that might not be okay. On 2/19/25 at 11:46 AM, the Assistant Director of Nursing (ADON), acknowledged she did not really know what happened in regards to resident #42's medication at her bedside. She explained if a resident requested to use their own medications and self-administer, they would first have to be assessed for self-administration of medications by nursing. The ADON said that a physician order for the PreserVision was now in the computer and the resident wanted to receive her own medication but preferred the nurses to administer it. On 2/19/25 at 12:14 PM, assigned Licensed Practical Nurse (LPN) C said she was not sure if residents could have medications at the bedside and explained, if residents wanted to administer their own medications, the supervisor would handle it. LPN C explained she was not aware resident #42 was taking her own eye vitamins and had not seen any medication on the resident's tray table. On 2/19/25 at 12:29 PM, the Director of Nursing (DON) said he was made aware of the medication on resident #42's tray table on Monday. He continued that, sometimes residents have a way of bringing stuff in the facility which in this case, was unfortunately missed. The DON went on to explain that the Interdisciplinary Team ultimately decided if it was appropriate for residents to take their own medications based on the assessment for self-administration of medications and the management of a lock box provided. Review of the undated facility policy regarding Self-Administration of Medications revealed Residents may self-administer their own medications only if the Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision -making capacity to do so safely.

Based on interview, and record review, the facility failed to ensure nurses followed physician orders regarding administration of blood pressure medication per parameters set by the physician, for 1 of 5 residents reviewed for unnecessary medications, of a total sample of 28 residents, (#44). Findings: A review of the medical record revealed resident #44 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of pancreas, benign neoplasm of colon, anxiety disorders, chronic pain, major depressive disorder and essential (Primary) Hypertension. The medical record revealed resident #44 had an active physician order for Clonidine HCL tablet 0.1 milligrams (mg) tablet that directed staff to give 1 tablet by mouth two times a day for hypertension. The order included a parameter to hold the medication if the resident's systolic blood pressure (SBP) was less than 170 millimeters of mercury (mm Hg) or diastolic blood pressure (DBP) was less than 90 mm HG. Clonidine is prescribed to treat high blood pressure (hypertension) by decreasing the levels of certain chemicals in your blood. This allows your blood vessels to relax and your heart to beat more slowly and easily, (retrieved on 2/23/25 from www.drugs.com/clonidine.html). Review of resident #44's Medication Administration Record (MAR) for January 2025 and February 2025 revealed Clonidine HCL 0.1 mg was scheduled twice a day at 10:00 AM and 9:00 PM. The document showed the medication was either administered (indicated by a check mark) or not administered (indicated by the number 4-Vitals outside of parameters; 5-Hold/see progress notes; 9-Other/see progress notes). Review of the January 2025 MAR revealed Clonidine HCL 0.1 mg was administered once at 10:00 AM on 1/27/25 for a blood pressure of 153/70, under the parameters of the physician order. The MAR also revealed the medication was checked as administered several times at 9:00 PM when it should have been held according to the physician order. On 1/06/25 when the resident's blood pressure was 157/65; on 1/07/25 when the resident's blood pressure was 129/57; on 1/11/25 when the resident's blood pressure was 141/67 and on 1/17/25 when the resident's blood pressure was 123/63. For the month of February 2025, resident #44's MAR indicated on 2/15/25 at 10:00 AM Clonidine HCL 0.1 mg was checked as administered even though the documented blood pressure was 149/67, less than the parameters set by the physician order. On 2/08/25 at 9:00 PM the medication was also checked as administered for a documented blood pressure of 112/65 and again on 2/18/25 at 9:00 PM for a blood pressure of 104/59. On 2/20/25 at 10:43 AM, the Director of Nursing (DON) verified the administration of Clonidine HCL 0.1 mg for resident #44 and confirmed the check marks on the MAR for January and February of 2025 indicated the medication was given by the nurse. He acknowledged the medication should have been held instead of given per the parameters set in the physician order. A review of the facility's undated Policy on Administering Medications indicated, Medications shall be administered from a unit dose system in a safe and timely manner, and as prescribed.

Based on interview, and record review, the facility failed to notify the resident representative of significant weight loss for 1 of 1 resident reviewed for notification of change in condition, out of a total sample of 33 residents, (#9). Findings: Resident #9 was admitted to the facility on [DATE] with diagnoses of unspecified dementia, Alzheimer's disease, major depressive disorder and anemia. Review of the Minimum Data Set (MDS) quarterly assessment with assessment reference date of 12/11/23 revealed resident #9 had a Brief Interview for Mental Status score of 1 out of 15 which indicated she had severe cognitive impairment. The document noted the resident had weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months and was not on a prescribed weight-loss regimen. A care plan for nutritional risk was initiated 11/05/21 and revised 11/03/23. The care plan indicated resident #9 was identified with significant weight loss on 7/13/23 and 11/03/23. The facility implemented interventions, but resident continued to lose weight. Review of resident #9's electronic medical record (EMR) demographic information revealed the resident's son was listed as the authorized Emergency Contact #1 and as her Power of Attorney for care. Review of documented weights for resident #9 revealed she weighed 150.3 pounds in April 2023 and began losing weight every month with a weight of 125.3 pounds recorded on 2/01/24. The Weights and Vitals Summary report identified resident #9 had a 10% change over 180 days on 10/04/23, 11/01/23, 11/30/23, 12/06/23, 12/13/23, 1/25/23 and 2/01/23. Review of resident #9's EMR revealed care plan meeting documentation dated 12/20/23 which read, Dietary: Resident is eating well. No changes in her diet. The form did not contain any documentation of resident representative being notified of resident's significant weight loss. On 2/08/24 at 9:25 AM, in a telephone interview with resident #9's son, he stated she had never been a fast eater, would eat dessert first and ate small bites. The resident's son stated the facility usually alerted him of any concerns but did not recall having a conversation about his mother's weight loss. He stated that was something he would definitely want to know about. On 2/08/24 at 11:29 AM, the Registered Dietician (RD) stated she was familiar with resident #9 and her weight loss. The RD stated she reviewed resident #9's status and her weight loss was discussed at weekly Risk Meetings. The RD acknowledged she had not notified the resident's representative of resident #9's significant weight loss. She explained she did not know who was responsible for notifying the resident's representative. On 2/08/24 at 12:17 PM, the Director of Nursing (DON) confirmed Risk Meetings were held weekly and weight loss was one of the areas discussed in the meeting. The DON stated resident #9's representative should have been contacted regarding the weight loss prior to the Risk Meeting. He acknowledged he had not contacted the family and suggested the RD may have notified the resident representative. The DON explained the resident's weight loss may have been discussed during the care plan meeting. He reviewed resident #9's EMR and could not provide any documentation of the resident's representative being notified. The DON stated a Change of Condition form should have been completed for a significant weight loss but was unable to locate one in the resident's medical record. The DON acknowledged the facility needed to contact the family to discuss resident #9's significant weight loss, interventions in place and possible alternatives. On 2/08/24 at 12:31 PM, the Risk Manager/MDS Coordinator reviewed resident #9's medical record. He acknowledged he was unable to locate any documentation where the resident's representative had been notified of her significant weight loss. The facility's policy and procedure for Change in a Resident's Condition or Status read, The [Center] shall promptly notify the resident, his or her Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status.

Based on interview, and record review, the facility failed to ensure resident grievance was promptly investigated and duly resolved for 1 of 1 resident reviewed for grievances, of a total sample of 33 residents, (#22). Findings: Resident #22, a [AGE] year-old female, was admitted to the facility on [DATE] with diagnoses that included right leg fracture with surgical repair, difficulty in walking, unspecified falls, anxiety disorder and osteoarthritis of the left hand. Review of the Minimum Data Set Admission assessment dated [DATE] revealed resident #22 was cognitively intact, with no behaviors toward herself or others. The assessment indicated resident #22 required maximum assistance for showers, application and removal of footwear and toileting. On 2/06/24 at 10:09 AM, resident #22 was noted to be alert and oriented to person, place and time. She was seated in a chair in her room and explained she had a concern with night shift Certified Nursing Assistant (CNA) A this past weekend for several issues. Resident #22 explained that while she used the toilet, CNA A spoke on her cell phone then left the room without cleaning up and was unhelpful. Resident #22 stated she informed the nurse and a supervisor, who came to see her about the concerns. She said the supervisor assured her CNA A would no longer be assigned to take care of her, so she felt the issue had been resolved at that time. Review of the facility Grievance Log for December 2023, January 2024 and February 2024 revealed only one grievance for resident #22 on 12/23/23 for a call light not working. That grievance was documented as resolved on 12/29/23. There were not other grievances documented for resident #22 for that time period. On 2/08/24 at 10:08 AM, resident #22 was seated in a chair in her room. She stated CNA A was assigned as her aide again overnight. Resident #22 spoke about being upset with problems with care or lack of care from CNA A. She reiterated she had been told by the supervisor on the weekend that CNA A would not be assigned to care for her again. She did not understand why CNA A was assigned to care for her the past night. On 2/08/24 at 10:27 AM, the Social Services Director confirmed resident #22 had only one grievance on the log from December 2023 which was resolved the same day. She acknowledged she was not aware of any concerns or a grievance from resident #22 concerning CNA A's care and service from the past weekend. A few minutes later at 10:32 AM, the Director of Nursing (DON) joined the conversation and said he was not aware of a grievance from resident #22 about CNA A. He said if it occurred over the weekend, the Weekend Supervisor would attempt to initiate and resolve the grievance. He confirmed CNA A was assigned to resident #22 the previous evening. The DON acknowledged staff should not be using a personal cell phone when in a resident's room or in care areas. In interviews on 2/08/24 at 10:45 AM and 11:03 AM, the Unit Manager (UM) stated she was aware resident #22 had filed a grievance over the weekend about a staff member. She indicated resident #22 was concerned CNA A did not tidy the room as she was rushed and ready to go home and used her cell phone in her room. The UM said she received a phone call from the Weekend Supervisor over the weekend about the grievance and said she was going to have a conversation with CNA A but was not informed that CNA A should not care for resident #22 again. The UM said she also received an email from the Weekend Supervisor which described a different CNA had been assigned to resident #22 on Saturday night and the resident was pleased. She confirmed the email did not mention CNA A should not be assigned to resident #22. The UM was unaware of where the actual grievance was located or why it had not been documented in the log. In a telephone interview on 2/08/24 at 10:55 AM, the Weekend Supervisor stated resident #22 had asked to speak to a supervisor over the weekend about her concerns with CNA A. She noted she offered her a grievance form which she completed. The Weekend Supervisor said resident #22 requested that CNA A not care for her again and after speaking with the resident and CNA A she re-assigned the CNA for Saturday night to a different assignment. She indicated she told CNA A that she should not care for resident #22 again. The Weekend Supervisor explained she sent an email to both the DON and UM in regard to the grievance and left the actual form in the DON's office. The Weekend Supervisor was unable to say where she left the grievance form. She thought she left it on the DON's desk or slipped it under his door as there was no designated box or place to put the forms for review by the Social Service Director. The Weekend Supervisor could not explain why the grievance was not documented on the grievance log, or why CNA A was assigned to care for resident #22 again on 2/07/24. On 2/08/24 at 11:11 AM, the DON reiterated he was not aware of resident #22's grievance, or an email from the Weekend Supervisor. He said he did not see a grievance form in his office or on his desk. He said the offices were locked on the weekend and confirmed there was no box or designated place for the weekend staff to submit grievance forms. He said some of the staff slipped them under the door if the door was locked. A short time later at 11:25 AM, the DON stated he found the grievance form on his desk. Review of the Grievance Form completed by resident #22 dated 2/03/24 revealed the statement of grievances included concerns about CNA A being, Late every morning, leaves without getting me ready, room a mess for the next aide, leaves you without a call buzzer. She continued, Talking loudly in Spanish on phone while I'm on toilet right next to me. Didn't show up at all today. I made some dangerous move to finally get up. Just stands watching me, making me ask for my shoes or anything I need- when it should be obvious, throws bedding sloppily when I'm trying to get settled for the night. Short of help because of her. The resolution/interventions taken indicated that on 1/03/24 CNA A was removed as her caregiver. On 2/08/24 at 12:03 PM, in a telephone call CNA A stated she was aware of the grievance concerning resident #22 and had been told by the Weekend Supervisor to not care for her again. She said when she came to work on Wednesday evening, 2/07/24 she was again assigned to resident #22, but did not explain why she did not tell anyone that she was not supposed to care for resident #22. On 2/08/24 at 3:47 PM, Licensed Practical Nurse C stated she did not know of a box or place to put the grievance forms if the Social Service Department was gone for the day. She said she would give it to a Supervisor on duty. On 2/08/24 at 2:32 PM, the DON confirmed neither he nor the Social Service Director were aware of resident #22' s concerns from the grievance she filed on 2/03/24 and no follow up was implemented to ensure CNA A did not care for resident #22 again nor to determine if there was any further need for education. He acknowledged there needed to be a designated central location for grievances to be placed when the Social Service Director or himself were not there and the offices were locked. The DON explained the process should be the Weekend Supervisor would note the grievance, attempt to resolve and investigate as warranted. He added the grievance would then be submitted to the Social Service Director who would ensure the grievance was filed and resolved promptly. The DON acknowledged it was a concern that he and the Social Service Director were unaware of resident #22's grievance and the form had not been found until requested by the surveyor. He said it had never been a problem before, but noted the grievance should go to one central location where the Social Service Department could ensure prompt and accurate follow up. The Problem Solving: Concern, Complaint, and Grievance Policy dated 07/08 declared each resident has the right to voice concerns, complaints or grievances and the facility would actively seek resolution of the concern or grievance and would keep the resident apprised of the progress toward the resolution. The document indicated staff would complete the Record of Concern form where a brief statement of the issue was documented with any interventions taken and or results/outcomes along with a record of dates, times and names of those involved. The procedure described that the information was to be forwarded to the Complaint Coordinator who would review the matter to see if the concerns were addressed. The procedure section also described the DON and Director of Health Services would be involved in the resolution process and would review all Record of Concern forms, then record of each Grievance were maintained and presented to the Quality Assurance Committee.

Based on observation, interview and record review, the facility failed to ensure hot water was maintained at safe temperatures, not exceeding 115 degrees Fahrenheit to prevent the potential of [MEDICAL CONDITION] residents on 3 of 3 hallways including rooms 200, 208, 210 and residents, (# 340, #10, #25) in a total of 23 sampled residents. Findings: On 3/01/21 at 10:28 AM, the hot water in room [ROOM NUMBER] bathroom sink was checked. The water was steaming and too hot to touch. At 12:08 PM, the hot water in room [ROOM NUMBER] bathroom sink was too hot to keep hand under the running water. At 12:43 PM the hot water in room [ROOM NUMBER] bathroom sink was very hot to touch. At 03/01/21 at 1:44 PM, the Certified Dietary Manager calibrated the thermometer and checked the hot water temperature in the nourishment kitchen. The temperature was 120 °Fahrenheit (F). rooms [ROOM NUMBERS] water temperatures were checked at 118 °F. The hot water temperature in room [ROOM NUMBER] measured 120.4 °F. The Health Center Director (HCD) was immediately informed of the excessively high temperature hot water. On 3/01/21 at 4:15 PM, the HCD said he had communicated with the Director of Maintenance (DOM) via phone of the excessive hot water temperatures in resident rooms and nourishment room. He said the DOM was under the impression that water temperatures were to be below 120 °F and they only had to be monitored monthly. On 3/01/21 and 3/02/21 interviews were conducted with alert residents able to use the bathroom sink independently. On 3/01/21 at 4:45 PM, resident #340 said that most of the time she used the cold water to wash and to brush her teeth as the hot water, gets hot too quickly. On 3/02/21 at 10:44 AM, resident #10 said the hot water in the bathroom sink was very hot at times. On 3/02/21 at 11:01 AM, resident #25 said there was something wrong with the plumbing. Sometimes it was too hot and then cold at the same time. I can't change the plumbing. On 3/02/21 at 1:10 PM, the Building Services Supervisor said he was covering for the DOM during his absence. He stated he had not monitored the water temperature after the mixing valve added cold water to bring the hot water to safe temperature range. He noted he had not checked the water temperatures after it was mixed with cold water and distributed to the resident rooms. He adjusted the water and the temperature was now between 112°F -115°F. Review of the monthly preventive maintenance report description noted, check temperature of hot water in shower rooms, a few resident rooms, common bathrooms . The log for 1/11/21 showed the Right Shower was 116.5 °F, the Left shower was 116.9 °F, room [ROOM NUMBER] was 115.3 F, room [ROOM NUMBER] was 116.4 °F, room [ROOM NUMBER] was 114.6 F, room [ROOM NUMBER] was 118 °F and room [ROOM NUMBER] was 119.8 °F. The log for 2/08/21 noted the Right Shower was 115.1 °F, Left shower was 115.8 °F, room [ROOM NUMBER] was 117.8 °F, room [ROOM NUMBER] was 116.7 °F, room [ROOM NUMBER] was 117.9 °F, room [ROOM NUMBER] was 118.2 °F and room [ROOM NUMBER] was 117.1 °F. Review of the maintenance building equipment daily log for hot water temperatures noted the temperature from the boiler was monitored Monday through Friday. For the month of February 2021, the lowest water temperature was 142 °F with highest temperature at 150 °F. Further review of the logs from December 2019 through January 2021 temperatures monitored were between 142 °F and 150 °F.

Based on record review and interview, the facility failed to administer medications as per parameters established by the physician for 1 of 5 residents reviewed for unnecessary medications out of a total sample of 23 residents, (#19). Findings: Resident #19 was admitted to the facility in 2020 with [DIAGNOSES REDACTED]. Review of the resident's medical record noted a physician order [REDACTED]. Review of the Medication Administration Record [REDACTED]. On 2/16/21 she was given [MEDICATION NAME] injection with no laboratory result of Hgb documented. On 2/23/21 she was given [MEDICATION NAME] with Hgb result dated 2/22/21 of 10.1 g/dl. On 3/02/21 she was given [MEDICATION NAME] injection when her Hgb was 10.4 g/dl. Review of the Consultant Pharmacist medication review dated 2/11/21 did not identify any concerns with medication administration for resident #19. On 3/02/21 at 9 AM, the Unit Manager acknowledged the nurse working on 3/02/21 gave the [MEDICATION NAME] injection even when the laboratory results exceeded the parameter for giving the injection. On 3/02/21 at 5:20 PM, the Director of Nursing (DON) reviewed the [MEDICATION NAME] administration for resident #19. The DON identified the nurses that administered the [MEDICATION NAME] were both agency nurses. The DON acknowledged the nurses had not followed the parameters set for administering [MEDICATION NAME] and noted the medication should not have been given. The DON reviewed the Agency Nurse Facility Orientation Checklist after concerns with the [MEDICATION NAME] injections were made known. He said the Orientation Checklist included review of laboratory access related to right dose for orders with hold parameters or obtain/check related measurements ( (blood pressure, pulse, hemoglobin etc.) before giving a medication. The DON acknowledged the Pharmacy Consultant had reviewed resident #19's medication process and had not identified the [MEDICATION NAME] was given inappropriately.

Based on interview and record review, the Quality Assurance and Assessment (QAA) committee failed to identify a quality deficiency related to medication errors and insufficient validation of nursing competencies in medication administration; and failed to revise an existing action plan to prioritize medication administration competency to prevent medication errors and ensure the safety and well-being of all residents. Findings: On 7/31/19 at 1:51 PM, an interview was conducted with the Director of Health Services, the administrator in training and the Director of Nursing (DON). The DON stated he was aware there were 6 medication errors identified during the 3 days of the recertification survey from 7/29/19 to 7/31/19. He acknowledged the error rate was significant. He confirmed the Unit Manager (UM) and Staff Development Coordinator (SDC) also informed him of concerns related to infection control and nursing skills during medication administration. The DON explained the QAA committee identified that the facility did not have a system in place for monitoring the competency and skills of nursing staff. He stated the committee initiated a process improvement program (PIP) on 12/04/18 to focus on staff development, specifically nursing competencies. The DON stated the QAA committee appointed a new SDC, reviewed the online training assignments selected by the previous SDC, and approved the topics for the in-service calendar on 2/28/19. The topics selected for the annual in-service calendar and the nursing competency skills fair held in (MONTH) 2019 were reviewed with the DON. He validated there was no reference to medication error prevention and no requirement for demonstration of competency in medication administration by any route other than by gastrostomy tube ([DEVICE]). The DON acknowledged the QAA committee failed to identify medication error prevention and administration skills as areas that needed to be assessed during nursing competencies. The Director of Health Services stated she attended all monthly QAA committee meetings and participated in discussions related to the QAA committee's PIPs. She explained she was not aware that medication error prevention was not included in the required education for all nurses. When asked if the facility had identified any medication errors since implementation of the staff development PIP, the Director of Health Services said, We went over the errors and did not find any pattern. The DON stated he assigned an online medication error prevention class to specific nurses who committed the errors, but did not make the class mandatory for all nurses. The DON said, The committee should have identified this issue. On 7/31/19 at 3:28 PM, a medication error report for the facility was reviewed with the DON. He confirmed since the implementation of the PIP for staff development related to nursing competencies, the facility identified the following medication errors in addition to the errors identified during the recertification survey: On 1/04/19, a nurse administered the wrong dose of the antibiotic [MEDICATION NAME], 1500 milligrams (mg) instead of 1200 mg. On 1/05/19, a nurse administered the wrong dose of [MEDICATION NAME], a medication used to treat [MEDICAL CONDITION], 10,000 units instead of 25,000 units. On 1/06/19, a nurse administered the wrong dose of the pain medication [MEDICATION NAME] 100 mg instead of 50 mg. On 1/10/19, a resident identified a wrong dose of medication and alerted the nurse prior to administration. An investigation showed an error in transcription of the antipsychotic medication [MEDICATION NAME], which was written as 100 mg instead of 25 mg as ordered. On 2/13/19, an investigation showed the physician was not notified of a lab test result in a timely manner, and nurses administered 2 doses of the blood thinner [MEDICATION NAME] when lab results were out of the therapeutic range. On 4/22/19, a nurse administered the wrong dose of a blood pressure medication, [MEDICATION NAME] 50 mg, one whole tablet instead of half tablet as ordered. On 5/15/19, a nurse administered medication to the roommate of the intended resident. The DON stated the data from the medication error report was not brought to the QAA committee for review, and the PIP was not revised to prioritize nurses' competency in medication administration by all routes to ensure the safety of all residents. Review of the QAA committee's Staff Development Process Improvement Program for Sufficient and Competent Nurse Staffing Review revealed the goals of the PIP included establishing a process to evaluate staff knowledge and skills on hire and throughout employment. The PIP indicated the team would identify required competencies, establish a process to evaluate staff and develop competency-based training. The course development team, the DON, SDC, ADON and Director of Health Services, were responsible for identifying, prioritizing and scheduling courses that needed to be implemented. The facility's QAPI Plan effective 10/29/18 revealed the Quality Assurance and Performance Improvement (QAPI) would . aim for safety and delivery of high quality clinical interventions . including the area of clinical nursing services.

Based on observation, interview and record review, the facility failed to follow physicians' orders to prevent medication errors for 3 of 6 residents on 3 of 3 halls (A, B & C halls) observed during the medication administration task, of a total sample of 27 residents (#28, 198 & 200). There were 6 errors in 30 opportunities for a medication error rate of 20%. Findings: 1. Resident #200 was admitted on [DATE] with [DIAGNOSES REDACTED]. [MEDICAL CONDITION] is defined as an abnormally low level of sodium in the blood. It can cause nausea, vomiting, headache, confusion, fatigue, and muscle cramps. Severe cases of [MEDICAL CONDITION] may be life-threatening if untreated. (www.merriam-webster.com) Review of resident #200's medical record revealed physician's orders [REDACTED]. [MEDICATION NAME] reduce the occurrence of diarrhea related to antibiotic use by restoring the normal balance of bacteria in the intestines. (www.webmd.com) On 7/29/19 at 10:17 AM, registered nurse (RN) B was observed during preparation of resident #200's scheduled morning medication. He added 1 tablet Sodium chloride 1 gm from a blister pack labeled Take 3 tablets (3 gm) . and 1 capsule Bio-K plus from a blister pack labeled Take 2 capsules . to the plastic cup with resident #200's other pills. RN B removed bottles of Bromfenac 0.09% and [MEDICATION NAME] 0.5% eye drops and entered resident #200's room with all medications. RN B administered 1 drop [MEDICATION NAME] 0.5% in each eye, then immediately placed 1 drop Bromfenac 0.09% in each eye. RN B completed administration of both eye drops in less than 1 minute. The RN B then administered resident #200's pills with sips of water. On 7/29/19 at 10:41 AM, RN B returned to the medication cart and was asked to read the labels on the Sodium chloride and Bio-K plus blister packs. After reading the labels on both blister packs, RN B said, Oh yes, I only gave one of each. He confirmed he should have given 3 tablets Sodium chloride and 2 capsules Bio-K plus as ordered. RN B acknowledged he gave resident #200 her Bromfenac 0.09% eye drops immediately after the [MEDICATION NAME] 0.5% eye drops. When asked if there should be a wait time between eye drops, RN B said, I don't remember if there is a specific time. On 7/29/19 at 10:44 AM, the Unit Manager (UM) was informed there were errors during administration of resident #200's medication. RN B confirmed he administered the wrong doses of the identified medications and did not wait between administration of 2 different eye drops. The UM validated there should be a wait time between different types of eye drops, but she could not recall the exact time period. The UM explained she would have to refer to the facility's policy and procedure. On 7/29/19 at 11:00 AM, the Staff Development Coordinator (SDC) stated her expectation was nurses would read medication labels to prevent medication errors, and wait a minimum of 2 to 3 minutes between administration of different eye drops in the same eye. Review of the policy and procedure for Eye Drop Administration effective (MONTH) (YEAR) was reviewed with the SDC. The document read, If another drop of the same or different medication is prescribed for administration in the same eye at the same time, wait 10 minutes . The document indicated it was important to review prescribing information specific to each eye medication regarding spacing timeframes. The manufacturers' directions for [MEDICATION NAME] and Bromfenac ophthalmic drops read, Wait at least 10 minutes before using any other eye drops your doctor has prescribed. (www.drugs.com) 2. Resident #198 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of resident #198's medical record revealed physician's orders [REDACTED]. On 7/30/19 at 5:17 PM, licensed practical nurse (LPN) D removed 1 capsule Tamsulosin 0.4 mg from a blister pack. She opened the Tamsulosin capsule and sprinkled the contents on top of a small amount of applesauce in a medication cup. LPN D explained she usually opened the capsule and administered the medication in that manner because resident #198 had difficulty swallowing the large capsule. LPN D entered resident #198's room and administered the medication in applesauce followed by another small cup of plain applesauce which she said would . get rid of the taste. On 7/31/19 at 12:02 PM, resident #198 stated he did not have a problem swallowing the Tamsulosin capsule due to its size. He explained the capsule had a bitter taste so nurses opened it and gave it in applesauce because it masked the bitter taste. Review of resident #198's blister pack for Tamsulosin 0.4 mg capsules revealed the direction Swallow Whole. Do Not Chew Or Crush. The manufacturer's directions for Tamsulosin read, Do not crush, chew, or open a capsule. Swallow the capsule whole. (www.drugs.com) On 7/31/19 at 9:22 AM, the UM was informed LPN D opened a Tamsulosin capsule and administered it to resident #198 with applesauce despite directions to swallow the capsule whole. The UM stated nurses should have notified the physician if resident #198 had a problem swallowing the capsule and requested clarification from the pharmacy regarding opening the capsule. 3. Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #28 had a physician's orders [REDACTED]. Review of the medical record revealed a care plan for pain that was revised on 5/15/19. The care plan included an intervention to Administer [MEDICATION NAME] gel to L (left) knee per order. On 7/31/19 at 8:53 AM, RN [NAME] was observed during administration of resident #28's medications and treatments. He squeezed approximately 0.25 inch of [MEDICATION NAME] 1% gel onto his gloved fingertip and applied it to resident #28's left knee. On 7/31/19 at 9:14 AM, RN [NAME] was asked how much [MEDICATION NAME] gel he applied to resident #28's left knee. He used 2 fingers to show a small area and confirmed he applied 0.25 inch of the [MEDICATION NAME] gel. RN [NAME] stated that was the usual amount he applied every day. He acknowledged the ordered dose was 2 grams. When asked how he measured the correct dose, RN [NAME] provided a standard paper tape measure from the treatment cart drawer and said, With this. He was informed the tape measure did not have a scale for dosage. RN [NAME] said, We had a measuring card, but now it's gone. He searched in the back of the drawer again and eventually retrieved a [MEDICATION NAME] 1% dosing card. Review of the dosing card with RN [NAME] revealed a dose of 2 grams was equivalent to a 2.25 inch strip of the medication. RN [NAME] confirmed he administered significantly less than the ordered dosage. On 7/31/19 at 9:22 AM, the UM was informed RN [NAME] applied resident #28's [MEDICATION NAME] 1% gel without measuring the ordered dosage. She confirmed RN [NAME] should have measured the [MEDICATION NAME] 1% gel with the dosing card to ensure accuracy of the dosage applied. The UM validated it was a medication error. The manufacturer's directions for [MEDICATION NAME] 1% topical gel read, This medicine is supplied with dosing cards that show you how much gel to use for a 2-gram dose . Squeeze the gel onto this card along the line for your dose. (www.drugs.com) On 7/31/19 at 11:28 AM, the consultant pharmacist stated eye drops required at least 3-5 minutes to allow for absorption of the medication. She was informed the manufacturers' directions and facility policy and procedure indicated a wait time of 10 minutes between administration of different eye drops. The consultant pharmacist acknowledged it was important to adhere to manufacturers' directions. She confirmed the administration of 2 different types of eye drops without adequate spacing would be 2 medication errors as there was no guarantee either medication would be fully absorbed. The consultant pharmacist explained it was not advisable to open a Tamsulosin capsule as it would cause rapid release of medication that could lead to a sudden drop in resident #198's blood pressure. She stated there was an alternative medication that could be crushed. The consultant pharmacist validated it was important to measure [MEDICATION NAME] 1% gel on the dosing card to ensure the correct dosage of the medication was given. Review of the facility's policy and procedure for Administering Medications (undated), revealed medications would be administered as ordered. The document read, The individual administering the medication must check the label to verify the right medication, right dosage, right time and right method of administration before giving the medication. The policy and procedure indicated medications may be crushed and given with applesauce .provided that the activity of the medication is not affected by this procedure.

Based on interview and record review, the facility failed to ensure a drug regimen was free of an unnecessary [MEDICAL CONDITION] medication for 1 of 5 residents reviewed for unnecessary medications, of 27 total sampled residents, (#28). Findings: Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) annual assessment with assessment reference date of 3/19/19 revealed resident #28 had long-term and short-term memory problems. She had no mood issues or behavioral symptoms. Resident #28 received antidepressant medication every day during the 7-day look back period, and had physician's orders [REDACTED]. Review of resident #28's medical record revealed a care plan for [MEDICAL CONDITION] Drug Use related to current use of antidepressant medications for depression and [MEDICAL CONDITION]. Interventions dated 4/16/18 directed staff to administer antidepressant medications as ordered, follow facility protocol for gradual dose reduction (GDR), periodically review [MEDICAL CONDITION] medication and consider elimination or dose reduction. The care plan was updated on 3/13/19 to show one of resident #28's antidepressant medications, [MEDICATION NAME], was discontinued as ordered by the physician. The consultant pharmacist provided a Note To Attending Physician/Prescriber form dated 8/15/19 with a recommendation to . please consider a gradual dosage reduction to discontinue the [MEDICATION NAME] if deemed appropriate. The form indicated resident #28 also received the antidepressants, [MEDICATION NAME] and [MEDICATION NAME], in addition to [MEDICATION NAME]. The physician reviewed the consultant pharmacist's recommendation and checked Agree on the form. The physician wrote, D/C (discontinue) [MEDICATION NAME] and signed the order on 9/07/18. A review of resident #28's medication administration records (MARs) revealed that [MEDICATION NAME] was not discontinued as ordered on [DATE]. Resident #28 continued to receive [MEDICATION NAME] 25 milligrams (mg) every day at bedtime, in addition to the other 2 antidepressants [MEDICATION NAME] and [MEDICATION NAME]. The [MEDICATION NAME] was finally discontinued on 3/13/19, 6 months after the order was given. On 7/30/19 at 1:58 PM, the Unit Manager (UM) stated once the physician responded to the consultant pharmacist's recommendations, she was responsible for transcription and implementation of any new physician's orders [REDACTED].#28's [MEDICATION NAME] was written. She acknowledged resident #28 received the medication for an additional 6 months, until (MONTH) 2019, contrary to the physician's decision to eliminate 1 of 3 antidepressant medications in (MONTH) (YEAR). On 7/30/19 at 3:30 PM, the Director of Nursing (DON) stated he received recommendations from the consultant pharmacist and forwarded them to the UM. He explained the UM was expected to follow up with the physician regarding recommendations, and ensure any new orders were transcribed to the medical record. On 7/31/19 at 10:50 AM, a telephone interview was conducted with the consultant pharmacist. She confirmed she recommended a dose reduction for resident #28's [MEDICATION NAME] 25 mg in (MONTH) (YEAR). The consultant pharmacist stated the physician agreed with the recommendation to discontinue the medication in (MONTH) (YEAR). She could not explain how it remained an active order until (MONTH) 2019. The consultant pharmacist acknowledged it was a problem that resident #28 received a [MEDICAL CONDITION] medication for 6 months after the physician deemed it to be unnecessary. On 7/31/19 at 1:38 PM, the DON validated resident #28 received the antidepressant [MEDICATION NAME] after the physician evaluated the consultant pharmacist's recommendation to discontinue the medication after a successful period of a tapered dose. He acknowledged the discrepancy was overlooked by the physician, consultant pharmacist, DON, UM and members of the Psychoactive Drug and Behavior Management Committee. The DON said, It got missed on many different levels. The job description for Staff Nurse / Charge Nurse revised in (MONTH) 2009, revealed responsibilities included Clarifies and processes physician orders [REDACTED]. Review of the facility's Policy and Procedures on Receiving/Writing Orders revealed the licensed nurse was expected to . accept, verify, transcribe, and implement orders from authorized prescribers, that are received by a variety of methods . including written orders, standing protocols and pre-printed order sets.

Based on interview and record review, the facility failed to ensure that facility admission packets containing resident rights, facility regulations, facilty policies, financial agreements, and Medicare/Medicaid regulations were given and acknowledged by 13 of 14 sampled residents admitted to the facility in the month of (MONTH) 2019, (#1, #97, #32, #247, #197, #149, #98, #147, #148, # 248, #43, #198, #200). Findings: A review of the facility's admission packet showed a prepared folder for all newly admitted residents. The folder contained the facility's admission contract/agreement, information on protection of the resident's valuables, financial agreements, Medicare/ Medicaid supplemental policies, costs, resident's trust fund and valuables information, Bed Hold Policy, Resident's Rights, Grievance Policy, Privacy Policy, Comprehensive Assessment and Care Plan (The resident/ responsible party's care plan conference attendance decision), Physician Services, Therapy Services (The resident/ responsible party's consent regarding therapy services), information of Pharmacy, Diagnostic Services, Mental Health Services, Podiatry Services, Restraint Services, Guide To Consents and Election, Mayflower Resident Rights Agreement, consent for on-site podiatry services, agreement of Medicare benefits, receipt from resident of Advance Directives Information, Health Service Acknowledgement Form, room rates, Nursing Home Residents' Rights pamphlet, reporting of theft form and the resident hand book. A review of the Admissions Coordinator's job description for health services administrative functions (bb) showed he/she completes admission paperwork with new residents. The Marketing/ Admissions Coordinator's job description for health services administrative functions (f) showed he/she ensures that all administrative paperwork relating to admissions in the Health Center is completed accurately and in a timely manner. On 07/31/19 at 3:25 PM, the Administrator stated she conducted an audit and none of the newly admitted residents had received an admission packet in the past month. On 7/31/2019 at 3:54 PM, the Admissions Coordinator for Health Services stated she assisted with giving the newly admitted residents the admission packet and getting the contract signed. She stated that she only remembered giving 2 newly admitted residents the admission packet since (MONTH) 2019 and none in the month of (MONTH) 2019. She stated that she did not track the residents who received the admission packet. On 7/31/2019 at 3:25 PM, the Marketing/ Admissions Coordinator stated that she was responsible for giving the admission packet as well as obtaining the signatures from the newly admitted residents. She stated she did not remember giving any resident admitted in the last month (July 2019) an admission packet because she was too busy. She stated that the admission packet was the only way that residents were informed of their rights and the rules and regulations of the facility as well as other information. She stated that when the admission packet was given to the resident or their family, a copy was kept in the resident's chart and uploaded to the computer. She stated she conducted an audit of the residents admitted to the facility in the month of (MONTH) 2019 and no one had received an admission packet. Review of the electronic records of all residents admitted to the facility in (MONTH) 2019 showed 13 of the 14 residents admitted to the facility did not receive an admission packet. Resident #148 was admitted to the facility on [DATE]. He was alert and verbal. On 7/31/2019 at 5:16 PM, both the resident and his wife reported they had not received an admission packet from the facility since admission. Resident #1 was alert, cognitively intact and verbal. She was admitted to the facility on [DATE]. On 7/31/2019 at 5:26 PM, the resident stated she did not remember getting or signing any paperwork from the facility since admission.

Based on observation, interview and record review, the facility failed to ensure nurses demonstrated competency in all routes of medication administration during orientation; and failed to ensure 4 of 6 nurses (A, B, D & E) observed during medication administration possessed the necessary competencies and skills to safely administer medications and treatments for 4 of 6 residents, of a total sample of 27 residents, (#18, 28, 198, 200). Findings: 1. On 7/29/19 at 10:17 AM, Registered Nurse (RN) B was observed during medication administration for resident #200. During preparation of resident #200's medication, RN B repeatedly wiped his face and adjusted the position of his glasses with his hand while he complained about the hot temperature in the hallway. On entering resident #200's room, he donned clean gloves without performing hand hygiene. RN B administered 2 sprays [MEDICATION NAME] 0.03% to resident #200's nostrils, then administered 1 drop [MEDICATION NAME] 0.5% to both eyes that were immediately followed by 1 drop Bromfenac 0.09% to both eyes and 1 spray [MEDICATION NAME] 50 micrograms (mcg) to both nostrils. RN B wore the same gloves for administration of the 2 nasal sprays and 2 eye drops, and provided only one tissue for resident #200 to wipe her eyes and nose after medication administration. RN B did not apply pressure to resident #200's inner canthus during eye drop administration and did not hold one nostril closed while he gave nasal spray in the other. RN B continued the medication administration task without changing gloves and performing hand hygiene. He placed resident #200's 10 tablets in her mouth one at a time, holding each one in his gloved fingers. During the procedure, RN B wiped his face with the back of his glove 3 times. On 7/29/19 at 10:41 AM, a review of resident #200's Sodium Chloride and Bio-K Plus blister packs was conducted with RN B. After he read the labels, he confirmed he had administered the wrong dosage of both medications. He validated he only gave one of each medication despite the labels' directions to administer 3 Sodium Chloride tablets and 2 Bio-K Plus capsules. At this time RN B acknowledged he gave one set of eye drops immediately after the other. When asked if there should be a space between administration of 2 different eye drops he said, I don't remember if there is a specific time. RN B explained he had been on staff for less than 2 months and did not recall any education in orientation regarding the facility's policy and procedure for medication administration. He stated he was not required to demonstrate competency in administration of pills, eye drops and nasal sprays prior to resident care assignments. On 7/29/19 at 10:44 AM, the Unit Manager (UM) was informed of RN B's medication errors and concerns with infection control and techniques observed during medication administration for resident #200. The UM confirmed use of a single pair of gloves to administer eye drops, nasal sprays and pills was not acceptable, nor was touching the face with hands or gloves during medication administration. She acknowledged there should be a wait time between 2 different eye drops, but could not provide the timeframe. The UM stated she had been on staff for approximately 6 months. On 7/29/19 at 11:00 AM, the Staff Development Coordinator (SDC) stated she was responsible for staff education and training. She explained her expectation was that nurses wait 2 to 3 minutes between administration of 2 different eye drops in the same eye. However, when the SDC was asked to review the policy and procedure for Eye Drop Administration effective (MONTH) (YEAR), she acknowledged it directed nurses to space different eye drops 10 minutes apart. On 7/29/19 at 11:37 AM, the SDC provided RN B's training transcript and competencies. After review of the documents, the SDC confirmed there was no record of competency in medication administration related to eye drops and nasal sprays. The SDC stated to her knowledge, it was not part of RN B's orientation. A few minutes later, at 11:55 AM, the SDC stated she received confirmation from the Assistant Director of Nursing (ADON) that policies and procedures for medication administration were not reviewed with nurses in the classroom portion of their orientation. She explained each newly hired nurse received a 3 to 5 day orientation on the floor with other nurses. On 7/30/19 at 12:34 PM, the SDC validated RN B did not receive training related to prevention of medication errors as it was not part of orientation education. The ADON confirmed it would be prudent for nurses to complete a class on prevention of medication errors prior to administering medications to residents. 2. On 7/30/19 at 5:17 PM, licensed practical nurse (LPN) D was observed during preparation of resident #198's medication. She opened 1 Tamsulosin 0.4 milligram (mg) capsule and sprinkled the contents on top of a small amount of applesauce in a pill cup. LPN D explained she usually administered the Tamsulosin in this manner because resident #198 had difficulty swallowing the capsule. Review of resident #198's blister pack for Tamsulosin revealed directions to Swallow Whole. Do Not Chew Or Crush. During the medication reconciliation process, there was no physician's order noted regarding opening the Tamsulosin capsule. 3. On 7/31/19 at 8:53 AM, RN [NAME] was observed during application of resident #28's [MEDICATION NAME] 1% topical gel to her left knee. He removed the tube of medication from the box and squeezed approximately a 0.25 inch strip onto the tip of his gloved index finger. RN [NAME] applied the [MEDICATION NAME] gel to resident #28's left knee. A few minutes later at 9:14 AM, RN [NAME] confirmed he applied approximately 0.25 inch [MEDICATION NAME] gel, the same amount he usually applied. He acknowledged the medication order read 2 grams and should be measured to ensure accuracy. RN [NAME] said, We had a measuring card but it's gone now. He searched the treatment cart drawer and eventually found the [MEDICATION NAME] dosing card. RN [NAME] validated the dosing card showed [MEDICATION NAME] 2 gram dosage actually measured 2.25 inches. In an interview conducted on 7/29/19 at 1:17 PM, the ADON stated he was ultimately responsible for the orientation of newly hired nurses. He explained he taught new nurses how to use the electronic medical record (EMR) and described his role in education as the computer stuff. He validated the orientation process for new nurses did not include demonstration of clinical skills and competencies before assignment to the floor. The ADON explained newly hired nurses were paired with another nurse for about 3 days. He said, The preceptors are responsible for clinical orientation. We have a preceptorship system. However, the ADON acknowledged that nurse preceptors did not receive any special training and were not required to observe specific medication administration skills of newly hired nurses. He explained the facility tried to use more experienced nurses as preceptors, but acknowledged that since preceptors were not trained on required nursing competencies, there was no guarantee they would instruct newly hired nurses according to facility policies and procedures. The ADON stated to his knowledge, RN B had not yet precepted any new nurses, but confirmed he could potentially be assigned to administer medication to any resident in the facility. The ADON said, We are overhauling the program. We are kind of disorganized. On 7/29/19 at 4:38 PM, RN A stated she had been on staff for less than 1 month. She confirmed she was not familiar with the facility's medication administration policies and procedures. She stated that she did not have to demonstrate competency related to different routes of medication administration during orientation, before being assigned to work on the floor. On 7/30/19 at 12:02 PM, LPN C stated she had been on staff for 6 months. She recalled 1 day of orientation in the classroom where she learned about the facility's electronic medical records (EMR). LPN C validated she did not have to show competency in medication administration on that day. She explained she was then assigned to work with nurses for 3 days. She said, They observed me passing meds on the floor. I was with a different nurse every day for 3 shifts. There was a checklist and I marked it off On 7/31/19 at 2:42 PM, the SDC stated she was the facility's Minimum Data Set Coordinator, and recently had staff development added to her responsibilities. She explained newly hired nurses did orientation with the Human Resources department first. Then they were scheduled with herself and the ADON for orientation to the EMR including doing mock admissions and documentation standards, but policies were not reviewed. The SDC stated she assigned mandatory online trainings for all newly hired nurses, but they did not have to be completed prior to starting work on the floor. The SDC was asked how the facility ensured newly hired nurses met minimum competency in all aspects of medication administration. She said, That's a good question. We need a more structured orientation process . To be honest no one has given me feedback from the floor, not the new or other nurses. The SDC explained the facility recently held a skills fair, but the only medication administration competency reviewed was for gastrostomy tubes. Review of the facility's Specific Medication Administration Procedures Eye Drop Administration effective (MONTH) (YEAR), revealed the purpose To administer ophthalmic solution/suspension into the eye in a safe, accurate, and effective manner. The procedure directed nurses to don gloves, instill 1 eye drop, instruct the resident to close his/her eye, compress the tear for 1 to 2 minutes or instruct the resident to keep the eyes closed for 3 minutes. The procedure read, If another drop of the same or different medication is prescribed for administration in the same eye at the same time, wait 10 minutes, then repeat procedure . After eye drop administration was complete the document indicated nurses were expected to remove and discard their soiled gloves and perform hand hygiene before moving on to the the next task. Review of the facility's Specific Medication Administration Procedures Nasal Administration effective (MONTH) (YEAR), revealed the purpose To administer nasal medications in a safe, accurate, and effective manner. The procedure directed nurses to don gloves, have the resident blow his/her nose, and press gently on the other nostril not receiving the medication. After repeating the procedure, nurses were directed to remove and discard gloves then perform hand hygiene. The facility's policy for Administering Medications (undated), directed nurses to . check the label to verify the right medication, right dosage . before giving the medication. The document indicated nurses could crush medication . provided that the activity of the medication is not affected by this procedure. The procedure revealed the facility's infection control procedures related to handwashing and use of gloves should be followed during the medication administration task. Review of online education transcripts and competency validations for RN B, RN [NAME] and LPN C revealed no evidence of training related to prevention of medication errors or competency validations for all routes of medication administration. The facility's Inservice Calendar 2019 approved by the Quality Assurance (QA) Committee on 2/28/19, did not include topics of medication administration and prevention of errors. Review of the Comprehensive Facility-Wide Assessment (MONTH) (YEAR) reviewed and approved by the Quality Assurance Committee on 10/29/18, revealed The (facility) ensures a coordinated program of staff education for all facility employees including pre-service orientation and In-service education . The Staff Development Coordinator oversees the education, skill and competency development of the nursing staff.

Based on observation, interview and record review, the facility failed to follow accepted standards of practice related to infection control during medication administration for 1 of 6 residents observed during medication administration, of a total sample of 27 residents, (#200). Findings: Resident #200 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/29/19 at 10:17 AM, Registered Nurse (RN) B was observed as he prepared resident #200's morning medications. During the process of pressing pills from blister packs into a plastic medication cup, RN B repeatedly wiped his face and adjusted the position of his glasses with his hands while he complained about the hot temperature in the hallway. RN B entered resident #200's room and donned clean gloves without performing hand hygiene. He then handed resident #200 a tissue and administered 2 sprays of [MEDICATION NAME] 0.03% in each nostril. He then administered 1 drop [MEDICATION NAME] 0.5% in each eye, followed by 1 drop Bromfenac 0.09% in each eye. The RN B then administered 1 spray [MEDICATION NAME] 50 micrograms (mcg) in each nostril. RN B did not provide additional tissues for resident #200, perform hand hygiene or don clean gloves before and after administration of the nasal sprays or eye drops. While wearing the same gloves, RN B began to administer resident #200's pills. She requested one pill at a time and RN B picked up a single pill from the medication cup with his gloved index finger and thumb, placed it on resident #200's tongue and offered her a sip of water. RN B repeated the procedure until he administered the 10 pills in the cup. During administration of the pills, RN B touched his face with the back of his gloved hand 3 times. On 7/29/19 at 10:44 AM, the Unit Manager (UM) was informed of the infection control concerns noted during medication administration for resident #200. She validated nurses were expected to perform hand hygiene prior to donning gloves, change gloves between administration of nasal sprays and eye drops, and avoid contaminating hands and gloves during the process of preparation and administration of medication. The procedures for Eye Drop Administration and Nasal Administration effective (MONTH) (YEAR), revealed directions to Remove and dispose of gloves . Wash hands thoroughly with antimicrobial soap and water or facility-approved hand sanitizer after completing administration of eye drops or nasal sprays. The facility's policy and procedure for Administering Medications (undated) indicated nurses would adhere to established infection control procedures such as handwashing and use of gloves. According to the Centers for Disease Control and Prevention (CDC), gloves can become a means for spreading infections. Touch contamination occurs when nurses .adjust their glasses, rub their nose or touch their face . while wearing gloves. Gloves should be worn when there is the potential for contact with mucous membranes. CDC guidelines for standard infection control precautions revealed the use of gloves was not a substitute for hand hygiene, which should be performed immediately before donning and after removal of gloves. Gloves should be changed between tasks on different areas of the body. (www.cdc.gov)

Based on interview and record review, the facility failed to identify an irregularity related to recommendation for gradual dose reduction (GDR) of a [MEDICAL CONDITION] medication during monthly medication review for 1 of 5 residents reviewed for unnecessary medications, of a total sample of 27 residents, (#28). Findings: Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed resident #28 received anti-depressant medication every day in the 7-day look back period. Review of resident #28's medical record revealed a care plan for Mood State related to a history of depression. Interventions dated 10/06/18 included, Administer antidepressant medications as ordered. Periodic review of medication for possible dosage reduction or elimination. A care plan for [MEDICAL CONDITION] Drug Use indicated resident #28 received antidepressant medication for [DIAGNOSES REDACTED]. The consultant pharmacist's Monthly Medication Review (MMR) form for resident #28 revealed on 8/15/18 a recommendation was made by the consultant pharmacist. The document indicated resident #28 had an order for [REDACTED]. The physician agreed with the recommendation and ordered discontinuation of the medication on 9/07/18. Documentation by the Psychoactive Drug and Behavior Management Committee revealed on 8/16/18 the committee discussed and recommended discontinuation of resident #28's [MEDICATION NAME] 25 mg. During the following month's meeting on 9/20/18, the committee discussed tapering other antidepressants ordered for resident #28 but declined to do so . due to recent discontinuation of [MEDICATION NAME] on 9/07/18. Review of resident #28's medication administration records (MARs) revealed [MEDICATION NAME] 25 mg was not discontinued as ordered on [DATE]. The MARs showed resident #28 received the medication every day at bedtime, until it was eventually discontinued 6 months later, on 3/12/19. A review of the consultant pharmacist's MMR forms for resident #28 revealed monthly reviews of the resident's medications were conducted. However, the irregularity related to continuation of [MEDICATION NAME] 25 mg after the recommendation to discontinue the drug was approved and ordered by the physician on 9/07/18, was not identified until (MONTH) 2019. The consultant pharmacist conducted additional medication reviews on 4/02/19 and 6/20/19 after resident #28 had falls. The pharmacist included [MEDICATION NAME] on the list of medications more likely to contribute to a fall although resident #28 no longer received the medication. On 7/31/19 at 10:50 AM, a telephone interview was conducted with the facility's consultant pharmacist. She confirmed she reviewed each resident's medication during monthly onsite visits. The consultant pharmacist acknowledged she recommended discontinuation of resident #28's [MEDICATION NAME] during the MMR conducted in (MONTH) (YEAR). She explained she completed a MMR in (MONTH) (YEAR) and noted resident #28's [MEDICATION NAME] was still an active medication. The consultant pharmacist said, I spoke to a nurse who is no longer here, and she told me the resident still wants to use it. I told her we needed to get documentation from the doctor. When asked about the MMRs conducted in October, (MONTH) and (MONTH) (YEAR), and (MONTH) 2019, the consultant pharmacist acknowledged [MEDICATION NAME] remained an active order and said, Since I saw it on the chart I assumed they had taken care of it. She stated she was aware it took time to make changes, but she relied on the nurse's verbal report and returned the [MEDICATION NAME] to the schedule for GDR review in (MONTH) 2019. The consultant pharmacist stated she prepared notes on medications to be reviewed in the monthly psychoactive meetings based on her MMRs. She acknowledged she did not identify the continuation of resident #28's [MEDICATION NAME] as an irregularity, and neither did the members of the psychoactive committee. On 7/31/19 at 1:38 PM, the Director of Nursing (DON) stated the consultant pharmacist was responsible for MMRs of every resident. He acknowledged the consultant pharmacist should not have accepted a verbal discussion with a nurse as a response to a recommendation for discontinuation of [MEDICATION NAME]. The DON validated the Unit Manager (UM) was responsible for ensuring the recommendation was followed, and neither the consultant pharmacist nor members of the committee that reviewed psychoactive drugs identified the discrepancy. The DON said, It got missed on many different levels. The policy and procedure for Medication Management effective (MONTH) (YEAR), revealed . facility staff, the attending physician/prescriber, and consultant pharmacist perform ongoing monitoring for appropriate, effective and safe medication use. The procedure indicated evaluation of a resident's medication regimen would be done when an irregularity was identified. If a medication was deemed unnecessary, the consultant pharmacist and DON would request evaluation by the physician for a reduced dosage or discontinuation of the medication.

Based on interview and record review, the facility neglected to follow the plan of care for safe transfers for 1 of 5 residents (#1) reviewed for accidents. This failure resulted in resident #1 sustaining an acute [MEDICAL CONDITION] proximal tibia fibula, which required a transfer to the hospital for further evaluation and surgical repair. The deficiency resulted in a scope/security of G actual harm. Findings: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE], indicated resident #1 had a Brief Interview for Mental Status (BIMS) of 3 (severe cognitive impairment) and was assessed to require extensive assistance for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, personal hygiene and bathing. Resident #1 was unsteady and unable to stand, turn or walk (related to impairment of lower extremities) without 2 person physical assist and the use of a mechanical lift for transfers. Review of resident #1's Admission Fall Risk assessment dated [DATE], indicated a score of 18 indicating high risk for falls. Interventions in place at the time of assessment were total care for all activities of daily living (ADLs) and assist of 2 persons for transfers with the use of a mechanical lift. Review of resident #1's ADL Functional/Rehab Potential Care Plan updated 8/16/18, noted interventions of call light within reach while in room, provide assistive mobility/safety device for transfer, and locomotion ambulation and stand-up lift for transfers. Review of the Physician Recapitulation Orders for 12/2018 indicated staff were to use a mechanical lift for all transfers for the resident. Review of a State Required Report dated 12/5/18 indicated that on 12/4/18 at approximately 8:35 PM, certified nursing assistant (CNA) A had asked CNA B to help get resident #1 off the floor and into bed. CNA A had told CNA B that Licensed Practical Nurse (LPN C) had already been notified of the fall. Both CNA's then proceeded to transfer the resident from the floor to the bed. At approximately 9:45 PM, CNA B asked LPN C how resident #1 was doing post fall. The LPN C immediately approached CNA A regarding resident #1's fall as she had not been notified of the fall. CNA A informed LPN C that at 8:35 PM, she had attempted to transfer the resident by herself with the use of a gait belt from her wheel chair to the bed. When transferring the resident with the gait belt, the resident slid and was lowered to the floor. Resident #1 was assessed by nursing and was noted to grimace and yell out when the right ankle was touched. Stat x-rays were ordered with results indicating an acute [MEDICAL CONDITION] proximal tibia fibula. The physician, administration and the resident's family were notified. CNA A was suspending pending the investigation. Resident #1 was sent to the emergency room for evaluation and treatment. Review of the Diagnostic Imaging Report of Resident #1's right knee dated 12/5/18, indicated an acute [MEDICAL CONDITION] tibia and fibula. During an interview on 12/27/18 at 9:45 AM, Resident #1 was interviewed regarding the fall on 12/4/18. She could only say that she fell and was unable to recall details of the fall. During an interview on 12/27/18 at 10:35 AM, CNA B indicated he had been asked by CNA A to assist in transferring resident #1 back to bed after a fall. CNA A told me that LPN C had been notified of the fall and had assessed the resident. When I asked LPN C how the resident was doing after the fall later that evening, she appeared clueless and upset, I knew I had to report what happened. LPN C had not been informed of the fall. During an interview on 12/27/18 at 11:55 AM, LPN C indicated she had not been notified by CNA A of resident #1's fall and was very upset upon hearing of the fall. I immediately found CNA A and we located the registered nurse supervisor (RN D) on call. CNA A was told to leave the floor and write a statement. The supervisor and I immediately assessed the resident and notified the physician, administration and the family. CNA A was suspended pending the investigation. During an interview on 12/27/18 at 1:55 PM, RN D confirmed the above information. She verified the importance of staff following and utilizing the interventions in place (use of mechanical lift by 2 persons) for resident #1 and reporting accidents immediately. During an interview on 12/27/18 at 2:35 PM, the Medical Director stated the importance of proper transfers for all residents and recalled the need of a mechanical lift for resident #1. He stated that the resident required a mechanical lift for transfers and that is how she should have been transferred. CNA A could not be interviewed as she did not return any calls following her suspension. During an interview on 12/28/18 at 9:05 AM, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) stated that CNA A was responsible for reviewing resident #1's Care Plan at the start of her shift for specific interventions in place for each resident on her assignment and acknowledging that the review had occurred. CNA A signed had validated that she had reviewed the Care Plan for resident #1 and obviously did not follow through with the interventions. She had received training on proper use of a mechanical lifts and had demonstrated competency and just decided to take a short cut and not use the lift. Review of the facility policy titled Safety and Supervision of Residents, no date, indicated the following: Resident Risks and Environmental Hazards 1. Bed Safety 2. Safe Lifting and Movement of Residents 3. Falls Employees shall be trained on the potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents. Review of the facility policy titled Lifting Machine, no date, indicated the purpose being to help residents using a manual lifting device. 1. Review the resident's care plan to assess for any special needs of the resident. 2. Assemble equipment and supplies as needed. Two (2) nursing assistants will be required to perform the procedure.

Based on interview and record review, the facility failed to invite/involve 1 of 1 residents to their care plan meeting (#19). Findings: On 5/02/18 at 3:05 PM, resident #19 stated she had not been invited to participate in her care plan meeting. On 5/03/18 at 1:14 PM, registered nurse (RN) A described the process that happens for care plan meetings. He sends out a letter every quarter to let them know about their care plan meetings. Resident #19's last care plan letter was sent on 3/19/18 to her daughter-in-law, who is listed as first contact for resident #19. On 5/03/18 at 1:20 PM, RN B said resident #19's family canceled and did not wish to attend the care plan meeting, but the interdisciplinary team still held the care plan meeting without the resident or family in attendance. On 5/03/18 at 1:20 PM, RN A said the facility invited the resident and the family but since the family did not want to attend the meeting, the facility held the care plan meeting on 3/22/18 with the Social Worker, RN B, 2 representatives from the social services department, the activity person, a therapist, a certified nursing assistant (CNA), and the infection preventionist. Dietary and the resident did not attend the care plan meeting. Review of the Care Conference Sheet, dated 3/22/18, validated resident #19 did not attend the meeting. Additional information included an email sent to the family member inviting them to resident #19's care plan meeting. On 5/03/18 at 1:22 PM, RN A said the facility asks the resident to the care plan meeting only if the resident is cognitively intact and can participate in it. For resident #19, the family is invited to her care plan meeting. RN A researched her cognitive ability score (BIMS) on the last quarterly minimum data set (MDS) on 3/19/18 and that score was 13 out of 15, indicting resident #19 was able to make her needs known, and was mostly cognitively intact with periods of forgetfulness. However, the BIMS score, dated 3/21/18 was 15 out of 15, indicating resident #19 was cognitive intact and would be able to understand her own care plan meeting. On 5/03/18 at 1:30 PM, RN B said at the last care plan meeting with only the family, the family said they did not want resident #19 to attend her own care plan meeting because the family thought resident #19 was unrealistic. On 5/03/18 at 1:32 PM, RN B said she did not believe resident #19 was deemed incapacitated and she was actually able to make her own decisions. She also said the last time resident #19's family had attended a care plan meeting was on 10/17/17. Resident #19 had not attended her own care plan meeting since 10/17/17. On 5/03/18 at 1:35 PM, the director of nursing validated resident #19 was not invited to her care plan meetings.

Based on observation, interview, and record review the facility coded the Minimum Data Set (MDS) incorrectly for 1 of 1 residents reviewed for MDS accuracy out of 34 residents (#11). Findings: Resident #11 medical record reflected an admission date of [DATE] from the hospital with [DIAGNOSES REDACTED]. She receives [MEDICATION NAME] 0.25 milligram (mg.) tablet by mouth each day for dementia with behaviors. [MEDICATION NAME] is an anti-psychotic medication used to treat [MEDICAL CONDITION], however resident #11 does not have a [DIAGNOSES REDACTED]. Her last quarterly Minimum Data Set (MDS) was 3/02/18 and revealed her active [DIAGNOSES REDACTED]. The medications she received according to that MDS were 7 days of antipsychotics, 2 days of anti-anxiety, 7 days of anti-depressant. According to the same MDS, her anti-psychotic medication was received on a daily basis. On 5/03/18 at 2:03 PM, the director of nursing (DON) stated the typical use of [MEDICATION NAME] are behaviors like hitting others. On 5/03/18 at 2:31 PM, registered nurse (RN) A verified the findings from the quarterly MDS dated [DATE] MDS section N for Medications indicated the resident received 7 days of the anti-psychotic [MEDICATION NAME]. 0.25 mg. daily for a [DIAGNOSES REDACTED]. RN A said the [DIAGNOSES REDACTED]. On 5/03/18 at 2:26 PM, the DON stated the only [DIAGNOSES REDACTED].

Based on record review and interview, the facility failed to accept responsibility for lost and stolen items for 4 of 5 sampled residents (#7, 12, 19 & 345). Findings: 1. Resident #7's responsible party signed a form entitled Patient waiver re: personal belongings Patient Name: (Resident #7) Item(s) describe, be specific) with a blank line for them to fill in, This is to acknowledge that I choose to keep this item /these items in my personal possession in my room, and I acknowledge that this is contrary to Mayflower policy and advice. I understand the risk involve and hereby agree not to hold The Mayflower responsible for its care. This form was signed and dated 2/01/18 by the responsible party and filed in the medical record. 2. Resident #12 signed the same waiver on 4/07/17 and it was filed in the medical record. 3. Resident #19's family signed the same waiver on 6/28/17 and it was included in the medical record. 4. Resident #345's responsible party signed the same waiver on 4/17/18 and it was located in the medical record. Interview with staff C on 5/03/18 at 10:42 AM, said the Admissions Department does not have the residents sign that waiver. That waiver was in direct contrast to the Admission Agreement page 2 policy. On 5/03/18 at 10:45 AM, staff C said that waiver for responsibility for lost and stolen items is obtained by nursing staff in their initial admission packet the day the resident moves in. At 10:46 AM, staff C said the facility may replace lost or stolen items if the resident wants reimbursement, but not always. At 10:47 AM, staff C stated the waiver for responsibility for lost or stolen items was in contradiction to the facility's policy in the Admission Agreement. On 5/03/18 at 10:50 AM, the director of nursing said since she started at the facility in (MONTH) (YEAR), the admission packet was changed and the current policy says the facility will look for the items and will replace completely or half of it, or if the resident accepts part of the risk - the facility will not replace at all. Those signed waivers indicate the Mayflower will not assume the replacement of lost or stolen items.

Based on observation, interview, and policy review, the facility failed to clean the thermometer before, between, and after taking the temperature of food items on the serving line that served food for 51 of 53 residents. Findings: On 4/12/17 at 4:02 PM, Staff A took the temperature for the dinner meal using a digital thermometer by dipping it into a Styrofoam cup filled with water and ice cubes. Between taking the temperatures of each food item, Staff A dipped the thermometer into the same ice water bath and inserted it into the next food item. In an interview with Staff A on 4/12/17 at 4:08 PM, she said she takes temperatures all the time that way and verified the liquid in the Styrofoam cup was water with ice. Interview with the Certified Dietary Manager (CDM) on 4/12/2017 at 4:20 PM, the CDM said the thermometer should be cleaned between protein foods and vegetables to prevent cross contamination. The CDM stated the correct way to clean the thermometer is to wipe the thermometer between food items with a sanitary wipe. To calibrate the thermometer, staff uses an ice water bath. On 4/13/17 at 4:26 PM, the CDM interviewed Staff A and asked if Staff A knew she was supposed to use the Thermo-Scan or Thermometer Probe Wipes to clean the thermometer between foods. Staff A replied Oh. On 4/13/17 at 11:52 AM, the CDM provided the procedure documenting food temperatures: Thermometer will be sanitized before; during and after all food temperatures are recorded. Thermometer probe will be sanitized and wiped with a clean sanitizing wipe each time it is inserted and removed in a food item. Cleaning the thermometer with the cleaning wipe between taking food item temperatures for the tray line foods prevents cross contamination of food and potential food bourne illnesses.

Based on observation, interview and record review, the facility failed to label and store medication in accordance with accepted professional practice in 2 of 3 medication carts (A and B) reviewed for medication storage, for 6 of 53 residents (#6, 21, 30, 71, 106 & 112). Findings: 1. On [DATE] at 4:45 PM the A hall medication cart was observed with RN C. One bottle Fluticasone propionate (Flonase) 50 micrograms (mcg) nasal spray, prescribed for resident #106 was in a plastic bag with a soiled label and a small amount of crusted material on the outside of the bag. The nasal spray had a sticker with an open date of [DATE] and no discard date. RN C acknowledged the medication bag and label were in poor condition. One bottle of Atropine 1% eye drops, prescribed for oral administration for resident #6, revealed stains on the manufacturer's label. Parts of the label were obscured, the sticker used to document the open date was worn away and the instruction For Oral Use was faded. She confirmed the bottle of Atropine 1% eye drops had a stained label and the instructions for oral administration were faded. RN C stated she would not administer this medication in this condition. The Atropine 1% eye drops were dispensed by the pharmacy on [DATE]. One bottle of Flonase 50 mcg nasal spray prescribed for resident #112, had an open date of [DATE], and no instruction for a discard date. RN C confirmed other medications in the cart did not show the date opened, and some labels indicated eye drops should be discarded 30 days after opening and nasal sprays should be discarded 60 days after opening. RN C stated she was unaware of the facility's policy, but her knowledge of best practice was eye drops should be discarded after being open for 30 days. She explained that containers of eye drops and nasal sprays may touch mucous membranes and become contaminated. On [DATE] at 5:11 PM the UM stated she thought eye drops and nasal sprays should be discarded 30 days after opening, but would verify with the pharmacy. 2. On [DATE] at 5:19 PM the B Hall medication cart was observed with licensed practical nurse (LPN) D. One bottle of Systane 0XXX,[DATE].4% eye drops, prescribed for resident #30, had an open date of [DATE]. One bottle Artificial Tears 1.4%, prescribed for resident #21, had an open date of [DATE]. Neither bottle had instructions on a discard date. One bottle Humalog insulin, prescribed for resident #71 had an open date of [DATE]. LPN D stated he thought insulin should be discarded 30 days after opening, and confirmed the Humalog insulin should no longer be in use. LPN D was not aware of a facility policy related to discarding eye drops and nasal sprays. On [DATE] at 5:30 PM the UM stated she spoke to the pharmacist who informed her all nasal sprays and eye drops could be used until the manufacturer's expiration date. However, the UM could not explain why some eye drops and nasal sprays had instructions to discard 30 and 60 days after opening respectively, and others did not. She confirmed that according to the facility's current labeling system, the same drugs would be administered to some residents for 30 - 60 days and to other residents for up to two years according to the expiration date. The UM acknowledged eye drops and nasal sprays could become contaminated after multiple uses and should not be used for over 60 days, despite expiration dates. On [DATE] at 10:06 AM the consultant pharmacist confirmed the facility did not have a specific policy regarding when to discard eye drops and nasal sprays after opening. The pharmacist stated her professional guidance would be that nasal sprays and eye drops should be discarded within 60 to 90 days of opening as these drugs could become contaminated over time with regular use. She explained nurses were expected to date eye drops, nasal sprays, nitroglycerin and insulin on opening. The pharmacist stated no food items should be stored in the medication fridge. On [DATE] at 10:30 AM the director of nursing (DON) stated the consultant pharmacist was responsible for monitoring storage and labeling of medication in the medication room and in the medication carts during monthly visits, and she expected the UM and nurses to do periodic checks as well. She confirmed food items should not to be stored in the medication room. The DON stated in her professional opinion, eye drops and nasal sprays should be discarded ,[DATE] days after being opened, and acknowledged the facility had experienced problems with pharmacies related to labeling of medication. On [DATE] at 11:45 AM RN E explained the pharmacist had provided instructions to staff to regarding dating bottles when opened and discarding eye drops 30 days after opening. Review of the World Health Organization (WHO) publication The International Pharmacopoeia - Sixth Edition, 2016 Ophthalmic preparations revealed Multidose ophthalmic drop (eye drop) preparations may be used for up to 4 weeks after the container is initially opened. (http://apps.who.int/phint/pdf/b/Jb.6.2.1.3.pdf). Review of the manufacturer's guidance for Flonase nasal spray instructed that this medication should be thrown away after being used for 120 sprays. Therefore, the recommended dosage of ,[DATE] sprays in each nostril once daily would require this medication to be discarded 30 - 60 days after opening (http://www.rxlist.com/flonase-drug/patient-how-to-take.htm). Review of the consultant pharmacist's monthly inspection reports from [DATE] to [DATE] revealed findings of expired medication and open, undated multi-dose vials such as insulin, nasal sprays and eye drops in medication carts during each visit. Review of the facility policy and procedure for Storage of Medications and Biologicals dated ,[DATE] revealed Outdated, contaminated, or deteriorated medications and those in containers that are cracked (or) soiled .are removed from stock . The procedure included routine monitoring of medication storage .and corrective action taken if problems are identified.

Based on observation, interview, and record review, the facility failed to follow proper infection control practices to prevent the development, transmission and potential spread of infections by washing linens in the same room used for sorting of soiled linens, having beverages in the laundry dryer area, storing chemical containers on the laundry floor under the sink, infection control report with incomplete surveillance process data, improper technique used for hand washing for 1 of 2 residents observed for wound care (#75), and storing personal items in 1 of 3 medication carts (A hall). Findings: 1. On 4/12/17 at 11:26AM, conducted a tour of the laundry area with the Building Services Director (BSD) Soiled linen was in blue bins, the hopper was on opposite side of room next to sink, and 3 washing machines were washing linens. Two machines were loaded from the top and one machine had a clear door. The BSD stated the washing machines contained mop heads and rags, but observation revealed the washing machine with clear door had green and blue pads, gowns, and white linens. The other 2 machines had white linens. The BSD confirmed that linen should not be in the washing machines. The Building Services Supervisor (BSS) stated soiled linen should not be in the same room while the washing machines are in use. The BSS stated those machines were being used because the other washer is broken. A second room revealed the middle washing machine was missing parts and not washing. At that time the BSS stated, the washing machine in room [ROOM NUMBER] has been broken for 2 weeks and they have been washing clothes in the soiled room for 2 weeks. The BSD confirmed the machine has been broken for 2 weeks. 2. On 4/12/17 at 11:53AM 2 beverage cups were observed in the dryer room. A white cup was sitting on the desk with clear liquid inside the cup and a blue and white cup on the folding table, had a dark color substance inside the cup. Two chemical containers were on the floor under the sink in the soiled room, one container red/orange in color and one container was green in color. An interview was conducted with the housekeeping supervisor at this time and she said, we wash mop heads and beauty shop linens. Two washers had white linens and the third washer was washing pads and gowns. The houskeeping supervisor confirmed drinks should not be kept in work area near wshing machines. She stated chemical containers should not be on the floor; they should be on the rack. The BSD validated chemical containers should be stored on the rack not on the floor. An interview was conducted on 4/12/1/7 at 3:30PM in the DON (director of nursing). The DON had additional duties in infection control/ risk manager/staff in-service coordinator. The DON said she had not looked at the laundry rooms for approximately 6 to 8 months. She stated the staff should not have any beverages in the laundry area. Review of the DON's job description for health services revised August 2009 page 3 section U, showed Makes daily rounds through health center, visiting residents and inspecting cleanliness and maintenance of the building. Notifies maintenance and/or environmental services of any needs identified. 3. An interview and record review conducted with DONon 4/12/1/7 at 3:30PM in her office showed an infection control report with incomplete surveillance process data. When asked how does the facility minimize exposure to potential sources of infection, she stated, universal precautions, handwashing, personal protective equipment (mask, gloves, and gown) and annual education. When asked what methods are used to collect, analyze data related to infections and how are they identified, she said, they keep a line item list in the computer and use an excel spreadsheet. When asked have there been any determined areas for improvement from surveillance data, she said, we realize that we are higher compared to national average for UTI (urinary tract infections) it is QAA/QAPI (quality assessment and assurance/quality assurance performance improvement) right now. When asked to provide documentation of the infection control surveillance process the DON provided incomplete infection logbook pages, which did not reveal documentation identifying origin of infections (fever, purulent drainage), trends/tracking (particular direction), monitoring (audits), and actions taken other than antibiotics (other interventions to resolve related problems), reassessment of residents' conditions (after antibiotics) or education for compliance (proper hand washing, use and disposal of gloves). Review of DON job description for health services revised August 2009 page 3 section Q, revealed Oversees the Infection Control program of the Health Center; develops, implements, and maintains the infection control program, and monitors all infectious disease among residents and staff. Prepares a log of all infections, interventions, and outcomes. 4. Resident #75 was admitted to the facility on [DATE] with a stage 4 pressure ulcer of the right medial buttock. Observation of wound care for resident #75 was conducted on 4/13/17 between 9:31 AM and 10:00 AM with licensed practical nurse (LPN) B, assisted by the registered nurse unit manager (UM). LPN B placed wound care supplies including gloves, gauze and normal saline solution on a table. She then picked up a trash can near the head of the bed, carried it to the foot of the bed, and placed it on the floor. Next, without performing hand hygiene, LPN B picked up the pile of gloves on the table to ensure she had an adequate amount for the procedure. She then held the edges of the table and pushed it towards the foot of the bed. LPN B washed her hands in preparation to begin wound care and required cueing to prevent use of the contaminated gloves. The UM removed the contaminated gloves from the table and LPN B replaced them with clean gloves. After removal of resident #75's soiled dressing LPN B washed her hands with soap and water. She reached for a paper towel, and used it to turn off right faucet with wet hand. She then used this paper towel along with two dry towels pulled from the dispenser to dry her hands. During the procedure the UM also washed her hands. She used soap and water, then turned off the tap with her wet right hand. Next the UM pulled paper towels from the dispenser and dried both hands. On 4/13/17 at 10:00 AM observations of handwashing technique were reviewed with LPN B and the UM. They both verbalized the correct procedure for washing hands included washing with soap and water, then drying hands thoroughly before using a dry paper towel in a dry hand to turn off the tap. LPN B stated she had attended an in-service on handwashing provided by the UM about 2 weeks ago. On 4/13/17 at 12:27 PM the DON explained all staff received training on handwashing in new hire orientation and about 3 or 4 times a year thereafter. The DON provided an attendance sheet for the last in-service on handwashing attended by LPN B dated 4/27/16. Review of the facility's Handwashing/Hand Hygiene policy, revised 05/12, revealed this facility considers handwashing/hand hygiene as the primary means to prevent the spread of infections. Employees were instructed to wash hands after handling potentially contaminated items, and use hand sanitizer Before handling dressings, gauze pads, etc. Review of the educational material used for in-services, Hand Washing step-by-step from the Florida Department of Health, revealed employees received instructions to wash hands and forearms with soap and water, use towels to dry hands and forearms, and lastly turn off the water with a towel. 5. On 4/13/17 at 10:26 AM the consultant pharmacist was observed beside the A hall medication cart. She instructed LPN B to remove her personal bag from the bottom drawer from the medication cart. LPN B removed the small personal bag, and explained she did not want to leave her wallet anywhere else. The pharmacist validated nurses' personal belongings should not be stored in the medication cart. On 4/13/17 at 12:22 PM LPN B opened the top drawer of the A hall medication cart and a cell phone and wallet were observed in the compartment next to residents' prescribed eye drops. LPN B removed the personal items and placed them in her pocket. On 4/13/17 at 12:27 PM the DON confirmed nurses should not keep their personal belongings including cell phones and wallets in the medication cart.