Every finding on record at Memphis Jewish Home

Based on review of Diclofenac Sodium Topical (where medication is applied directly to a specific surface of the body) Gel 1% (a medication applied to the skin used to treat arthritis pain) packing insert user guide, Federal Drug Administration website, policy review, medical record review, observation, and interview, the facility failed to ensure 1 of 9 (Registered Nurse (RN) B) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 2 errors were observed out of 27 opportunities, resulting in a medication error rate of 7.41%. The findings include: 1. Review of the Diclofenac Sodium Topical Gel 1% .user guide, dated 2/2022, revealed .Remove the dosing card from inside of the carton. You should always use the dosing card to measure out the correct dose of Diclofenac Sodium Topical Gel.Measuring the correct amount using the dosing card.For each upper body area.Squeeze gel from tube equal to the length shown on the upper body section of the dosing card (2.25 inches). Review of the Federal Drug Administration website (fda.gov/drugsatfda) label information for Protonix (pantoprazole) (a medication used to decrease the amount of acid produced in the stomach), dated 2009, revealed .PROTONIX Delayed- Release Tablets [tab] should be swallowed whole.PRONTONIX Delayed- Release Tablets are prepared as enteric-coated tablets so that absorption of pantoprazole begins only after the tablet leaves the stomach.should not be split, crushed, or chewed.should be swallowed whole. 2. Review of the facility policy titled, Administering Medications, dated 9/2025, revealed .Medications will be administered.as prescribed by the resident's attending physician or the facility's medical director.The individual administering the medication must ensure that the right medication, right dosage, right time and right method of administration are verified before the medication is administered. 3. Review of the medical record revealed Resident #97 was admitted to the facility on [DATE], with diagnoses including Dysphagia, Peptic Ulcer, and Primary Osteoarthritis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #97 scored a 5 on the Brief Interview for Mental Status (BIMS) assessment, which indicated Resident #97 was severely cognitively impaired. Review of the Physician Order dated 1/26/2026, revealed diclofenac sodium [OTC [over the counter] gel.1 % .topical.APPLY 2 GRAM TOPICALLY TO AFFECTED AREA THREE TIMES PERDAY. Review of the Physician Order dated 1/26/2026, revealed pantoprazole tablet, delayed release.40 mg [milligram].oral.Take 1 tab po [by mouth] twice [two times] daily before meals. Review of the Physician Order dated 1/26/2026, revealed sucralfate suspension.100 mg/ml [milliliter].oral [by mouth].Take 10ml po in the morning, at noon, in the evening, and at bedtime. Observation during medication administration on 2/10/2026 at 4:34 PM, revealed RN B removed the following medications from the medication cart to administer to Resident #97. a. diclofenac sodium gel 1%. b. pantoprazole 40mg delayed release 1 tablet. c. sucralfate suspension 100mg/ml 10 ml RN B crushed the pantoprazole 40mg delayed release tablet and mixed it with pudding, poured 10ml of sucralfate suspension 100mg/ml into a medicine cup, removed the diclofenac sodium 1% gel from its box and squeezed 10ml from the tube into a medicine cup, entered Resident #97's room, administered the pantoprazole delayed release and the sucralfate suspension to the resident by mouth. Resident #97 was assessed for pain and voiced pain in left shoulder. RN B removed the 10 ml of diclofenac sodium 1% gel from medicine cup and applied it to Resident #97's left shoulder. RN B crushed a delayed release medication and failed to use the manufacturers supplied dosing card to measure and administer an accurate dosage of a topical medication, resulting in administration errors for both medications. During an interview on 2/10/2026 at 4:48 PM, RN B was asked if 10 ml of diclofenac sodium 1% gel was equivalent to the ordered 2 grams. RN B stated, Honestly I usually put about 10 ml in this cup. RN B was asked if that could result in a dosage other than the prescribed 2 gram. RN B stated, Yeah. RN B was asked if delayed release medications should be crushed. RN B stated, Probably no, but if she is an aspiration risk they can. She has difficulty swallowing. During an interview on 2/11/2026 at 12:07 PM, the Director of Nursing (DON) was asked if staff should follow the Physician's Order when administering medications. The DON stated Yes. The DON was asked if an order is to apply 2 gram of a topical gel, and the box includes a dosage card that has directions to apply 2.25 inches to obtain the prescribed dosage, and the nurse instead administered 10ml of the medication, would that give the required dosage of that medication. The DON stated, No. The DON was asked if that could result in a dosage greater than or less than the ordered dose. The DON stated, It could. The DON was asked if staff should crush delayed release medication. The DON stated, No. The DON was asked if crushing a delayed release medication can alter the effectiveness and absorption of the medication. The DON stated, It can.

Based on policy review, the Centers of Disease Control Guideline for Disinfection and Sterilization in Healthcare Facilities review, Centers for Disease Control and Prevention Enhanced Barrier Precautions sign, medical record review, observation, and interview, the facility failed to ensure proper infection control practices were followed when 4 of 11 staff (Licensed Practical Nurse (LPN) A and I, Treatment Nurse J, and Certified Nursing Assistant (CNA) K) failed to wear Personal Protective Equipment (PPE) for Transmission Based (Isolation) Precautions (TBP) and Enhanced Barrier Precautions, failed to follow infection control standards for the use of reusable equipment, and failed to perform hand hygiene for 4 of 14 (Resident #6, #116, #175, and #179) sampled residents. The findings include: 1. Review of the facility policy titled Administering Medications, dated 9/2025, revealed .Established facility infection control procedures must be followed during the administration of medications .isolation precautions . Review of the facility policy titled Enhanced Barrier Precautions, dated 9/2025, revealed .It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO] that employs targeted gown and gloves use during high contact resident care activities.All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions.Signs will be placed on the closet door.An order for enhanced barrier precautions will be obtained for residents with any of the following.indwelling medical devices.urinary catheters.even if the resident is not known to be infected or colonized with a MDRO.PPE [personal protective equipment] for enhanced barrier precautions is only necessary when performing high-contact care activities.Handwashing is available in all resident rooms.High-contact care activities include.Device care or use.urinary catheters.Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or.discontinuation of the indwelling medical device that placed them at high risk. Review of the facility policy titled Infection Prevention and Control Program, dated 9/2025, revealed . It is policy of this facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per national standards and guidelines.Hand Hygiene Protocol.All staff shall wash their hands.after handling contaminated objects, after PPE removal.Staff shall wash their hands before and after performing resident care procedures.Equipment Protocol.All reusable items and equipment shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment . Review of the facility policy titled Hand Hygiene/Hand-washing, dated 2025, revealed .Hand-washing/hand hygiene is considered the most important single procedure for preventing healthcare-associated infections.Hand-washing with antimicrobial soap and water is indicated and must be performed under the following conditions.After contact with blood, body fluids, secretions, mucous membranes, or non-intact skin.After handling items potentially contaminated with blood, body fluids, or secretions. Review of the facility policy titled COVID-19 Prevention, Response and Reporting, dated 9/2025, revealed .It is the policy of this facility to ensure that appropriate interventions are implemented to prevent the spread of COVID-19 .HCP [Health Care Provider] who enter the room of a resident with suspected or confirmed SARS-CoV-2 [the pathogen that causes COVID-19] infection should adhere to standard precautions and use a .gown . 2. Review of the Centers of Disease Control Guideline for Disinfection and Sterilization in Healthcare Facilities.Recommendations for Disinfection and Sterilization in Healthcare Facilities, dated June 2024, revealed .Cleaning of Patient-Care Devices .Disinfect noncritical medical devices (e.g., blood pressure cuff) with an EPA [Environmental Protection Agency]-registered hospital disinfectant .Ensure that, at a minimum, noncritical patient-care devices are disinfected when visibly soiled and on a regular basis (such as after use on each patient). Review of the undated Centers for Disease Control and Prevention sign titled Enhanced Barrier Precautions, revealed EVERYONE MUST.Clean their hands, including before entering and when leaving the room.PROVIDERS AND STAFF MUST ALSO.Wear gloves and a gown for the following High-Contact Resident Care Activities.Device care or use.urinary catheter. 3. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses including Adult Failure to Thrive, Gastrostomy Status, and Pneumonia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #6 scored a 9 on the Brief Interview for Mental Status (BIMS) assessment, which indicated he was moderately cognitively impaired. Resident #6 was assessed for the use of a feeding tube and an indwelling urinary catheter (tube inserted into the bladder to drain urine). Review of the Physician Order dated 12/30/2025, revealed Finasteride [a medication used to treat an enlarged prostate] tablet [tab] 5 mg [milligram] .TAKE ONE TAB PER PEG [percutaneous endoscopic gastrostomy] [a tube inserted through the abdomen into the stomach to deliver nutrition, fluids, and medications] ONCE DAILY . Review of the Physician Order dated 12/30/2025, revealed Eliquis [a prescription blood thinner] tablet .5 mg .TAKE ONE TAB PER PEG TWICE DAILY . Review of the Physician's Order dated 2/10/2026, revealed . Apply barrier cream to buttocks and sacrum with each brief change. Review of the Physician's Order dated 1/1/2026, revealed . Osmolite [supplemental peg tube feeding] 1.5 @ [at] 270mL [milliliter] per PEG [Percutaneous Endoscopic Gastrostomy] [a tube placed through the abdominal wall into the stomach to provide nutrition, fluids, and medications] 5x [times]/day via [by way of] bolus [feeding administered at one setting] feedings with 270mL H2O [water] flushes per PEG 5x/day. Review of the Physician's Order dated 2/2/2026, revealed . INDWELLING FOLEY CATHETER PLACED FOR URINARY RETENTION. The facility failed to have a physician's order for the use of EBP. Observation during medication administration in the 400 Hallway, on 2/11/2026 at 8:35 AM, revealed LPN I removed an Eliquis 5mg tab and a finasteride 5mg tab from the medication cart and prepared the medications for administration. LPN I entered Resident #6's room and administered the medications as ordered by way of gastrostomy tube, after verifying placement of the tube and checking for residual. LPN I failed to don a gown prior to administering medications through a gastrostomy tube. Observation at the treatment cart outside of Resident #6's room on 2/11/2026 at 9:02 AM, revealed Treatment Nurse (TN) J obtained barrier cream from the treatment cart, used hand sanitizer and donned gloves, entered the resident's room. An Enhanced Barrier Precautions sign was posted in the room that listed gloves and gown as being required by staff during High Contact Resident Care Activities. TN J adjusted catheter tubing at the catheter drainage port, rolled the resident over, opened the incontinent brief, removed her gloves, washed her hands, and exited the room to get additional gloves from her treatment cart. TN J washed her hands, donned gloves, entered the resident's room, applied barrier cream to Resident #6's sacrum, fastened the brief, removed her gloves, and washed her hands. TN J failed to wear a gown while providing direct resident care. During an interview on 2/11/2026 at 9:11 AM, TN J was asked if Personal Protective Equipment (PPE) should be worn when providing care to residents in EBP. TN J stated, He doesn't have a wound. TN J was asked if resident had a foley catheter and peg tube. TN J stated, Yes. I probably should have worn PPE. I wasn't thinking about that since he did not have an open wound. During an interview on 2/11/2026 12:08 PM, the Director of Nursing (DON) was asked what is the purpose of EBP. The DON stated, To prevent the spread of multidrug resistant organisms. The DON was asked what determines the use of EBP. The DON replied, For example, indwelling foleys or wounds, peg tube. The DON was asked what PPE was required for EBP. The DON stated, A gown and gloves. The DON was asked if there should be a physician's order for EBP for residents that require it. The DON stated, We don't use orders we just use what their diagnoses are and our policies. The DON was asked if staff failed to wear the appropriate PPE could that potentially create an infection risk for the residents. The DON stated, Yes. 3. Review of the medical record revealed Resident #116 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction (type of Stroke), Dysuria (pain, burning, or discomfort during urination), and Acute Kidney Failure. Review of the Physician's Orders dated 12/2/2025, revealed .INDWELLING FOLEY CATHETER. The facility failed to have a physician's order for the use of EBP. Review of the admission MDS assessment dated [DATE], revealed Resident #116 scored a 15 on the BIMS assessment, which indicated he was cognitively intact. Resident #116 had use of an indwelling urinary catheter. Observation during catheter care in Resident #116's room on 2/9/2026 at 3:03 PM, revealed CNA C was assisting Resident #116 to reposition in bed, donned a pair of gloves, retrieved a plastic urinal (a container used to urinate in), opened the catheter tube valve (plastic valve to allow the urine to drain) and drained the catheter bag into the urinal. CNA C closed the catheter tube valve, entered the bathroom and emptied the urinal into the toilet. CNA C exited the bathroom, doffed the gloves and exited the room and walked down the hallway. CNA C failed to don a gown during catheter care, failed to place a barrier underneath the catheter and urinal while emptying the catheter bag, failed to disinfect the catheter valve after closing, and failed to perform hand hygiene before and after handling the catheter bag and urinal, and after removing her gloves. During an interview on 2/9/2026 at 3:36 PM, 500 Hall Unit Manager was asked to explain the process of catheter care including emptying a catheter bag. 500 Hall Unit Manager stated, .they check the area daily.handwashing.especially if touching a drainage bag you should have gloves on. 500 Hall Unit Manager was asked if any other supplies or items was needed when emptying a catheter bag. 500 Hall Unit Manager stated, No. During an interview on 2/11/2026 at 1:41 PM, the Infection Control Preventionist (ICP) was asked when should EBP be used. The ICP stated, .indwelling medical device, caths [catheters]. The ICP was asked if they use Physician's Orders for EBP. The ICP stated, .we do not [obtain Physician's Orders] for EBP .it's not restricting for the resident . The ICP was asked to explain the process for emptying a catheter bag. The ICP stated, .[perform] hand hygiene, [don] gown and gloves, get container, barrier, place on barrier on floor below catheter bag.open the tubing to drain [urine from the catheter bag] into the container, close the valve, then clean the catheter tip with alcohol wipe and secure back onto the bag.remove gown and gloves and wash hands with soap and water. The ICP was asked when staff should wash their hands. The ICP stated Before leaving the room. The ICP was asked if staff should wear a gown when emptying a catheter bag. The ICP stated, Yes, or anytime they are touching that catheter. During an interview on 2/11/2026 at 2:53 PM, the DON was asked what PPE should staff wear during catheter care. The DON stated, Gown and gloves. 4. Review of the medical record revealed Resident #175 was admitted to the facility on [DATE], with diagnoses including 2019-nCoV (Covid-19), Emphysema, and Chronic Obstructive Pulmonary Disease. Review of the Physician Order dated 2/4/2025, revealed Resident remains in DROPLET isolation related to COVID-19. Review of the Progress Note dated 2/9/2026 at 8:15 PM, revealed Resident Covid negative remains on droplet isolation pending 2nd Covid test. Observation in Resident #175's room on 2/9/2026 at 1:00 PM, revealed CNA K entered Resident #175's room with meal tray and provided set up assistance without donning a gown. During an interview on 2/9/2026 at 1:06 PM, CNA K was asked if staff should wear a gown if going into a covid isolation room. CNA K stated, We do if performing care, I don't know if it is right, but they say we don't have to just deliver a tray. Review of the Progress Note dated 2/10/2026 at 12:37 AM, revealed Remains on droplet precautions for covid. During an interview on 2/11/2026 at 12:07 PM, the DON was asked what PPE should be worn by staff in a droplet precautions room. The DON stated, N95 mask, gown, gloves, face shield/goggles. The DON was asked if staff doesn't adhere to wearing those items, could that potentially create a risk of transmitting illness to themselves or other residents. The DON stated, It could but not in the circumstance with this patient, she did test negative on Saturday [2/7/2026]. The DON was asked if that the first test. The DON stated, Yes. The DON was asked how many negative tests are required to discontinue the isolation precautions for Covid-19 residents. The DON stated, .it requires 2 negative tests. 5. Review of the medical record revealed Resident #179 was admitted to the facility on [DATE], with diagnoses including Parkinson's, Hypertension, and Dysphagia. Review of the admission MDS assessment dated [DATE], revealed Resident #179 scored an 11 on the BIMS assessment, which indicated he was moderately cognitively impaired. Observation in Resident #179's room on 2/11/2026 at 7:01 AM, revealed LPN A knocked on the door, rolled the portable vital sign machine into room, obtained the resident's blood pressure, the pulse oximetry (ox) was not working, LPN A exited the room to obtain another pulse ox. LPN A returned to the room, obtained the resident's pulse oximetry, and exited the room pushing the portable vital machine. LPN A failed to complete hand hygiene before or after resident contact and failed to clean the reusable equipment before or after use on the resident. During an interview on 2/11/2026 at 7:25 AM, LPN A was asked if reusable equipment should be cleaned before and after use. LPN A stated, The cuff [blood pressure cuff] and pulse ox should have been cleaned. During an interview on 2/11/2026 at 12:17 PM, the DON was asked if staff should perform hand hygiene between glove changes. The DON stated, Yes. The DON was asked if reusable medical equipment should be cleaned between uses on residents. The DON stated, Yes, we should wipe it down.

Based on policy review, medical record review, observation, and interview, the facility failed to follow physician's orders for the use of oxygen for 1 of 2 (Resident #182) sampled residents reviewed for respiratory care. The findings include: Review of the facility policy titled, Administering Medications, dated 9/2025, revealed .Medications will be administered.as prescribed by the resident's attending physician or the facility's medical director. Review of the medical record revealed Resident #182 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Dependence on Supplemental Oxygen, and Hypoxemia [low levels of oxygen in the blood]. Review of the quarterly Minimum Data Set assessment dated [DATE], revealed Resident #182 scored a 15 on the Brief Interview for Mental Status assessment, which indicated she was cognitively intact. Review of the Care Plan revised 9/10/2024 revealed .Administer oxygen per MD [Medical Director] orders. Review of the Physician's Orders dated 1/10/2026, revealed .7/23/2025.O2 [Oxygen] @ [at] 2 L [Liters] BNC [by nasal canula] O2 Sat [saturation] qshift [every shift] when O2 is in use Three Times A Day. Review of the Respiratory Therapy Progress Notes revealed Resident #182 was receiving oxygen therapy at 3L BNC on the following dates: a. 1/3/2026 at 11:00 AM b. 1/5/2026 at 7:35 AM c. 1/6/2026 at 11:00 AM d. 1/7/2026 at 9:20 AM e. 1/8/2026 at 1:40 PM f. 1/9/2026 at 7:30 AM g. 1/10/2026 at 11:07 AM h. 1/11/2026 at 7:14 AM i. 1/12/2026 at 10:05 AM j. 1/13/2026 at 9:40 AM h. 1/14/2026 at 1:00 PM Review of the Medication Administration Record (MAR) dated 1/2026, revealed oxygen therapy was documented as being administered at 2 L via (by way of) BNC per physician order every shift daily from 1/1/2026 to 1/31/2026. Review of the MAR dated 2/2026, revealed oxygen therapy was documented administered at 2 L via BNC per physician order every shift daily 2/1/2026 to 2/11/2026. Observation in the facility's front lobby on 2/9/2026 at 11:40 AM and 2/10/2026 at 11:05 AM, revealed Resident #182 was receiving O2 via BNC at 3L per portable tank. Observation in the resident's room on 2/9/2026 at 2:39 PM and 2/10/2026 at 3:26 PM, revealed Resident #182 was receiving O2 BNC at 3L per oxygen concentrator. Observation in the resident's room on 2/10/2026 at 8:55 AM, revealed Resident #182 was receiving O2 via BNC at 2.5 L per oxygen concentrator. During an interview on 2/11/2026 at 11:10 AM, Licensed Practical Nurse (LPN) I was asked what rate Resident #182's oxygen should be. LPN I stated, I think 3L.the order is for 2L. LPN I was asked what Resident #182's oxygen was usually administered at. LPN I stated, 2 Liters. Observation in Resident #182's room on 2/11/2026 at 12:36 PM, revealed Resident #182 was receiving O2 BNC at 3.5L per oxygen concentrator. During an interview on 2/11/2026 at 12:43 PM, the 400 Hall Unit Manager was asked what rate Resident #182's oxygen should be. The 400 Hall Unit Manager stated, 2 Liters. During an observation and interview in Resident #182's room on 2/11/2026 at 12:44 PM, the 400 Hall Unit Manager was asked what rate Resident #182's oxygen was being administered at. The 400 Hall Unit Manager stated 3.5 [liters]. During an interview on 2/11/2026 at 2:22 PM, RT D was asked if she was providing Respiratory Therapy with a resident that has a physician's order for 2L what the resident's oxygen should be administered at. RT D stated, 2 Liters.we can not change their oxygen order. RT D was asked if the resident was receiving oxygen therapy at 3L but the physician's order was for 2L what would she do. RT D stated, Change it to 2 [liters]. During an interview on 2/11/2026 at 2:53 PM, the Director of Nursing (DON) was asked to explain the process of oxygen administration. The DON stated, The orders go to their [Resident's] MAR, so the nurse should know that. The DON was asked if oxygen should be administered at the rate prescribed by the physician. The DON stated, Yes, it's a treatment order.

Based on policy review, medical record review, observation, and interview, the facility failed to have a physician's order for the use of an indwelling urinary catheter (a tube inserted into the bladder that drains urine) for 1 of 3 (Resident #57) residents reviewed for the use of an indwelling catheter. The findings include: 1. Review of the facility policy titled, Appropriate Use of Indwelling Catheters, dated 8/2024, revealed . An indwelling urinary catheter will be utilized only when a resident's clinical condition demonstrates that catheterization is necessary .The use of an indwelling urinary catheter will be in accordance with physician orders . 2. Review of the medical record reveled Resident #57 was admitted to the facility on [DATE], with diagnoses including Parkinson's, Dementia, Retention of Urine, and Benign Prostatic Hyperplasia. Review of the annual Minimum Data Set, dated dated dated [DATE], revealed Resident #57 had a Brief Interview for Mental Status score of 11, which indicated the resident was moderately cognitively impaired, and did not have an indwelling urinary foley catheter. Review of the signed Physician Orders dated 10/01/2024 to 10/31/2024 and 11/01/2024 to 11/22/2024 revealed Resident #57 did not have an order for the use of an indwelling urinary catheter. Review of a Progress Note dated 10/9/2024, revealed .arrived at facility at 4:40 pm . indwelling foley catheter . Review of a Progress Note dated 10/10/2024, revealed .foley catheter intact and patent . Review of a Progress Note dated 10/14/2024, revealed .Foley catheter intact below bladder, draining properly .' Review of a physician's progress note dated 11/5/2024 revealed .Resident ready to get rid of the foley catheter .

Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured when 1 of 15 (300 Hall Medication Cart) medication storage areas was observed unlocked and unsecured and when 1 of 4 staff (Licensed Practical Nurse (LPN A) left medications unsecured and unattended on top of a medication cart. The findings include: 1. Review of the facility policy titled Medication Storage, dated 1/2021, revealed .It is the policy of this facility to ensure all medication housed on our premised will be stored in the pharmacy and/or medication rooms .All drugs and biologicals will be stored in locked compartments ( .medication carts, cabinets, drawers .) .During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart . 2. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE], with diagnoses including Acute Respiratory Failure, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, and Hypertension. Review of the Physician's Order dated 8/8/2024, revealed Anoro Ellipta (an inhaler used to open the airway to assist in breathing) 62.5-25 mcg (micrograms) inhale one puff every day. Observations during medication administration on 11/20/2024 at 8:16 AM, revealed LPN A entered Resident #32's room to administer the resident's medications leaving an Anoro inhaler on top of the medication cart in the hallway unsecured and unattended. 3. Random observation and interview on the 300 Hall on 11/20/2024 at 3:51 PM, revealed the 300 Hall medication cart unlocked and unattended with a drawer opened and Registered Nurse (RN) B was in a resident's room with the 300 hall medication cart out of her vision. RN B was asked should the medication cart be left unlocked, unsecured and out of her view. RN B confirmed the medication cart should be locked and no medication cart drawer should be let opened and unattended. 50408

Based on the Level 1 Pre-Admission Screening and Resident Review (PASRR) form, medical record review, and interview, the facility failed to resubmit a PASRR after a resident had a new mental health diagnosis and new antipsychotic medication for 1 of 1 sampled resident (Resident #70) reviewed for PASRRs. The findings include: 1. Review of the medical record revealed Resident #70 was admitted to the facility on [DATE], with diagnoses including Dysphagia, Muscle Weakness, Dementia, and Anxiety. Review of the ICD -10 Diagnoses revealed Resident #70 had an added diagnosis of Psychotic Disorder with hallucinations on 3/30/2023. Review of the Physician Order dated 5/31/2024, revealed Resident #70 had an order for Quetiapine (an antipsychotic medication used to treat Psychosis) 50 mg(milligram) tablet to take one by mouth 2 hours before bedtime. Review of the quarterly Minimum Data Set, dated dated dated [DATE], revealed Resident #70 had a Brief Interview for Mental Status score of 10, which indicated the resident was moderately cognitively impaired, and had diagnosis of Psychotic Disorder, and the use of an Antipsychotic medication. Review of the Medication Administration Record (MAR) dated 10/2024 and 11/2024, revealed Resident #70 received the Quetiapine as prescribed. During an interview on 11/22/2024 at 11:58, the Resident Assessment Coordinator confirmed the facility failed to complete a Level 2 PASRR after the resident was given a mental illness diagnosis and given an order for an antipsychotic medication.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure the environment was free of accident hazards when unattended and unsecured sharps were observed in 1 of 119 (room [ROOM NUMBER]) occupied resident bathrooms. The findings included: 1. Review of the facility policy titled Bloodborne Pathogens/Contaminated Sharps Occupational Exposure, dated 11/2021, revealed .Universal Precautions will be observed to prevent contact with blood and other potentially infectious materials. Sharps Containers will be provided to all staff to dispose of any potentially contaminated sharp, product or object that may have been exposed . 2. Review of the medical record revealed Resident #52 was admitted to the facility on [DATE], with diagnoses including Parkinson's, Dementia, and Epilepsy. Review of the Care Plan dated 3/13/2024, revealed .Self Care Deficit related to inability to independently perform Activities of Daily Living skills (ADLs) secondary to cognitive and physical deficit . Review of the annual Minimum Data Set assessment dated [DATE], revealed a Brief Interview of Mental Status score of 10, which indicated Resident #52 was moderately cognitively impaired and was dependent on staff for assistance with ADLs. Observation in room [ROOM NUMBER]'s bathroom on 11/18/2024 at 10:06 AM and 3:41 PM, revealed an unattended and unsecure disposable razor with the blades exposed on the bathroom vanity. During an interview and observation in room [ROOM NUMBER] on 11/18/2024 at 3:53 PM, the Director of Nursing (DON) was asked if the razor should be left in the resident's bathroom unsecured and unattended. The DON confirmed that the razor should not be left in resident's room or bathroom and that razors should be discarded in a sharps container after use.

Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when multi-use blood glucose meters were not cleaned and disinfected to prevent cross-contamination of bloodborne pathogens for 5 of 5 sampled residents (Resident #65, #74, #88, #277, and #376) reviewed for blood glucose monitoring, 6 of 9 nurses (Licensed Practical Nurse (LPN) #1, #2, #4, #5, #6 and Unit Manager #2) failed to perform hand hygiene, failed to place barriers when performing accucheck monitoring, failed to dispose of contaminated sharps and glucose strips in the sharp container, and administered contaminated pills to 8 of 11 sampled residents (Resident #65, #74, #82, #88, #226, #227, #232, and #376) observed during medication administration. The facility's failure to educate staff on the proper use of the glucometer placed residents at risk and resulted in Immediate Jeopardy. The failure occurred during a COVID-19 pandemic. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Executive Director and the Director of Nursing (DON) were notified of the Immediate Jeopardy on 3/24/2022 at 4:17 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-880. The IJ existed from 3/23/2022 through 3/24/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 3/25/2022 at 10:26 AM, and was validated onsite by the surveyors on 3/25/2022 through review of staff education, interviews with staff on all shifts, and review of the audits conducted. The findings include: Review of the facility's policy titled, Cleaning and Disinfection of Equipment, revised 3/2020, revealed .Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC [Center for Disease Control] recommendations in order to break the chain of infection .Blood Glucose Meter .Clean and disinfect blood glucose meters between each resident test to avoid cross-contamination issues .Use a bleach wipe to clean the inside and the outside of the glucometer .Make sure the meter is completely dry before testing a resident's glucose level .Medication carts should be cleaned using bleach wipes .This should be done at change of shift .Hand hygiene shall be performed prior to and after using the equipment .Each user is responsible for routine cleaning and disinfection . Review of the facility's policy titled, Administrating Medications, revised 2/6/2015, revealed .The Director of Nursing Services is responsible for the supervision and direction of all personnel with medication administration duties and functions .Established facility infection control procedures must be followed during the administration of medications ( .handwashing/hand hygiene, antiseptic technique, gloves .) . Review of the facility's policy titled, Hand Hygiene/Hand-washing, revised 1/2019, revealed .Hand-washing/hand hygiene is considered the most important single procedure for preventing healthcare-associated infections .Hand-washing with antimicrobial soap and water is indicated and must be performed under the following conditions .When hands are visibly dirty or contaminated .When hands are visibly soiled .After handling items potentially contaminated .Wash [hands] well under running water for a minimum of 15-20 seconds, using a rotary motion and friction .Turn off faucets with a clean, dry paper towel .Waterless Hand-washing Products .Before direct contact with residents .Before performing any non-surgical invasive procedure .Before preparing or handling medications .After contact with resident's intact skin .After handling .contaminated equipment . Review of the SCOPE OF CONSULTATION SERVICES, revealed .Consultant Pharmacist shall assist the Facility in assessing the performance of the nursing staff in medication administration . Review of the STAFF DEVELOPMENT/EDUCATOR, job description revealed .Identifies and prioritize the facility's educational needs through the completion of an educational needs assessment .Collaborates with the department manager for developing competencies required for meeting resident's needs .Follows established infection control policies and procedures . Observation in the resident's room on 3/22/2022 at 8:28 AM, revealed LPN #6 entered Resident #232's room, placed the medication cup on the resident's nightstand, and failed to clean the nightstand or place a barrier on the nightstand. LPN #6 opened the medication packets, dropped one of the pills on the plastic wrap next to the medication cup, picked the pill up with her bare hand, placed it back in the medication cup, and administered the medication. LPN #6 donned her gloves, administered a nasal spray, removed her gloves, exited the resident's room, and failed to perform hand hygiene. During an interview on 3/22/2022 at 8:36 AM, LPN #6 confirmed she should not have given the Vitamin D pill that was dropped on the resident's nightstand. Observation in the resident's room on 3/22/2022 at 9:14 AM, revealed LPN #4 donned her gloves to crush Resident #82's medication, placed the medications on a Styrofoam tray, entered the resident room, went into the resident's bathroom, filled the plastic cup with water, removed her gloves, donned a new pair of gloves, and failed to wash her hands after removing the gloves. LPN #4 administered the medications through the Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube to administer medications, water, and nutrition into the stomach). LPN #4 removed her gloves, donned new gloves, failed to wash her hands after the removal of the gloves, and helped reposition Resident #82 in the bed. Random observation of the 100 Hall Medication Cart on 3/22/2022 at 12:23 PM, revealed the medication cart had a dried white powdery substance and a clear liquid splattered on top of the cart. Observation in the resident's room on 3/23/2022 at 8:52 AM, revealed LPN #4 removed the blood glucose meter from the medication cart, donned her gloves, cleaned the top of the blood glucose meter with an alcohol pad, placed the blood glucose meter on a Styrofoam tray with the supplies, removed her gloves, and failed to perform hand hygiene. LPN #4 entered Resident #74's room, placed the Styrofoam tray on the dresser, donned her gloves, and checked the resident's blood sugar. LPN #4 removed her gloves, entered the resident's bathroom, and washed her hands for 5 seconds. LPN #4 exited the resident's room and placed the blood glucose meter strip and lancet that was contaminated with blood in the trash can with the Styrofoam tray. LPN #4 donned her gloves, cleaned the top of the blood glucose meter with an alcohol pad, and placed the blood glucose meter into the medication cart. During an interview on 3/24/2022 at 7:50 AM, LPN #4 was asked what the process was for checking a resident's blood sugar. LPN #4 stated .wash your hands first .clean the meter before you use it .I asked someone here do I use alcohol wipe .they said to use that [alcohol wipes] .I should have used the bleach cloths . LPN #4 confirmed the lancet and strips should be placed in the sharp container. LPN #4 confirmed she should wash her hands for 15-20 seconds and hands should be washed when gloves were removed. Observation in the resident's room on 3/23/2022 at 9:37 AM, revealed LPN #4 entered Resident #82's bathroom, washed her hands for 5 seconds, donned her gloves, checked the resident's vital signs, and started his nebulizer treatment. LPN #4 completed the resident's nebulizer treatment, removed the face mask, entered the bathroom, washed and dried the equipment, removed her gloves, washed her hands for 6 seconds, exited the bathroom, donned new gloves, and checked the resident's vital signs again. LPN #4 removed her gloves and washed her hands for 5 seconds. Observation in the resident's room on 3/23/2022 at 10:13 AM, revealed LPN #1 entered Resident #227's room, placed the medications on the table and failed to clean the table or place a barrier on the table. LPN #1 went into the bathroom, washed her hands for 10 seconds, donned her gloves, cleaned and dried the back of Resident #227's neck, applied a medicated ointment, removed her gloves, and exited the room. LPN #1 collected her supplies, donned her gloves, assisted Resident #227 to the bathroom in her wheelchair, pulled down the resident's pants, cleaned and dried the resident's hip, and applied the medicated patch. LPN #1 failed to change her gloves and wash her hands prior to cleaning the resident's hip and applying a medication patch. LPN #1 assisted the resident back to her room, removed her gloves, and washed her hands for 9 seconds. During an interview on 3/24/2022 at 1:14 PM, LPN #1 confirmed that she should have washed her hands or used hand sanitizer when she removed her gloves. LPN #1 confirmed she should have removed her gloves when she touched Resident #227's wheelchair and should have washed her hands before applying the medication patch. Observation in the resident's room on 3/23/2022 at 10:55 AM, revealed LPN #4 removed the blood glucose meter from a plastic bag in the medication cart and placed it on a Styrofoam tray. LPN #4 donned her gloves, collected the supplies, cleaned the top of the blood glucose meter with an alcohol pad, placed the blood glucose meter on the Styrofoam tray, and removed her gloves. LPN #4 entered Resident #88's bathroom and washed her hands for 7 seconds. LPN #4 placed the Styrofoam tray on the over bed table, donned her gloves, removed her gloves, and exited Resident #88's room to obtain a container of glucose strips. LPN #4 entered the resident's bathroom, washed her hands for 5 seconds and exited the room to obtain a box of gloves. LPN #4 donned her gloves, checked the residents blood sugar, placed the lancet and strip back on the Styrofoam tray, removed her gloves and placed them on the Styrofoam tray, washed her hands for 4 seconds, exited the room with the Styrofoam tray and placed the entire Styrofoam tray with the lancet, strip, and gloves into the trash can on the medication cart. LPN #4 failed to place the sharps in the sharp container. LPN #4 placed the blood glucose meter back into the plastic bag and placed it in the top drawer of the medication cart. LPN #4 failed to disinfect the blood glucose meter after use and did not perform hand hygiene. Observation in the resident's room on 3/23/2022 at 11:13 AM, revealed LPN#1 assembled the supplies, donned her gloves, cleaned the blood glucose meter with a bleach wipe, and placed the blood glucose meter on top of some papers that were on top of the medication cart, contaminating the blood glucose meter that had just been cleaned. LPN #1 entered Resident #277's room with the blood glucose meter in her bare hands and the supplies in a plastic cup. LPN#1 placed the blood glucose meter on top of a book on the resident's nightstand. LPN #1 failed to clean or place a barrier on the medication cart or the resident's nightstand. During an interview on 3/24/2022 at 1:14 PM, LPN #1 confirmed she should have used a barrier before placing the blood glucose meter on the medication cart and on the book in the resident's room. Observation at the 300 Hall Medication Cart on 3/23/2022 at 12:16 PM, revealed Unit Manager #2 assembled her supplies and medications and placed them on a barrier on the medication cart. Unit Manager #2 walked to the nursing station to obtain a container of bleach wipes. Unit Manager #2 walked back to the medication cart with the bleach wipes and with her bare hands cleaned the medication cart. Unit Manager #2 donned her gloves and dried the medication cart. Unit Manager #2 removed her gloves and failed to perform hand hygiene. Unit Manager #2 entered Resident #226's bathroom, washed her hands for 13 seconds, exited the resident's room to obtain a towel from the cart in the hallway, reentered the resident's room, entered the bathroom and washed her hands for 6 seconds. Unit Manager #2 placed the medications under the blue towel that was on the resident's bed. Unit Manager #2 donned her gloves, cleaned the over bed table, removed her gloves, entered the bathroom, washed her hands for 8 seconds, and using the same wet paper towel turned the faucet off. Unit Manager #2 donned gloves, positioned the resident in her wheelchair with her gloved hands, failed to remove her gloves or perform hand hygiene and assessed the IV (intravenous) site with the same gloved hands. Unit Manager #2 mixed the IV medication, removed her gloves, donned a new pair of gloves, failed to perform hand hygiene, spiked the IV bag, primed the tubing by placing the end of the tubing on the resident's bed, and failed to perform hand hygiene after removal of the gloves and prior to donning a clean pair of gloves. Unit Manager #2 removed her gloves and went to the medication cart to obtain the 2 normal saline flush syringes to flush the IV line. Unit Manager #2 removed her gloves, donned a clean pair of gloves, cleaned the port, flushed the IV line, and started the infusion of the IV medication. Unit Manager #2 entered the bathroom, washed her hands for 6 seconds, and using the same wet paper towel, turned the faucet off. Observation in the resident's room on 3/23/2022 at 1:22 PM, Unit Manager #2 entered Resident #226's room, washed her hands for 13 seconds, and turned the faucet off with the same wet paper towel. Unit Manager #2 donned her gloves, disconnected the IV line, cleaned the site, flushed the IV with normal saline, disposed of the IV bag in the trash, removed the trash bag, exited the room, walked to the biohazard room, and placed the trash in a red bag. Unit Manager #2 removed her gloves and washed her hands for 7 seconds. During an interview on 3/24/2022 at 8:11 AM, Unit Manager #2 confirmed she should wash hands for at least 20 seconds. Unit Manager #2 confirmed she should not have placed the resident's medication on the resident's bed. Observation in the resident's room on 3/23/2022 at 5:06 PM, revealed LPN #5 collected her supplies, removed the blood glucose meter from the medication cart, placed the supplies and blood glucose meter into her front pocket. LPN #5 entered Resident #376's room, administered the oral medications, removed the blood glucose meter and supplies from her front scrub pocket, donned her gloves, checked the resident's blood sugar, removed her gloves, folded the lancet and strip into her gloves and placed the contaminated strip and lancet in the resident's trash can. LPN #5 exited the resident's room and placed the blood glucose meter and bottle of strips back in the top drawer of the medication cart. LPN #5 failed to disinfect the blood glucose meter before or after use and failed to perform hand hygiene. LPN #5 failed to place the contaminated lancet and strip into the sharp container. During an interview on 3/24/2022 at 12:54 PM, LPN #5 confirmed she should not have placed the blood glucose meter into her front pocket and should disinfect the blood glucose meter before and after use. LPN #5 stated .clean the meter with an alcohol pad before .that is what I was told .after you clean with a bleach wipe .I was supposed to put it on a tissue .I was out of tissue at the time so I had to improvise . LPN #5 confirmed she should have washed her hands or used hand sanitizer before and after medication administration and the blood glucose check, and also when she removed her gloves. LPN #5 confirmed the lancet and glucose strip should be disposed in the sharps container. Observation in the resident's room on 3/24/2022 at 7:20 AM, revealed LPN #2 removed the blood glucose meter from the top drawer of the medication cart, removed the blood glucose meter from the plastic bag and placed it on top of the medication cart, collected the supplies, and placed the supplies in the front pocket of her uniform. LPN #2 carried the blood glucose meter with her bare hands, entered Resident #65's room and placed the blood glucose meter on the resident's over bed table without a barrier. LPN #2 donned her gloves, removed the supplies from the front pocket of her uniform, and checked the resident's blood sugar. LPN #2 placed the blood glucose meter into the front pocket of her uniform with the supplies, removed her gloves, folding the strip and lancet inside of her gloves. LPN #2 went back to the medication cart and disposed of the gloves in the sharp container. LPN #2 removed the supplies and the blood glucose meter from her front pocket, wiped the blood glucose meter with a bleach wipe and placed it in the plastic bag on the medication cart. LPN #2 failed to allow a 4-minute contact time for the blood glucose meter to dry before placing it in the plastic bag in the medication cart. During an interview on 3/24/2022 at 7:34 AM, LPN #2 stated the blood glucose meter should be disinfected after use. LPN #2 confirmed after cleaning the blood glucose meter, she did not allow a contact time of 4 minutes for the meter to dry before placing the blood glucose meter back in the plastic bag. LPN #2 confirmed she should not have put the blood glucose meter and supplies in the front pocket of her scrubs. LPN #2 confirmed she should have a barrier on the table before placing the blood glucose meter and supplies on the table. LPN #2 confirmed she should have used hand sanitizer or washed her hands when she removed her gloves. During an interview on 3/24/2022 at 3:58 PM, the DON confirmed the staff should wear gloves, should disinfect the entire blood glucose meter with bleach wipes, and allow the blood glucose meter to dry. The DON confirmed nursing staff should not disinfect blood glucose meters with alcohol wipes. The DON confirmed staff should clean their medication cart and place a barrier during preparation of the medications or medication administration. The DON confirmed nursing staff should not place the blood glucose meter and supplies in their scrub pocket. The DON confirmed Nursing Staff should wash their hands for 15-20 seconds or use hand sanitizer when they remove their gloves or when touching contaminated items in the residents' rooms. The DON confirmed nursing staff should not use the same wet towel they used to dry their hands to turn the faucet off. The DON confirmed when a pill is dropped on a contaminated surface, the nursing staff should not administer the medication. The DON confirmed staff should place the lancets and strips into the sharp container. The DON confirmed she is ultimately responsible to ensure that the nursing staff members are trained and monitored. During an interview on 3/25/2022 at 8:09 AM, the Medical Director confirmed the blood glucose meters should be cleaned with bleach wipes and the nursing staff should not place the blood glucose meters and supplies in the pocket of their uniform. The Medical Director confirmed nursing staff should wash their hands when they remove their gloves. The Medical Director confirmed nursing staff should place contaminated sharps and glucose strips in the sharp container. During a telephone interview on 3/25/2022 at 6:51 PM, the Pharmacy Customer Reaction Specialist stated, .I do a medication pass with the nurses .whatever they mess up on .I do an in-service .I get with Unit Manager .get the policy out .go over everything found in the medication pass with the nurse and unit manager .I ask for the facility policy .for example of a medication pass .I try to look at the beginning of every shift .make sure nurses verify orders .gather supplies .I have a check sheet as well .how they enter the residents rooms .wash hands before putting on their gloves .when staff remove gloves .wash their hands .if they don't wash their hands long enough .I will intervene .I will remind them to sing the song while they are washing their hands . The Pharmacy Customer Reaction Specialist confirmed nurses should disinfect the blood glucose meter with the bleach wipes, allowing 4 minutes contact time before and after use, and have a barrier or a Styrofoam tray. The Pharmacy Customer Reaction Specialist confirmed the nurses should not use alcohol swabs to disinfect the blood glucose meter. The surveyors verified the Removal Plan by: 1. The Administrator and DON reviewed the Facility's policy regarding the proper cleaning and disinfection of all blood glucose meters and determined the Facility's policy was consistent with current infection control standards. The surveyors reviewed the policy and interviewed the DON. 2. The DON or Designee will ensure all blood glucose meters are immediately cleaned and disinfected. Blood glucose meters will be cleaned and disinfected per manufacturer's instructions. The surveyors interviewed nursing staff on all shifts. 3. The DON or Designee will ensure all licensed nursing staff have a documented 1 on 1 re-in-service on proper cleaning and disinfection of all blood glucose meters according to facility policy. This re-in-service will include return demonstration to verify compliance with the policy. This re-in-service training will begin on 3/24/2022 and any licensed nursing staff not working on 3/24/2022 will be re-in-serviced prior to returning to work. The surveyors reviewed the in-service and return demonstration records and interviewed nursing staff on all shifts. 4. The DON or Designee will ensure all licensed nursing staff have a 1 on 1 re-in-service on handwashing. This re-in-service training will begin on 3/24/2022 and any licensed nursing staff not working on 3/24/2022 will be re-in-serviced prior to returning to work. The surveyors reviewed the in-service and return demonstration records and interviewed nursing staff on all shifts. 5. The DON or Designee will ensure all licensed nursing staff have a 1 on 1 in-service on the disposal of sharps according to the facility policy. This in-service training will begin on 3/24/2022 and any licensed nursing staff not working on 3/24/2022 will be re-in-serviced prior to returning to work. The surveyors reviewed the in-service and return demonstration records interviewed nursing staff on all shifts. 6. For 14 days the DON or Designee will conduct unscheduled audits of handwashing, sharps disposal and proper blood glucose meter cleaning and sanitation to ensure compliance with facility policies is maintained and in-service training is understood by all staff. During the initial 14 days, the DON or Designee will conduct the unscheduled audits by making 4 observations per day of licensed nursing staff to ensure handwashing, sharps disposal, and cleaning and disinfection of blood glucose meters are in accordance with facility policies. Results of these audits will be documented. Staff will be randomly selected to ensure multiple staff are observed demonstrating these infection control skills. Any licensed nursing staff not demonstrating proper technique or failing to follow facility policy will be immediately removed from resident care and given additional in-service training. The surveyors interviewed the DON and reviewed the audit forms. 7. After 14 days, if facility staff demonstrate continued compliance, the observation audit schedule will be adjusted to 4 observations per week, The audits will be conducted weekly for 1 month, then monthly for the next 2 months. Any negative findings will be corrected immediately and reported to the Quality Assurance Committee for review and appropriate action will be taken. The surveyors interviewed management staff. The facility's noncompliance at F-880 continues at a scope and severity of E for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured when 4 of 9 staff members (Licensed Practical Nurse (LPN) #2, #3, and #4, and Unit Manager #2) left medication carts unlocked, unattended, and out of sight and left medications out of sight and unattended, and when 2 of 16 medication storage areas (200 Hall Low Medication Cart and 400 Hall Low Medication Cart) had internal and external medications stored together. The findings include: Review of the facility's policy titled, Medication Storage, dated 1/2021, revealed .All drugs and biologicals will be stored in locked compartments .medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart .Disinfectants and drugs for external use are stored separately from internal and injectable medications . Random observation of the 300 Hall High Medication Cart on 3/22/2022 at 9:10 AM, revealed the medication cart was unlocked, unattended, and out of the sight of the nurse. During an interview on 3/22/2022 at 9:14 AM, LPN #4 was asked if the medication cart should be left open, unlocked, and unattended in the hallway. LPN #4 stated, .No ma'am . LPN #4 confirmed she should not have left the medication cart unlocked. During an interview on 3/22/2022 at 9:46 AM, Unit Manager #1 confirmed the medication cart should not be unlocked and unattended in the hallway Observation of the 200 Hall Low Medication Cart on 3/22/2022 at 12:02 PM, revealed 1 syringe of normal saline in the same drawer as lancets, scissors, tape, keys, and plastic bags for the pill crusher. Observation in the resident's room on 3/23/2022 at 8:35 AM, revealed LPN #3 entered Resident #100's room, placed the medication cup on the over bed table with a barrier, instilled eye drops, picked up the medication and placed it on the television stand with a barrier, and went into the bathroom to wash her hands, leaving the medication at the bedside and out of sight. Observation at the 200 Hall Low Medication Cart on 3/23/2022 at 12:16 PM, revealed Unit Manager #2 collected her supplies and medication and placed them on top of the 200 Hall Low Medication Cart. Unit Manager #2 left the medication and the supplies on top of the medication cart and went to the Nurses' station to obtain bleach wipes. Unit manager #2 then pulled the medication cart down to Resident #226's room and placed the cart in front of Resident #226's room. Unit Manager #2 entered Resident #226's room, leaving the medication on top of the medication cart unattended and entered the bathroom to wash her hands. Unit Manager #2 exited the bathroom, went into the hallway to get a towel, and reentered the resident's room. Unit Manager #2 removed the medication from the top of the medication cart, leaving 4 syringes of normal saline on top of the medication cart, and placed the medication, supplies, and towel on top of the resident's bed. Unit manager #2 exited Resident #226's room to obtain the bleach wipes from the cart in the hallway, reentered the resident's room to clean the over bed table, exited the room to place the bleach wipes on the cart in the hallway, reentered the resident's room, and then entered the bathroom to wash her hands. Unit Manager #2 left the medication and supplies unattended multiple times during medication administration. Random observation of the 400 Hall High Medication Cart on 3/24/2022 at 7:30 AM, revealed the medication cart was unlocked, unattended, and out of the sight of the nurse. During an interview on 3/24/2022 at 7:34 AM, LPN #2 confirmed she should not have left the medication cart unlocked and unattended. During an interview on 3/24/2022 at 8:11 AM, Unit Manager #2 confirmed she should not leave the medications out of sight and unattended. Observation of the 400 Low Hall Medication Cart on 3/24/2022 at 10:43 AM, revealed a blood glucose meter in the same drawer as 7 alcohol pads, 1 bottle of blood glucose meter strips, 1 vial of [MEDICATION(S)] insulin, and 1 vial of [MEDICATION(S)] Insulin. During an interview on 3/24/2022 at 10:45 AM, LPN #3 confirmed the blood glucose meter, insulin, and alcohol pads should not be in the same drawer. During an interview on 3/24/2022 at 3:58 PM, the Director of Nursing (DON) confirmed staff should not leave medication carts unlocked and unattended and should not leave medication unattended during medication administration. The DON confirmed the medication carts should not have internals and externals stored together.

Based on policy review, observation, and interview the facility failed to ensure food was served under sanitary conditions when 3 of 17 staff members (Pantry Aide #1, Sous Chef (the second in command in a kitchen) #1 and Certified Nursing Assistant (CNA) #1) failed to sanitize a thermometer and failed to perform proper hand hygiene during meal service. This had the potential to affect 31 residents who received supper trays on the 100 Hall. The facility had a census of 131 with 126 residents receiving supper trays. The findings include: Review of the undated facility's policy titled, Food: Preparation, revealed .The Food Services Director ensures that all staff practice proper hand washing technique and practice proper glove use .The Food Service Director or Chef/Cook(s) is responsible to ensure that all utensils, food contact equipment, and food contact surfaces are cleaned and sanitized after each use . Observation in the 100 Hall Dining Room on 3/22/2022 at 4:59 PM, revealed Pantry Aide #1 was serving food from a steam table wearing gloves. Pantry Aide #1 was asked to check food temperatures. Pantry Aide #1 obtained a thermometer and checked the temperature of the fish, hashbrown casserole, and mixed vegetables without sanitizing the thermometer between the foods. Pantry Aide #1 turned on the faucet with his gloved hand and placed the thermometer under the running water, dried the thermometer with a paper towel and placed it in a pan of ravioli. Pantry Aide #1 obtained sanitizing wipes from a shelf and used a wipe to clean the thermometer and checked the temperature of 4 other food items, sanitizing between each item. Sous Chef #1 instructed Pantry Aide #1 to change his gloves. Pantry Aide #1 removed his gloves and, without performing hand hygiene, donned new gloves. Pantry Aide #1 placed the thermometer in a pan of chopped meat and Sous Chef #1 instructed Pantry Aide #1 to change gloves again after observing him touch his face. Observation in the Kitchen on 3/22/2022 beginning at 5:16 PM, revealed Sous Chef #1 reheating pureed fish (from the 100 Hall Dining Room) in the steamer. Sous Chef #1 washed his hands, donned gloves, removed the pan of fish from the steamer, placed the pan on a table, removed his gloves, donned new gloves without performing hand hygiene, and used a thermometer to check the temperature of the fish, and then returned the pan of fish to the steamer. Observation in the 100 Hallway on 3/22/2022 at 5:38 PM, revealed CNA #1 obtained a meal tray from the meal delivery cart and delivered it to Resident #108. CNA #1 placed the meal tray on the over bed table, picked up the resident's telephone with her bare hands and handed it to the resident, picked up a small bag from the table and handed it to the resident, raised the head of the bed with the bed remote and began preparing the tray. Resident #108 stated she did not want to eat. CNA #1 removed the tray from the room, took it to the Dining Room and placed it on a table. Then, without performing hand hygiene, CNA #1 walked back to the meal cart, removed a tray and delivered it to Resident #279. CNA #1 placed the tray on the over bed table, moved a cup to the other side of the table, pulled the resident's bed linens back and then went out in the hall to obtain a pair of gloves. CNA #1 returned to the room holding the gloves, and with her bare hands, removed the plate cover, opened the drink and handed the resident a fork. CNA #1 threw the gloves away and exited the room, without performing hand hygiene. During an interview on 3/24/2022 at 4:12 PM, the Director of Nursing (DON) confirmed staff should wash their hands between trays during meal tray delivery if they touch other items in the resident's room. During an interview on 3/25/2022 at 11:09 AM, the Dining Services Director confirmed staff should sanitize the thermometer between food items, when checking food temperatures, and should perform hand hygiene when removing and reapplying gloves.

Based on policy review, observation, and interview, the facility failed to promote care that maintained residents' dignity, respect, and quality of care when staff failed to provide and utilize indwelling urinary catheter privacy bags for 3 of 5 sampled residents (Resident # 66, #73, and #377) reviewed for indwelling urinary catheters. The findings include: Review of the facility's policy titled, Promoting/Maintaining Resident Dignity, revised 1/2022, revealed .It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality .Maintain resident privacy .Random observations and/or verifications are conducted by the Director of Nursing Services (DNS), or designee, to ensure compliance with this policy . Review of the facility's document titled [Named Skilled Nursing Facility] Patient Bill of Rights, dated 1/1/2022, revealed .It is the objective of [Named Skilled Nursing Facility] .to herein set forth the rights of Patients so as to assure the protection and preservation of dignity, individuality and, to the extent medically feasible, independence .[Named Skilled Nursing Facility] PATIENTS SHALL HAVE THE RIGHT TO .Privacy in treatment and personal care .treated with consideration, respect, and full recognition of his dignity and individuality . Observation in the resident's room on 3/21/2022 at 10:25 AM and 2:48 PM, and on 3/22/2022 at 8:48 AM, revealed Resident #66 had a urinary catheter drainage bag hanging on the side of the bed uncovered without privacy bag. Observation in the resident's room on 3/22/2022 at 8:18 AM and on 3/23/2022 at 8:17 AM, revealed Resident #73's urinary catheter bag hanging on the bed uncovered, next to the privacy bag. Observation in the resident's room on 3/21/2022 at 11:42 AM and 3/22/2022 at 4:59 PM, revealed the urine in Resident #377's urinary catheter drainage bag was visible from the hallway and it was not covered with a privacy bag. During an interview on 3/22/2022 at 8:48 AM, Licensed Practical Nurse (LPN) #4 confirmed the urinary catheter bags should be covered and secured in a privacy cover. During an interview on 3/25/2022 at 9:25 AM, Unit Manager #1 confirmed urinary catheter bags should be covered and secured in a privacy bag.

Based on medical record review and interview, the facility failed to accurately assess residents for antipsychotic medications for 1 of 33 sampled residents (Resident #21) reviewed. The findings include: Review of the medical record, revealed Resident #21 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .twice a day . Review of the Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #21 was coded as receiving antipsychotic medications daily over the last 7 days and was also coded as not receiving antipsychotic medications in section N0450A. During an interview on 3/25/2022 at 2:18 PM, MDS/Resident Care Coordinator #2 confirmed antipsychotic medications were given and section N0450A was coded incorrectly.

Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to complete required quarterly Minimum Data Set (MDS) assessments for 2 of 33 sampled residents (Resident #7 and #8) reviewed. The findings include: Review of the MDS 3.0 RAI Manual version 1.17.1 dated 10/2019, page 2-17, revealed .Quarterly .Assessment Reference Date [ARD] .any type + [plus] 92 calendar days . Review of the medical record, revealed Resident #7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment revealed an ARD dated 11/11/2021. The facility was unable to provide a quarterly MDS dated [DATE] (92 days after 11/11/2021). Review of the medical record revealed, Resident #8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment revealed an ARD on 11/5/2021. The facility was unable to provide a quarterly MDS dated [DATE] (92 days after 11/5/2021). During an interview on 3/24/2022 at 3:13 PM, MDS/Resident Care Coordinator #1 confirmed both of these assessments were not done and should have been completed.

Based on policy review, medical record review, and interview, the facility failed to have discharge and transfer documentation for 1 of 3 sampled residents (Resident #20) reviewed for hospitalization . The findings include: Review of the facility's policy titled, Discharge/Transfer Form in LTC [Long Term Care], dated 8/2013, revealed .At Discharge/Transfer pertinent paperwork will be completed for any resident/patient being transferred from [Named Skilled Nursing Facility] by a Charge Nurse or Nurse Supervisor .Two copies made: one for the ambulance service and one for the ER [emergency room ] or transferring facility . Review of the medical record, revealed Resident #20 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Physician's Telephone Order dated 11/2/2021, revealed .Send to [Named Hospital] for eval [evaluation] and tx [treatment] intractable nausea . Review of a Nurses' Progress Note dated 11/2/2021, revealed .large emesis this AM [morning] with foul odor .new order to send resident out for eval .ambulance and resident left unit . The facility was unable to provide transfer documentation for Resident #20's hospital transfer on 11/2/2021. During an interview on 3/23/2022 at 11:55 AM, the Director of Nursing confirmed she was unable to provide transfer documentation related to the 11/2/2021 emergency room visit.

Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual v 1.16 (MONTH) 1, (YEAR), medical record review and interview the facility failed to transmit MDS assessments timely for 3 of 32 (Resident #2, #3, and #8) sampled residents reviewed. The findings include: 1. The MDS 3.0 RAI Manual v 1.16 (MONTH) 1, (YEAR), page 5-2 documented, .In accordance with the requirements .long-term care facilities participating in the Medicare and Medicaid programs must meet the following conditions ., page 5-3 documented, .Assessment Transmission .MDS assessments must be submitted within 14 days of the MDS Completion Date . and page 5-6 documented Fatal File Errors . Files that are rejected must be corrected and resubmitted. 2. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the discharge MDS with an Assessment Reference Date (ARD) of 3/8/19 revealed a completion date of 3/22/19. Review of the facility's MDS transmission logs revealed the assessment was previously transmitted and rejected related to a Fatal Error. The facility failed to correct and resubmit the assessment. Interview with the Director of Assessments on 7/16/19 at 5:51 PM, in the Board Room, the Director of Assessments confirmed the assessment had not been retransmitted. The Director of Assessments stated No .I marked it as rejected in the system but didn't correct it. 3. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an ARD of 6/4/19 revealed a completion date of 6/18/19. Review of the facility's MDS transmission log revealed the assessment was not transmitted until 7/16/19. 4. Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an ARD of 6/4/19 revealed a completion date of 6/18/19. Review of the facility's MDS transmission log revealed the assessment was not transmitted until 7/16/19. Interview with the Director of Assessments on 7/16/19 at 5:51 PM, in the Board Room, the Director of Assessments was asked when the assessments for Resident #3 and 8 should have been transmitted. The Director of Assessments stated, 7/2 . The Director of Assessments confirmed that the assessment had not been transmitted timely.

Based on policy review, medical record review, observation, and interview, 2 of 7 (Licensed Practical Nurse (LPN) #1 and Registered Nurse (RN) #1) failed to ensure practices to prevent the potential spread of infection were maintained when a medication syringe was not cleaned after use for 2 of 2 (Resident #39 and #164) sampled residents reviewed for Percutaneous Enteral Gastrostomy (PEG) Feedings and failed to perform proper hand hygiene during medication pass. The findings include: 1. The facility's .Medication Administered Through and Enteral Tube policy with a revised date of (MONTH) (YEAR) documented, .Clean medication syringe and return to the bag . 2. The facility's .Hand Hygiene / Hand-washing policy with a revised date of (MONTH) (YEAR) documented, .Hand-washing/hand hygiene is considered the most important single procedure for preventing healthcare-associated infections .Before direct contact with residents . 3. Medical record review revealed Resident #164 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME]-ACETAMIN ([MEDICATION NAME]) 5-325 MG (milligrams) TAKE 1 TABLET VIA PEG TUBE TWICE DAILY . Observations in Resident #164's room on 7/16/19 at 9:21 AM, revealed LPN #1 entered Resident #164's room, went to the bathroom, washed her hands, donned gloves, removed a medication syringe from the plastic bag, and checked PEG placement. LPN #1 removed the gloves, donned a new pair of gloves, placed the medication syringe into the PEG tubing and administered the medication. LPN #1 then placed the syringe back into the plastic bag. LPN #1 did not perform hand hygiene after removal of her gloves, before donning clean gloves, and did not clean the medication syringe before placing back into plastic bag. Interview with LPN #1 on 7/16/19 at 6:04 PM, in Resident #164's bathroom, LPN #1 was asked what should she have done after removing the gloves and donning a new pair. LPN #1 stated, Wash my hands between glove changes . LPN #1 was asked should the medication syringe be cleaned before placing it back into the plastic bag. LPN #1 stated, Yes . 4. Medical record review revealed Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] 5 MG TABLET .GIVE ONE TABLE PPT (per peg tube) BID (twice a day) .MODAFINIL 100 MG TABLE GIVE 1.5 TABS .PPT BID . Observations in Resident #39's room on 7/16/19 at 5:33 PM, revealed RN #1 entered Resident #'39's room, donned gloves, removed the medication syringe from the plastic bag, checked PEG placement,, placed the medication syringe into the PEG tubing and administered the medications. RN #1 then placed the syringe back into the plastic bag. RN #1 left Resident #39's room, placed the trash in a barrel, removed her gloves, and washed her hands. RN #1 did not perform hand hygiene before donning gloves and did not clean the medication syringe before placing the syringe back into plastic bag. Interview with RN #1 on 7/16/19 at 6:04 PM, in Physician Room, RN #1 was asked what she should have done before donning gloves. RN #1 stated, Wash my hands . RN #1 was asked should the medication syringe be cleaned before placing it back into the plastic bag. RN #1 stated, Yes . Interview with the Director of Nursing (DON) on 7/17/19 at 2:00 PM, in the Board Room, the DON was asked what she expected the nursing staff to do before applying gloves. The DON stated, .wash hands . The DON was asked what she expected the nursing staff to do after removing gloves and donning new gloves. The DON stated, .wash hands . The DON was asked what would she expect the nursing staff to do after using a medication syringe to administer medications through a PEG. The DON stated, Should be rinsed and put back in bag .

Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual v 1.16 (MONTH) 1, (YEAR), medical record review, and interview, the facility failed to ensure assessments were completed to accurately reflect the resident's status for medications and hospice care for 2 of 32 (Residents #37 and #157) sampled residents reviewed. The findings include: 1. The MDS 3.0 RAI Manual v 1.16 (MONTH) 1, (YEAR), page 1-7 documented .Federal regulations at 42 CFR 483.20 (b)(1)(xviii ), (g), and (h) require that (1) the assessment accurately reflects the resident's status . 2. Medical record review revealed Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 4/18/19 quarterly MDS revealed the assessment was coded in section N0410A as not receiving antipsychotic medications and coded in section N450A as receiving antipsychotic medications on a regular basis. Review of the physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Interview with the Director of Assessments on 7/17/19 at 2:43 PM, in the Board Room, the Director of Assessments confirmed the 4/18/19 assessment was coded incorrectly for antipsychotic medication use. 3. Medical record review revealed Resident #157 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].ADMIT TO (Named) HOSPICE . Review of the quarterly MDS dated [DATE] revealed the MDS was not coded to reflect Resident #157 receiving hospice care. Interview with the Director of Assessments on 7/16/19 at 5:51 PM, in the Board Room, the Director of Assessments confirmed Resident #157 was receiving hospice care and the 6/27/19 MDS was coded incorrectly for hospice care.

Based on policy review, medical record review, observation, and interview, the facility failed to follow the policy for the administration of medications through a percutaneous gastrostomy tube (PEG) for 1 of 1 (Resident #409) sampled resident observed receiving medications through a PEG during medication administration. The findings include: The facility's Medication Administered Through an Enteral Tube policy documented, .16 .Allow medications to flow down the medication syringe via gravity. Do not push medications through a tube . Medical record review revealed Resident #409 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The (MONTH) (YEAR) Physician order [REDACTED].[MEDICATION NAME] .200 MG 2 TABS (tablets) .PPT Q 8 HRS . Observations in Resident #409's room on 7/31/18 at 2:27 PM during observation of administration of medications revealed Licensed Practical Nurse (LPN) #1 flushed the gastrostomy tube with 15 milliliters (ml) of water, dissolved each medication in 30 ml of water and administered the [MEDICATION NAME] and the [MEDICATION NAME] separately. LPN #1 flushed the gastrostomy tube with 15 ml water after each medication. LPN #1 administered the medications and water flushes by pushing the water and medications with a syringe through the PEG and did not allow the water or medications to flow by gravity. Interview with the Director of Nursing (DON) on 8/1/18 at 8:00 AM, in the hall outside the Board room, the DON was asked if she expected a nurse to push water and medications through a PEG. The DON stated, No.

Based on policy review, observation and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by a brown sticky substance on 3 of 5 large muffin pans, a dirty mixer bowl, and a scoop left in the sugar bin. The findings included: 1. The facility's Equipment policy for the kitchen documented, .The Food Services Director or designee will ensure that all food contact equipment is cleaned and sanitized after every use . 2. Observations in the parve bakery on 8/7/16 at 9:18 AM, revealed a mixer on the counter with a pair of eyeglasses in the mixer bowl. Interview with the Certified Dietary Manager (CDM) on 8/7/16 at 9:19 AM, in the parve bakery, the CDM was asked about the eyeglasses in the mixer bowl. The CDM stated, They must of fell off the shelf into there. Interview with the CDM on 8/9/16 at 5:02 PM, in the boardroom, when asked if she would expect to find the eyeglasses in the mixer bowl. The CDM stated, .it was just carelessness . 3. Observations in the kitchen on 8/7/16 at 9:20 AM, revealed 3 of 5 large muffins pan with a brown sticky substance. Interview with the CDM on 8/7/16 at 9:20 AM, in the kitchen, the CDM was asked about the brown sticky substance on the 3 muffin pans. The CDM stated, They are just old, they have been scrubbed until the paint is coming off .ran out of carbonol (cleaner). 4. Observations in the dairy kitchen on 8/7/16 at 9:24 AM, revealed a scoop in the sugar bin. Interview with the CDM on 8/7/16 at 9:25 AM, in the dairy kitchen the CMD was asked if the scoop should be left in the sugar bin. The CDM confirmed that the scoop should not be kept in the sugar bin.

Based on policy review, observation and interview the facility failed to ensure 1 of 1 (Licensed Practical Nurse (LPN) #1 )nurses checked PEG (percutaneous endoscopic gastrostomy) placement before administering PEG medications. The findings included: 1. The facility's Medication Administered Through an Enteral Tube policy documented, .check placement of the gastrostomy tube .insert a small amount of air into the tube with a syringe and listen with stethoscope for placement . 2. Medical record review revealed Resident #195 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED].crush meds to administer per tube . Observations in Resident # 195's room on 8/9/16 at 8:25 AM revealed LPN # 1 inserted a syringe into the PEG tube and aspirated contents, then administered medications without listening for placement. Interview with the Director of Nursing (DON) on the 200 hall on 8/10/16 at 8:55 AM, the DON was asked should the nurse instill air and listen to check placement of PEG tube. The DON stated, .Yes .