Every finding on record at Menno-Olivet Care Center

Based on observation, interview, and record review, the provider failed to maintain clean and sanitary conditions in one of one observed kitchen where residents' food was stored and prepared. Findings include: 1. Observation on 10/28/24 at 2:54 p.m. in the kitchen revealed: *The walk-in cooler metal wire shelving had a black substance on it. *The walk-in cooler flooring was a metal surface that contained rust and had a black substance on the caulking where the floor met the wall. *The caulked area on the food preparation counter where the countertop met the backsplash: -Had black and brown unidentified particles pressed into the caulking. -Was sticky when touched. *Area of the food preperation countertop were cracked and not sealed. *In the refrigerator there were: -A container of thickened orange juice had an expiration date of 7/6/24. -A container of tomato juice had an expiration date of 8/8/24. *Two containers of half and half had an expiration date of 10/13/24. *More than 12 containers of yogurt had a use by date of 10/20/24. 2. Interview on 10/29/24 at 2:30 p.m.with dietary manager C revealed: * The caulking on the food preparation counter had been recently replaced by the maintenance department. *She had asked for a new countertop and was told it would be too expensive. *She was not aware of the area of the countertop that was not sealed. *She stated that there was a cleaning schedule for the kitchen and walk-in cooler. -The responsibility for cleaning would alternate between the morning and evening cooks. *It was her expectation that the wire shelves would be properly cleaned and signed off as completed each week. 3. Interview on 10/30/24 at 10:05 a.m. with administrator A revealed: *During a walk-though of the kitchen, she reported she had not been made aware of the condition of the countertop caulking. *She agreed that the caulking was not a cleanable surface. *She said this issue would be addressed. *She reported they were working with a flooring company on other projects and to see what could be done to fix the rusted floor in the walk-in cooler. 4. Review of the provider's weekly cleaning schedules revealed: *The task Wipe shelves down in walk-in cooler areas for week one and week two were signed off for the month of October, weeks three and four were not signed off as completed. *For the month of September, week one and week 5 were signed off as completed, weeks two, three, and four were not signed off as completed. 5. Review of the provider's November, 2022 Sanitization policy revealed: *Policy Interpretation and Implementation, number two, All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. 6. Review of the provider's November 2022 Food Receiving and Storage policy revealed: *Refrigerated/Frozen Storage, number seven, Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded.

Based on observation, record review, interview and policy review, the provider failed to ensure resident care plans were revised to reflect the current needs of three of fifteen sampled residents (11, 12, and 21). Findings include: 1. Observation on 10/29/24 at 10:39 a.m. of resident 11's room revealed: *Her bed was up against the wall and had a wrap-around head and arm pillow with an air mattress on the bed. *A recliner was in the corner of the room and placed in the seat of the recliner were two heel protector booties. *In front of the recliner was an Omni-chair (Chair for pressure ulcer management). Review of resident 11's care plan on 10/29/24 revealed: *An initiated 6/20/24 focus area that included, [Resident 11] has an unstageable pressure ulcer to [her] right heel r/t [related to] limited mobility. *The 6/20/24 goal for that focus area included: - Pressure ulcer will show signs of healing and remain free from infection by/through review date. -Monitor dressing daily to ensure it is intact and adhering. -The resident requires supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing. - Treat pain as per orders prior to treatment/turning etc. to ensure The resident's comfort. - Turn and Reposition at least Q [every] 2 hours when in bed. Change position throughout the day between Omni-chair. And w/c [wheelchair] (for meals) assist to lay in bed during the day. - [Resident 11] requires Pressure relieving/reducing device on bed. - Weekly treatment documentation to include measurements of each area of skin breakdown's width, length, depth, type of tissue and exudate. Review of the facility provided 10/28/24 Matrix did not indicate resident 11 had a pressure ulcer. Interview on 10/29/24 at 3:35 p.m. with director of nursing (DON) B regarding resident 11's care plan revealed: *She did not have a pressure ulcer on her right heel. *DON confirmed the focus area for the pressure ulcer should have been resolved on her care plan. 49958 2. Observation on 10/28/24 at 4:51 p.m. of resident 12's room revealed: *He was not in his room. *His call light was clipped to itself against the wall in the center of the room. Review of resident 12's care plan revealed: *Be sure call light is within reach and encourage the resident to use it for assistance as needed. *[Resident 2] does not utilize call light. Call light is a tripping hazard and risk for strangulation for him. Staff are not to place call light by bed/chair due to this. Interview on 10/30/24 at 7:46 a.m. with DON B regarding resident 12's care plan revealed she: *Was responsible for updating his care plan. *Confirmed both of the interventions above remained on his current care plan. *Stated he was not to have a call light and when that changed, she had forgotten to remove the previous intervention. 3. Observation and interview on 10/28/24 at 4:31 p.m. with resident 21 revealed: *She stated she had recently been hospitalized after experiencing side effects of a medication that caused her to act funny. -She recalled she had left the facility through her window. *The window had been secured to make it more difficult to open. Review of resident 21's care plan revealed: *[Resident 21 is an elopement risk/wanderer r/t [related to] disoriented to place, Impaired safety awareness, delusional. *Monitor location every 15 min. Document wandering behavior and attempted diversional interventions. Interview on 10/30/24 at 1:18 p.m. with DON B regarding resident 21's care plan revealed she: *Confirmed both of the interventions above remained on her current care plan. *Indicated care plans should be updated when the interventions change or after the facility risk meeting. *Stated, I am good at putting them [interventions] on and not as good at taking the items off the care plan. *Confirmed resident 21 remained an elopement risk but the intervention to monitor her location every 15 minutes had ended on 10/17/24. Review of the providers' revised March 2022 Care Plans, Comprehensive Person-Centered policy revealed: *A comprehensive, person-centered care plan that includes measurable objectives in timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. *The comprehensive, person-centered care plan: . describes the services that are to be furnished to attain and maintain the resident's highest practicable physical, mental, and psychosocial well being . * The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the residence condition; b. when the desired outcome is not met; c. when the resident has been admitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on observation, interview, record review, and the Centers for Medicaid and Medicare (CMS) Resident Assessment Instrument (RAI) Manual review, the provider failed to ensure the Minimum Data Set (MDS) assessments were coded accurately for: *One of one resident (6) who received insulin. *One of one resident (12) who had a bed alarm. Findings include: 1. Observation and interview on 10/29/24 at 9:24 a.m. with resident 6 revealed he was diabetic and received daily injections of insulin. Review of resident 6's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *His 10/17/24 Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated he was cognitively intact. *A 10/7/24 physician's order for Insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/ML [unit per milliliters] (Insulin Glargine) Inject 16 unit subcutaneously two times a day. *He had been administered that insulin injection as ordered two times a day. Review of resident 6's 10/17/24 initial Minimum Data Set (MDS) assessment, section N (Medications) revealed: *Record the number of days that injections of any type were received during the last 7 days or since admission/entry or reentry if less than 7 days. -It was marked 1. *Insulin injections - Record the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry if less than 7 days. -It was marked 0 [zero]. *Orders for insulin - Record the number of days the physician (or authorized assistant or practitioner) changed the resident's insulin orders during the last 7 days or since admission/entry or reentry if less than 7 days. -It was marked 0 [zero]. Interview on 10/29/24 at 11:03 a.m. with director of nursing (DON) B regarding resident 6 revealed she: *Was responsible for the completion of the MDS assessment. *Confirmed resident 6 was on daily injections of insulin. *Confirmed that the MDS assessment did not accurately reflect that resident 6 had received insulin daily since he had been admitted . *She stated, I will create the modification now. Thank you for catching that. 2. Observation on 10/28/24 at 4:51 p.m. of resident 12's room revealed: *He was not in his room. *His call light was clipped to itself against the wall in the center of the room. *The bed contained a bottom sheet and an incontinent pad. -A bed alarm pad was visible under the bottom sheet. Observation on 10/29/24 at 2:39 p.m. of resident 12's revealed: *He was in his bed. *His call light was clipped to itself against the wall in the center of the room. Review of resident 12's EMR revealed: *He was admitted on [DATE]. *His 9/12/24 BIMS score was 6, which indicated he was severely cognitively impaired. *A 4/3/24 physician's order for Bed/chair alarm in use for high fall risk. Review of resident 12's 9/12/24 quarterly MDS assessment, section P (Restraints and Alarms) revealed: *Bed alarm was coded as Not used. *Chair alarm was coded as Not used. Interview on 10/30/24 at 7:46 a.m. with DON B regarding resident 12 revealed: *Resident 12 had a bed and a chair alarm that he used at all times. -The alarms were silent alarms that notified the nurse and were used as the call light so that when he gets up it alerts the staff. -They were assessed as an intervention and not as a restraint. *She confirmed that the bed and chair alarms had been coded on the previous MDS assessment. *She stated, I missed it [coding of the alarm] on the last [9/12/24] MDS [assessment]. Review of the October 2023 CMS RAI Version 3.0 Manual Section N, Page N-1 revealed: *The intent of the items in this section is to record the number of days, during the last seven days (or since admission/entry or reentry if less than 7 days) that any type of injunction, insulin, and/or selected medications were received by the resident. Review of the October 2023 CMS RAI Version 3.0 Manual Section P, Page P-8 revealed: *An alarm is any physical or electronic device that monitors resident movement and alerts the staff, by either audible or inaudible means, when movement is detected, and may include bed, chair, and floor sensor pads .

Based on observation, interview, record review, and policy review the provider failed to assess one of one sampled resident (13) who self-administered medications to determine if she was able to do so appropriately and safely. Findings include: 1. Observation and interview on 10/29/24 at 8:51 a.m. with resident 13 revealed she: *Was sitting in her recliner eating her breakfast. *Had her morning medications in a medication cup on her bedside table. *Stated she eats her breakfast in her room. *Stated the nurses would bring her morning medications and leave it for her to take after she eats her breakfast. *Would have called the nurses if anything was wrong with her morning medications. *Stated when the nurses came back to pick up the breakfast tray, they made sure she had taken her morning medications. Interview and medication administration record (MAR) review on 10/29/24 at 9:05 a.m. with licensed practical nurse (LPN) E revealed resident 13 ' s 10/29/24 morning medications were documented as administered. Observation and interview on 10/30/24 at 8:40 a.m. with medication aide (MA) F regarding resident 13's ability to self-administer medications revealed resident 13 had been care planned for the medication aides to leave medications on the bedside table and then the medication aides would have returned to the resident's room to verify that the medications had been taken. Interview on 10/30/24 at 9:30 a.m. with MA F regarding resident 13 revealed: *MA F had documented resident 13 ' s medications as administered after she left them on the bedside table. *MA F had not verified resident 13 had taken those medications before she documented them as administered in the MAR. Reviewed of resident 13's EMR revealed: *She was admitted on [DATE] and had a Brief Interview for Mental Status (BIMS) assessment score of 13, which indicated she was cognitively intact. *Her diagnoses included: Alzheimer's disease, dementia, falls, and hypertension. *There was no documentation that indicated medication self-administration assessments were completed. Review of resident 13's current care plan on 10/29/24 revealed: *An initiated 5/30/24 focus area that included, [Resident 13] has a behavior problem. *A 9/26/24 intervention included, [Resident 13] wants to take her morning meds while eating. She is capable of responsibly taking her medications once set up for her. CMA [certified medication aide] to check back with resident to ensure she has taken her meds. *An initiated 9/29/22 focus area that included, [Resident 13] has impaired cognitive function/dementia or impaired thought process r/t [related to] Dementia. *The 9/29/22 goal for that focus area was, [Resident 13] will develop skills to cope with cognitive decline and maintain safety by the review date. --This goal was marked as revised on 6/14/24. --The 9/29/22 intervention for that focus area included: - Ask yes/no questions in order to determine the resident's needs. - The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues-stop and return if agitated. -Cue, reorient and supervise as needed. - Present just one thought, idea, question, or command at a time.' - Use task segmentation to support short term memory deficits. Break tasks into one step at a time. Interview on 10/30/24 at 2:40 p.m. with director of nursing (DON) B revealed she had thought the medication self-administration assessment only needed to be completed when the residents' kept bottles of medications in their rooms. Review of the provider's revised August 2023 Self-Administration of Medications policy revealed: *Policy Statement: -Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. *Policy Interpretation and Implementation: 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident., 3. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely self-administer medications is reassessed periodically based on changes in the resident's medical and/or decision-making status. 5. Residents are assessed upon initiation of self-administering medication, quarterly, and with any significant change in condition.

Based on South Dakota Department of Health (SD DOH) facility report, record review, observation, interview, and policy review, the provider failed to ensure one of one sampled discharged resident (1) had been thoroughly assessed by nursing for change in condition and appropriately care planned for increased need for supervision and assistance with eating prior to a final choking event. Findings include: 1. Review of the 11/26/23 SD DOH facility report revealed: *On 11/25/23 at 5:40 p.m. resident 1 had been seated in the dining room for supper and had been served a ham sandwich that was his normal diet order. -Registered nurse (RN) C entered the dining room and noticed his color was grayish-blue and lips were purple. -Certified nurse assistant (CNA) A was attempting to get his arms up and get him to cough as she had noted his color had changed and he was trying to cough. *Resident 1 had lost consciousness, the nursing staff and dietary staff present removed him from his wheelchair, laid him on the floor, performed the Heimlich maneuver, and were able to remove a large amount of lunch meat from his throat. -While that care was provided, other staff summoned emergency medical services (EMS) and the EMS transported him to the hospital. Review of resident 1's electronic medical record (EMR) between 9/5/23 and 11/25/23 revealed: *On 9/5/23, a quarterly Minimum Data Set (MDS) social services note indicated he had a brief interview for mental status score of 15. He had no problems with cognition and was able to communicate his needs and understood what was being said to him. *On 9/14/23 a nursing services MDS Note: He required extensive assistance of 2 staff with bed mobility, transfers, dressing, toilet use, and bathing. He was independent with eating. He continued to have a supra-pubic urinary catheter. He was continent of bowel. *On 9/14/23 a dietary services MDS: He was on a regular texture diet. He went to the dining room for all his meals and ate independently. He did need to avoid raw vegetables and nuts due to not having any teeth. *On 9/22/23 at 10:32 a.m. a communication with physician: He ordered Cipro 500 milligram (mg) twice a day (BID) for 10 days and then recheck urinalysis (UA). *On 9/22/23 1:30 p.m. a health status note (late entry): Staff reported residents Depends incontinent brief was soaked with urine. The catheter tubing had a thick settling of urine with sediment. His catheter was changed using sterile technique and a return of slightly pink, cloudy, thick urine. Physician notified and a UA was ordered. *On 11/6/23 1:26 p.m. a health status note: Reported that resident had disconnected part of his catheter tubing during the night. He was also confused. Resident has been lethargic, sleeping in his wheelchair after being assisted up by the nurse's station before his noon meal. Informed the physician assistant (PA-C) when resident had changes in his mentation and has lethargy he had a urinary tract infection (UTI). This was sent to the PA-C by facsimile. *On 11/6/23 at 1:28 p.m. a order note: Order received for UA and to culture if UA indicated an infection. *On 11/7/23 at 12:18 a.m. a laboratory result note: UA results had not shown an infection so a culture was not completed. Results sent to PA-C by facsimile. *On 11/8/23 a health status notes from 1:39 a.m. through 3:28 a.m. resident vomited twice. His skin color was pale. He had received a COVID-19 booster on 11/7/23. *Health status notes from 11/8/23 at 5:31 a.m. through 11/11/23 at 9:50 a.m. revealed: -He stated he had not felt good. -He appeared tired. -Attempted to leave the facility. -Had a Wanderguard device put on his wheelchair. -Tried to get his legs out of bed by putting his legs over the side of the bed. *On 11/11/23 at 12:53 a.m. a health status note: CNAs [certified nursing assistants] alerted by other resident that [resident 1] was choking on his dinner. CNA calls RN [registered nurse] over radio to come to the dining room. [resident 1] was coughing up food when the RN entered dining room. He did have a large amount of undigested food on his shirt and pants. This RN stayed with the resident for 45 minutes encouraging him to keep coughing and spitting out the secretions that were coming out. He continued to have thick white secretions for about an hour. His vital signs are stable at this time - see vital signs. Lung sounds are slightly wheezy. Non-labored breathing at this time. He was assisted to the bathroom where his clothes were changes and he was brought back to sit outside of the nurse's station for observation. He is resting comfortably and states that he is feeling better. He still has the occasional cough. His voice is clear when he speaks. *On 11/11/23 at 7:38 p.m. a health status note: resident with possible aspiration of his noon meal. Lung sounds with audible wheezes. *On 11/14/23 at 2:11 a.m. a incident note: Resident was found on his knees in the bathroom holding onto the grab bar. Was incontinent of a bowel movement. *Behavior, incident, and infection progress notes from 11/14/23 at 12:23 p.m. through 11/17/23 at 10:15 a.m. revealed: -Monitoring of his UTI and antibiotic. -Behaviors of attempting to elope and sexually inappropriateness to the CNAs. -Attempting to get out of bed. *On 11/17/23 at 4:51 p.m. a physicians order from the on-call physician revealed: He stated [resident 1] urine had some bacteria but they thought it might have been contaminated. New orders to STOP Cipro. Start Keflex 500 mg po [by mouth] QID [four times a day] for 7 days. Follow up in ER [emergency room ] if worse over the weekend. Follow up in clinic or repeat NH [nursing home] evaluation if no better 5-7 days. -He had not been seen in the ER, nor had the provider been contacted after the above order had been received. *On 11/25/23 at 6:44 p.m. a health status note revealed: -[Resident 1) did lose consciousness et [and] was laid on floor. Staff continued the [NAME] [Heimlich] maneuver until lunch meat was removed. His POA [power of attorney] was notified that he was transferred [name of hospital]. -1740 [5:40 p.m.} Recorder went to Dining Room et [and] noticed that [resident 1] color was greyish blue et lips were purple. CNA was trying to get his arms up et get him to cough. We laid him on the floor et did the Himelich Maneuver. Several staff members tried to clear throat. CNA did mouth swipe et pulled large amt [amount] of lunch meat out of his throat. He did take a deep breath but color was still blue. Call placed at 1745 [5:45 p.m.] to [director of nursing] et EMT [emergency medical technician]. 1743 [5:43 p.m.] EMTs arrived and DON arrived. Agonal breathing [abnormal pattern of breathing characterized by labored, gasping breaths that occur because of insufficient oxygen] et light pulse. [resident 1] was bagged [artificial respirations] until EMTs arrived. Ambulance left with resident to [hospital]. Review of an 11/6/23 nurses request to the PA-C and subsequent order for resident 1 revealed: *[Resident 1] having increased confusion, very lethargic today. He does get changes in mentation/behavior with UTI's. He has Supra Pubic cath [catheter] and was changed last week on 10/31/23. May we check UA please? *The PA-C gave the order UA with reflex [culture if positive for infection]. Review of an 11/8/23 nurses request to the physician and subsequent order for resident 1 included: *Had vomiting during the night, skin color is pale, respirations labored, oxygen started at 3 liters per nasal canula. *Had audible wheezing noted. Resident had COVID-19 booster on 11/7/23. *Was started on Cipro 500 mg BID on 11/7/23 for a questionable UTI even though the UA was not positive. *As for an order for as need Zofran. *Order received for Zofran 4 mg every 8 hours as need for nausea and vomiting. Review of a 11/11/23 nurses request to the physician and subsequent order for resident 1 included: *A request for laboratory tests complete blood count (CBC) and comprehensive metabolic panel (CMP). *He had increased confusion since he had received his COVID-19 and respiratory syncytial virus (RSV) vaccines on 11/7/23. *The physician replied with a yes. Review of a 11/13/23 nurses request to the physician and subsequent order for resident 1 included: *Resident continued to have changes in his mental status and now having inappropriate sexual behaviors. *UA was completed but not cultured. Started on Cipro 500 mg BID for 10 days on 11/7/23. Still dealing with issues. *Asked if should try a different medication. *The physician increased resident 1's fluoxetine to 30 mg daily for sexually inappropriate behaviors. Review of a 11/17/23 nursing home order sheet from the on-call physician for resident 1. There are no notes only the orders which included: *Stop Cipro. *Start Keflex 500 mgt QID for 7 days. *Follow-up in ER if worse over the weekend. *Follow-up in clinic with repeat nursing home evaluation if no better in 5 to 7 days. Observation and interview on 11/29/23 at 11:30 a.m. with CNA A revealed she: *Was in the dining room and was assigned to assist residents to eat their noon meal. *Showed the surveyor where resident 1 had sat. *The area where he had been seated was a table that two residents would have used to dine, it was within five feet to the right of a large round table where all of the residents who required total assistance with eating sat. *Was not sure when he had been moved to the assisted area. *Had thought it was when he had his first choking episode. Interview on 11/29/23 at 11:45 a.m. with dietary manager B revealed: *Resident 1 had been sleepier in the last couple of weeks. *He had the COVID-19 booster and it had really made him sick. *She was not sure when he had been moved to the assisted dining area. *She was aware he had a previous choking episode so she thought it was after that. *His diet texture had not been changed. *She had not consulted the registered dietitian. Interview on 11/29/23 at 12:10 p.m. with RN C revealed:*Resident 1 had a significant decline in the last 2-3 weeks. *It had started with a UTI but even with antibiotics he had not seemed to get better. *He would attempt to leave the facility. *He had received both his COVID-19 booster and RSV vaccination on the same day. *She was not sure of the exact date he had those immunizations. *She did not know when he had been moved to the assisted area in the dining room. *He did need assistance with eating at times since he had been moved to the assisted area. *He would also fall asleep at times during his meals. Interview on 11/29/23 at 2:20 p.m. with CNA D revealed: *Resident 1 had declined in the last few weeks. *He used to be able tell her what he wanted, he was not able to do that anymore. *He did not use his call light anymore. *He tried to crawl out of bed. *He was incontinent of bowel. *Normally he was independent with eating but then he had problems with eating. She thought he had been moved to the assisted dining area due to him being a choking risk. *He had been found on the floor twice. He had not fallen since she has been here. *He was transferred with the sit-to-stand lift. Continued interview on 11/29/23 at 3:00 p.m. with CNA A revealed:*She had worked with resident 1 for approximately 2 years. *He would have a slight decline when he had a UTI, but not like this or for this long. *His decline was significant to her. *He did have to been assisted to eat at times. He would fall asleep at times. Interview on 11/30/23 at 10:15 a.m. with administrator E and DON F revealed:*They had been aware of resident 1's significant change of condition. *They were not sure when he had been moved to the assisted dining area. *There were residents who had been eating in their rooms due to COVID-19 and as he had been wandering, he had just been placed there to eat one day. *They confirmed he had not been moved to the assisted dining area due to his decline and choking episode on 11/11/23. *Agreed the physician had not been notified of his choking incident from 11/11/23. *His primary care provider (PCP) had been changed per his POAs request. Due to his new PCP being very ill, the PA-C had initially established care on 10/17/23. *The interdisciplinary team had a weekly risk management meeting to discuss all the residents. They had identified his change of condition and had scheduled a significant change of condition MDS assessment. *No one had thought about changing his diet texture to decrease his risk of choking. *They agreed they should have had a physician examine him or send him to the ER. Review of resident 1's 6/17/20 care plan revealed: *He was independent in eating. *Diet as ordered. Consult with dietitian and change if chewing or swallowing problems were noted. Review of the provider's undated Texture and Consistency-Modified Diets policy revealed: *Individuals with observed indicators of dysphagia (coughing, choking, delayed swallow, pocketing of food, etc,) would be referred to the speech language pathologist (SLP) for the evaluation of dysphagia. *Individuals who needed a change in diet consistency could be placed on a mechanical soft diet, chopped, ground, or pureed foods. Diets would be adjusted to meet individual needs. Review of the provider's revised March 2018 Acute Condition Changes - Clinical Protocol/Guidelines policy:*The physician would help identify individuals with a significant risk for having acute changes of condition during their stay; for example, a resident with an indwelling urinary catheter who has had recurrent symptomatic urinary tract infections. *The nurse shall assess and document and report baseline information including: -Vital signs. -Neurological status. -Level of consciousness. -Onset, duration, and severity. -All active diagnoses. -All current medications. *Direct care staff, including, nursing assistants would be trained in recognizing subtle significant changes in the resident (for example, decrease in food intake, increased agitation, changes in skin color, or condition) and how to communicate those changes to the nurse. Review of the provider's revised May 2017 Change in a Resident's Condition or Status policy revealed:*The nurse would notify the resident's attending physician or physician on call when there has been an: -Need to alter the resident's medical treatment significantly. -Specific instruction to notify the physician of changes in the resident's condition. -Significant change in the resident's physical condition. *A significant change of condition is a major decline in the resident's status that: -Would not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. -Impacts more than one area of the resident's health status. -Requires interdisciplinary review and/or revision to the care plan. -Ultimately is based on the judgement of the clinical staff and clinical guidelines for standards of care.

Based on observation, interview, and policy review, the provider failed to prevent potential cross-contamination and follow their policy for cleaning and disinfection during floor care during one of one randomly observed resident 21's room cleaning by housekeeper M. Findings include: 1. Observation and interview on 7/26/23 at 9:05 a.m. with housekeeper M who was cleaning a randomly observed resident 21's room revealed: *There was a mop bucket with water and a mop in it outside a resident's room. *The housekeeper mopped the resident's room and bathroom with the same mop and mop water from the hallway. *She reported they changed the mop water between every four residents' rooms/bathrooms. *She used the same mop head for all her floor cleaning for the day throughout the facility. *At the end of the day she took off the mop head and placed it in the soiled laundry room and it was laundered in the washing machine. *The floor cleaner product they used was [NAME]'s Super Shine-All. -The product was mixed with water in the mop bucket, and they used a mop to clean the floors. *She had worked in housekeeping for five years and had received her training from housekeeper N, who came into the resident's room during the interview and was assisting with the room cleaning and dusting. *Housekeeper N confirmed they used the same mop and mop water from the hallway, changed the mop water between every four residents' rooms/bathrooms, and used the same mop head for all the floor cleaning for the day throughout the facility. Review of the [NAME]'s Super Shine-All manufacturer's product description and instructions for use revealed: *It's protective sheen helped preserve and protect floors. *It was an excellent choice for damp mopping. *The neutral pH would not harm the floor finish. *There was no mention of it being a disinfectant. Interview on 7/27/23 at 9:07 a.m. with administrator/emergency permit holder A and director of nursing/infection preventionist B regarding the process for environmental floor cleaning and disinfecting revealed: *They had followed up with their [NAME] representative and he had confirmed the Super Shine-All floor cleaner was not a disinfectant product. *They had not been aware that the Super Shine-All floor cleaner was not a disinfectant product and that was the product the [NAME] representative had recommended staff to use throughout the facility. *They were aware housekeepers used the same mop water for four residents' rooms/bathrooms but had not realized they used the same mop head to clean floors for the entire day. *Their expectation was the housekeeping staff follow the provider's Cleaning and Disinfection policy and maintain infection control. *They agreed using the same mop water and mop head in several residents' rooms and bathrooms would be a concern for cross contamination to other areas in the facility. *They agreed the current floor care process was not consistent with the facility's Cleaning and Disinfection of Environmental Surfaces policy and it had not ensured proper disinfection was occurring throughout the facility. *They confirmed their processes for not using a disinfectant and not following their policy related to cleaning floors created an infection control risk to the residents. *They agreed they should have ensured their floor cleaning practices were in accordance with their policy. Review of the provider's August 2019 Cleaning and Disinfection of Environmental Surfaces policy revealed: *c. Non-critical items are those that come in contact with the intact skin but not mucous membranes. (1) Non-critical environmental surfaces include bed rails, some food utensils, bedside tables, furniture, and floors. 2. Non-critical surfaces will be disinfected with an EPA-registered intermediate or low-level hospital disinfectant according to the label's safety precautions and use directions. 12. Disinfection (or detergent) solutions will be prepared as needed and replaced with fresh solution frequently (e.g., floor mopping solution will be replaced every three resident rooms or changed no less often than at 60-minute intervals). 13. Mop heads and cleaning cloths will be decontaminated regularly (e.g., laundered and dried at least daily).

Based on observation, interview, and record review the provider failed to ensure: *One of one sampled resident (18) was free from serious injury after being served hot liquids that resulted in severe [CONDITION(S)] with blistering and open wounds. *Assessments had been completed to ensure one of one sampled resident (18) was appropriate to consume hot liquids. *They had a policy in place to prevent serious injuries from hot liquids. *Preventative measures including monitoring of liquid temperatures prior to serving one of one sampled resident (18)'s serious injuries. * Findings include: On 5/10/22 at 4:48 p.m. an immediate jeopardy had been identified related to accident/hazard F689. Notice: Notice of immediate jeopardy was given verbally on 5/10/22 at 6:54 p.m. to interim administer A and director of nursing B. *On 5/10/22 at 4:48 p.m. an immediate jeopardy had been determined when the facility failed to ensure: *Liquids were served at a safe temperature. *Resident had been assessed for hot beverage safety. *Safe eating practices relating to hot liquids. On 5/10/22 at 6:54 p.m. interim administrator A, director of nursing B were asked for an immediate removal plan. Plan: On 5/11/22 at 10:51 a.m. the provider's immediate jeopardy plan was accepted. The facility provided the following acceptable removal plan on 5/11/22 at 10:51 a.m.: 1. Hot liquid safety policy created. All residents will be assessed tonight. Policy is attached and includes that all residents will be assessed on admission, quarterly and with any sig change. Policy also includes that no beverages, soups or hot cereals will be served over 150 degrees. I have already called the dietary manager and the cook that will be doing breakfast tomorrow and informed them of this. 2. Unsupervised feeding safety assessment has been created. This will be done on admission, quarterly and with any sig change. These will be started tonight and finished in the morning to fully assess functional status while residents are eating. All staff will receive training on these two new policies. Nurses will receive training on the assessments. This training will be started tonight and be completed tomorrow. Staff will not be allowed to work after 5/11 at 0900 until they have read these two new policies and signed that they have received the education. Education will be provided during shift change for nursing department and by dietary manager in the morning upon the arrival of dietary staff. Dietary manager or designee will audit food temps for all room trays five times a week for four weeks then three times a week for four weeks then once a week for four weeks. Dietary manager or designee will also audit food temps in dining room five times a week for four weeks then three times a week for four weeks then once a week for four weeks. The immediate jeopardy had been removed on 5/11/22 at 12:45 p.m. during onsite revisit after verification the provider had implemented their removal plan. After removal of Immediate Jeopardy the scope and severity of this citation is level G. 1. Observation and interview on 5/10/22 at 9:30 a.m. with resident 18 revealed she: *Had been sitting with the head of bed elevated. *Had lived in the facility since 6/20/10. *Had worn oxygen at 2-3 liters per nasal cannula, would fall asleep frequently during the interview, but would awoke with verbal stimuli. Record review of resident 18's electronic medical record revealed she: *Had a brief interview for mental status score of 15. -Indicating cognitively intact. *Had a history of diabetes. *On 3/19/22 at 8:30 a.m. she had received a room tray with broth. *She had lost her grip on the cup of broth and burned her right thigh. *Had been received daily and as needed dressing changes to the affected area. *Initial wound size had measured 12 centimeters (cm) by 29 cm. -Open areas noted to wound. *On 3/25/22 resident developed shivering and was not feeling quite right. *On 3/25/22 resident had been transferred to hospital. -Had been hospitalized for elevated white count related to burn and aspiration pneumonia. *On 3/31/22 resident had been returned from the hospital to the facility. Interview with dietary manager D on 5/10/22 at 3:43 p.m. regarding temperatures of beverages served revealed: *She had taken any temperatures of hot liquids before serving them to the residents. *She had started taking temperatures after resident 18 returned from her hospital stay on 3/31/22. Interview on 5/10/22 at 4:30 p.m. with interim administrator A and director of nursing B regarding the above revealed: *They had not assessed the resident for hot liquids safety. *Did not have a policy related to safe liquid temperature to be served. *Agreed that hot liquids had not had temperatures obtained prior to being served to the residents.

A. Based on observation, interview, and record review the provider failed to ensure resident 18 had been placed on contact precautions as a result of a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: *One of one sampled resident (18) had open wounds and had been receiving daily dressing changes. *Endanger all residents with potential of cross contamination related to no contact precautions. On 5/10/22 at 4:48 p.m. immediate jeopardy had been identified related infection control/contact precautions F880. Notice: Notice on 5/10/22 at 6:57 p.m. interim administrator A and director of nursing B had been in formed verbally and written immediate jeopardy removal template given, and asked for an immediate jeopardy removal plan. Plan: On 5/11/22 at 10:51 a.m. the provider's removal plan had been accepted. The facility provided the following acceptable removal plan: 1. Resident has been placed on contact precautions. Signs are up on the door and PPE is out as well as bins for disposal of PPE. Care plan has been updated. Nurse working tonight and all staff working tonight have been educated that patient is positive for [CONDITION(S)]. I updated the contact precaution policy to include putting communication on PCC, putting up the signage and getting the PPE when you note off the order of a pathogen requiring contact precautions. Staff working have reviewed the contract precautions policy and have signed that they have been educated on this. NOC shift will be educated by the NOC nurse working tonight and the day shift tomorrow will also be educated by the NOC nurse in change or report tomorrow morning. DON will be here for morning education as well. Educating all direct care staff, laundry and housekeeping on donning and doffing PPE related to contact precautions. Started this tonight with all staff available. NOC nurse will educate NOC staff and morning staff during report. DON will be here for morning education as well. Communication of any illness requiring contact precautions will be placed on PCC homepage by the nurse that notes off the order. They will also update the care plan, place signage on the door and get the appropriate PPE. On 5/11/22 at 12:45 p.m. during onsite revisit the removal plan was verified and immediate jeopardy removed, the scope and severity of this citation is level F. 1. Observation and interview on 5/10/22 at 9:30 a.m. with resident 18 revealed she: *Had been sitting with the head of bed elevated. *Had lived in the facility since 6/20/10. *Had worn oxygen at 2-3 liters per nasal cannula. *Would fall asleep during the interview. -Awoke with verbal stimuli. Record review of resident 18's electronic medical record revealed: *On 3/19/22 at 8:30 a.m. she had sustained injury to her right thigh. *Initial wound size had measured 12 centimeters (cm) by 29 cm. -Open areas noted to wound area. *Treatment consisted of changinf dressing daily and as needed. *On 3/25/22 resident had been transferred to hospital for an elevated white blood cell count. -She had received IV [MEDICATION(S)] and [MEDICATION(S)] for a history of methacillin-resistant staph aureus ([CONDITION(S)]). *On 3/31/22 she returned from the hospital for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 5/10/22 at 4:30 p.m. with director of nursing B regarding resident 18 diagnosed who had been diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] *She had not been aware that the resident had been diagnosed with [CONDITION(S)]. -[CONDITION(S)] had been added to resident 18's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] *She had completed the infection preventionist course. *Stated the nurse that readmitted resident 18 was the current infection preventionist. *Stated that all nurses should know when and how to place residents on precautions. *Agreed that resident 18 should have been placed on contact precaution upon return to the facility. B. Based on observation, interview, and manufacturer's instructions review, the provider failed to follow instructions for disinfecting one of one observed whirlpool tub cleaning. Findings include: Observation and interview on 5/12/22 at 8:25 a.m. during a whirlpool tub disinfection by certified nursing assistant (CNA) H revealed after each bath she: *Closed the drain. *Filled the tub with water up to just below the overflow drain. *Pushed the disinfection button for five seconds to put the Cascade disinfectant in the tub. *Started the air jets. *Used a long-handled brush to clean every surface of the tub. *Allowed the jets to continue while she waited for the disinfectant's ten-minute wet time. *Sprayed the tub chair that had remained outside the tub with Vindicator (disinfectant) and scrubbed the chair, then waited the disinfectant's ten-minute wet time. *After the ten-minute disinfection she drained the disinfectant and sprayed the tub and chair with clean water. Interview with the CNA H during the above process revealed: *She had worked as the bath aide for approximately eighteen months. *She had been trained to disinfect the tub and chair in the above manner. *There was not a tub cleaning guide posted in the tub room. *She removed a black binder from the cupboard beside the tub. The binder contained the tub disinfection guide. *She was not aware the tub was not to be filled with water during the disinfection. Interview on 5/12/22 at 10:35 a.m. with the director on nursing (DON) B regarding the disinfection of the whirlpool tub confirmed: * CNA H had: -Not disinfected the whirlpool tub according to the whirlpool manufacturer's instructions.-Not used enough disinfectant to adequately disinfect the tub. *The provider used the manufacturer's instructions as a policy for the tub disinfection. *The tub was not to be filled with water during the disinfection process. *The whirlpool tub had been used by the nursing home and assisted living residents. Review of the manufacturer's disinfection instructions revealed: *The Tub Fill Button should have been pressed and the Temperature Control Knob should have been turned all the way to the left to heat the disinfectant. *Residue should have been removed from the tub using the shower sprayer. *The Tub Fill Button should have been pressed again to turn the water off. *The tub should have been allowed to drain completely and the drain plug placed over the drain. *The Disinfectant Button should have been continuously pressed until 1 to 1.5 gallons of disinfectant solution was in the footwell of the tub. *The disinfectant solution should have been: -Scrubbed on all surfaces of the tub. -Left on the tub surfaces for ten minutes. *After the ten minutes, the tub should have been drained and rinsed using the shower sprayer and the Rinse button until clear water ran through the air-jets. *Then, the Aqua-Aire Button should have been pressed and allowed to run for 30 seconds to push the rinse water out of the air injection system.

Based on observation, interview, and policy review, the provider failed to ensure full Sharps containers were stored in a secured manner when awaiting pick-up for destruction in one of one soiled utility room. Findings include: 1. Observation on 5/10/22 at 1:50 p.m. of the soiled utility room revealed:*The soiled utility room had a key code lock. *A large cardboard box containing a red medical waste bag with two Sharps containers sat on the floor beside the sink. -Both containers were full of syringes. -One container held an open vial. --This surveyor was not able to see the contents or label of the vial. *Several employees entered and exited the room during the observation. Observation on 5/11/22 at 1:50 p.m. of the soiled utility room revealed: *The door was slightly open and unlocked allowing the surveyor to enter without assistance. *The box containing the Sharps containers remained unsecured on the floor. Interview at that time with housekeeper G regarding the door lock and access by staff or residents revealed:*All employees had the key code to enter the room. *All staff knew how to enter the locked utility room if the eyewash station in the room needed to be used. *When asked if the housekeepers were responsible for handling the Sharps containers housekeeper G stated they did not. Observation on 5/12/22 at 8:35 a.m. of the soiled utility room revealed the door was slightly opened and unlocked. No employees were in the room. Interview on 5/12/22 at 10:32 a.m. with director of nursing (DON) B regarding the security of the Sharps containers confirmed: *Staff kept the Sharps containers in the soiled utility room. *The provider's waste management company came monthly to remove the medical waste. *All staff had the key code to access the soiled utility room. *She: -Sometimes placed used medication vials into the Sharps containers. -Said they do not put pills into the Sharps containers. *The medical waste waiting for removal should have been in a location where staff access was limited. Review of the provider's February 2019 policy for Sharps Disposal had not indicated: *Directions for secure storage of Sharps containers. *What should or should not be placed in the Sharps containers.

Based on observation, interview, and policy review the provider failed to ensure in a census of twenty-seven, seven of seven residents (7, 8, 12, 13, 18, 22, 25) with side rails had a preventive maintenance assessment completed ensuring the rails were compatible with the bed frame and the residents were safe from possible entrapment. Findings include: 1. Random observations 5/10/22 from 1:30 PM through 4:00 PM of all resident rooms revealed positioning rails were present for seven of the twenty-seven residents. 2. Interview on 5/12/22 at 8:08 AM with interim administrator A revealed: *The maintenance person was responsible for the preventive maintenace assessment. -The facility had not had a maintenance person since August 2021. *At one time they had a form to assess for bed safety. *It had not been done for some time. 3. Review of provider's June 2019 revised Proper Use of Side Rails policy revealed: *When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment (the amount of safe space may vary, depending on the type of bed and mattress being used).

Based on observation, interview, record review, and policy review, the provider failed to ensure the South Dakota Department of Health (SD DOH) had been notified of an incident that caused physical harm one of one sampled resident (18). Findings include: 1. Review of medical record of resident 18's chart revealed documentation made by unknown author. *On 3/19/22 at 8:30 a.m. the resident had requested broth because her stomach had been not feeling quite right. *The record reflected she had the cup between her legs and as she grabbed the it to take a drink, it slipped from her grip and spilled on her right thigh. *She immediately used her call light. *Upon assessment of the area, a large red area and two blistered open areas had formed. *The burn measured 12 centimeters (cm) by 29 cm. *Within the affected area three spots had skin peeled away. *One area had been unmeasureable. *Two areas lateral thigh measured: -1 cm by 0.8 cm and the other 3 cm by 2 cm. Interview on 5/10/22 at 4:30 p.m. with Interim administrator A and director of nursing B regarding incident revealed: *It had not been reported to the SD DOH. *They had not felt that it needed to be reported. Review of provider's October 2012 policy for Accident and Incidents-Investigating and Reporting revealed: *The nurse supervisor/charge nurse and/or department director of supervisor would have a Report of Incident/Accident form and submitted the original to the director of nursing within 24 hours of the incident or accident. *The director of nursing would ensure that the administrator received a copy of the form for each occurrence. *Policy had not identified reportable incidents or accidents. *Request made to director of nursing B for a copy of the report of incident/accident pertaining to this incident. -No copy of the report had been received during the survey.

Based on observation, interview, record review, and policy review, the provider failed to ensure an effective system was in place for the emergency (E-kit) medications stored in one of one medication room to ensure control and accountability was maintained for three of three randomly reviewed medications. Findings include: 1. Observation, interview, and record review on 10/01/19 at 2:45 p.m. with the director of nursing (DON) during audit of the medication storage areas revealed:*The E-kit medications were stored in locked drawers and a few other cabinets in the medication room. -There were multiple vials, bottles, blisters packs, and containers of different medications throughout those areas. *She indicated the pharmacist looked at the medication storage during his monthly visits. -She stated the pharmacist verified the E-kit medications with her according to a list he brought with him. --She did not have a copy of that list available for review. *There was a binder containing a large stack of log sheets labeled specifically for each medication. -That was the tracking system used for control and accountability of the E-kit medications. *An attempt to verify the count of three random medications in the drawer revealed: -A blister pack of [MEDICATION NAME] 250 milligrams (mg) had seven caplets (caps) in it. --The log sheet indicated it should have had eight caps with the last dose being removed on 12/3/18. -One blister pack of [MEDICATION NAME] 500 mg had two caps, and another pack had six caps in it. --The log sheet indicated there should have only been two caps total with the last doses removed on 9/12/19. -There were two cetriazone 1 gram vials. --The log sheet indicated there should have been zero vials left with the last one removed on 9/17/19. *The first log sheet in the binder was for [MEDICATION NAME] liquid, but other medications had been signed out incorrectly on that sheet including: -On 1/23/19, six caps of an unknown medication. -On 9/17/19, a bottle of [MEDICATION NAME] and a bottle of [MEDICATION NAME] ([MEDICATION NAME]). *The DON confirmed it was difficult to reconcile the amounts of medications without going through each medication and reviewing the log sheet for each one individually. -That had not been done during the monthly audits by her and the pharmacist. *The log sheets had not matched up for the three random medications above, and they should have. *When asked about a master list of E-kit medications she was unsure where that would have been located. -She stated they usually just used the one the pharmacist brought with him. *After a few minutes she found a list of the E-kit medications posted on the refrigerator. *Review of that 6/18/15 Stock Supply list indicated: -No quantities were listed for each E-kit medication that was supplied by the pharmacy and stored in the facility. -Staff should have signed out medications from the binder when they removed them, reordered the medication, then ensured the medication was signed back in when it was re-filled from the pharmacy. -Prescription and over-the-counter (OTC) medications available in the E-kit included: antibiotics, [MEDICATION NAME], cardiovascular medications, gastrointestinal medications, opthalmics, [MEDICAL CONDITION], respiratory medications, topicals, and other miscellaneous medications. *She was unsure if that list was current for all the E-kit medications they had in-house now since it had not been updated since (YEAR). *The DON stated the process for E-kit medications needed to be fixed. -The current process was not being completed properly, and it was not effective. *She confirmed the nurse and medication aide had keys and access to the medication room and those E-kit medications. -There should have been an effective process in place to verify the amounts of those medications for control and accountability. Interview on 10/02/19 at 11:40 a.m. with the administrator confirmed there should have been an effective system in place to ensure control and accountability of all medications including the E-kit medications. Review of the provider's 3/19/19 Storage of Medications policy revealed:*The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. *2. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner. Review of the provider's (MONTH) (YEAR) Medication E-kit policy revealed:* .These medications are kept in a locked drawer in the medication room, and non-prescription medications are located in the cabinet behind the locked medication room door. Only a licensed nurse may remove medication (prescription and OTC) from the E-kit supply. These medications are counted and expiration dates are reviewed monthly during the licensed Pharmacist visit. *2. When an order is received to remove a medication (non-narcotic) the nurse will log out the medication on the inventory sheet and reduce the inventory accordingly .

Based on observation, record review, interview, and policy review, the provider failed to ensure: *One of one sampled resident (7) who had a head lice had an investigation of how the resident had acquired the head lice, if any other residents or staff had been checked for head lice, and when the head lice was resolved. *Two of two nurses (licensed practical nurse (LPN) A and registered nurse (RN) B) had completed appropriate hand hygiene and glove use during three of three randomly observed residents' (15, 19, and 21) blood glucose testing and insulin administration. *Appropriate disinfection of the shared blood glucose meter for two of two observed residents (2 and 11) had been done by one of two nurses (LPN A). *A process for the safe storage and use of applesauce and pudding during medication administration by two of two certified medication assistants (CMA) (C and D). Findings include: 1. Review of resident 7's medical record revealed: *On 7/29/19 at 9:53 a.m. a communication to her physician: -A number of living lice were visualized by this nurse during resident's bath. She had another delousing tx (treatment) this morning. (MONTH) we have an order to do another delousing tx in 8 days? *On 7/29/19 at 2:21 p.m. a quarterly Minimum Data Set (MDS) note included: -She is on isolation recently for lice. She has been treated as well as her furniture in room. She is to remain in her room until treatment complete. *On 8/6/19 at 2:47 p.m. nurses note included: -I informed daughter (name) that this resident continues to have head lice. We would like this resident to move out of the room and the room be cleaned and sprayed. *On 8/7/19 at 10:32 a.m. risk team meeting minutes included: -Continues with head lice. Have an order for [REDACTED].>*She had been treated for [REDACTED]. Review of resident 7's 8/1/19 care plan for the head lice revealed it had been resolved on 9/11/19. Interview on 10/02/19 at 10:00 a.m. with the MDS coordinator/infection control nurse revealed: *She was aware resident 7 had been treated for [REDACTED]. *She was on leave when the lice had been discovered and treated. *She agreed it had not been included in the infection control documentation of it having been investigated. *There was no documentation of where she had acquired the head lice, if any other residents or staff had been affected, and when the head lice were no longer present. *The care plan had not reflected the correct date the head lice problem had been resolved. *There was no policy and procedure on how to manage head lice. *She would have used the Centers for Disease Control on how to manage head lice. Interview on 10/02/19 at 10:30 a.m. with the administrator revealed EcoLab had sprayed her room on 8/8/19. Quality assurance had not reviewed the head lice episode to make any recommendations. She agreed no investigation appeared to have been completed. 2a. Observation, interview, and label review on 9/30/19 at 4:11 p.m. with LPN A during resident 15's blood glucose testing revealed:*Without performing hand hygiene she: -Collected supplies from the medication cart. -Brought those supplies to the resident's room. -Set them on top of his personal items on the table beside his chair without a barrier underneath them. *She then put on gloves without performing hand hygiene and performed his blood glucose test. *With her soiled gloves still on she brought the contaminated supplies back to the medication cart and set the glucose meter directly on the uncleanable mouse pad. *She then removed her gloves, used a Super Sani-cloth wipe to clean the meter for approximately two to three seconds, and set it back down on the uncleanable mouse pad to air dry. *She stated she would let the meter air dry for two minutes, and then she could use it again for the next resident. *The Super Sani-cloth label and instructions for use indicated the surfaces should have remained wet for two minutes for proper disinfection. *She confirmed the meter appeared dry in approximately twenty to thirty seconds. *After questioning her about appropriate disinfection she then put another wipe around the meter and set it back down on the mouse pad. *She had not performed hand hygiene during the above observation or prior to going to the next resident's room. b. Observation and interview on 9/30/19 at 4:42 p.m. with LPN A during resident 21's blood glucose testing and insulin administration revealed:*She had not completed hand hygiene prior to starting the process. *She got supplies out of the medication cart and went into the resident's room setting those supplies on his bedside stand. *Without performing hand hygiene she put on gloves and performed his blood glucose test. *With her soiled gloves still on she brought the contaminated supplies back to the medication cart and set the glucose meter directly on the uncleanable mouse pad. *She removed her gloves and wrapped the blood glucose meter with a Super Sani-cloth wipe. -She had not wiped the surfaces of the meter prior to wrapping it. *She then used hand sanitizer, got the insulin supplies out of the cart, and drew up the insulin dose according to his sliding scale orders. *Without performing hand hygiene she put on gloves, went back to his room, and administered the insulin injection to the resident. *With her contaminated gloves on she put the supplies back on the cart, and then used hand sanitizer. *The above process was her usual practice. *She agreed performing the blood glucose meter disinfection properly was important since multiple residents' used it. c. Observation and interview on 10/01/19 at 11:07 a.m. with RN B during resident 15's blood glucose testing revealed: *She performed hand hygiene, put on gloves, and then opened the medication cart drawer to get all the supplies. *With her supplies and gloves on she went into the resident's room and performed the blood glucose test. *After testing the resident's blood glucose she kept those contaminated gloves on and: -Brought the supplies back to the cart. -Opened the drawers to get a Sani-cloth wipe. -Wiped the glucose meter and left that wipe wrapped around the meter. *She then removed her gloves and used hand sanitizer. *She stated the surface needed to stay wet for two minutes to be properly disinfected. d. Observation and interview on 10/01/19 at 11:13 a.m. with RN B during resident 19's blood glucose testing and insulin administration revealed: *She completed the process the same way as resident 15's observation above. *Her clean hands and gloves could have been contaminated by touching the drawers and items in the medication cart. -She used those potentially contaminated gloves to perform the resident's blood glucose test. *Following the blood glucose check she returned to the cart with her contaminated gloves on and got the Sani-cloth wipe out of the cart to clean the meter. *She then used hand sanitizer, got the insulin supplies out of the cart, and drew up the insulin dose according to the resident's sliding scale orders. *She put on gloves, went back into the resident's room, and administered the insulin injection. *With her contaminated gloves on she put the supplies back on the cart, and then used hand sanitizer. *The above process was her usual practice. e. Interview on 10/01/19 at 11:36 a.m. with RN B and the director of nursing (DON) regarding infection control practices related to blood glucose testing, insulin administration, and the above observations revealed:*Infection control practices should have been maintained during those processes. *The blood glucose meter was shared for multiple residents and should have been handled and disinfected properly. -The Sani-cloth instructions for use should have been followed including: --The surface remaining wet for two minutes, wiping all the surfaces of the meter, and keeping it free from re-contamination once it was disinfected. *Hand hygiene should have been completed before and after glove use or resident contact. *Gloves could have been contaminated when touching multiple surfaces including the medication drawers and other supplies. -Potentially contaminated gloves should not have been worn for resident care. *Contaminated gloves should have been removed prior to touching the medication cart and other items. Interview on 10/2/19 at 11:25 a.m. with the Minimum Data Set (MDS) coordinator/infection control nurse revealed she expected proper hand hygiene, glove use, and blood glucose meter disinfection to have been done. All staff had ongoing training on those infection control topics in the past. Review of the provider's undated Cleaning and Disinfecting guidelines for the blood glucose meter revealed:*Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicide wipe. *To use a wipe, remove from container and follow product label instructions to disinfect the meter . Review of the 2019 Sani-Cloth General Guidelines for Use revealed to: *Thoroughly wet the surface with a clean wipe. *Allow the treated surface to remain wet for two minutes and then let air dry. Review of the provider's (MONTH) 2019 Handwashing/Hand Hygiene policy revealed:*2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. *Hand sanitizer or handwashing should have been done: -Before and after direct contact with residents. -Before preparing or handling medications. -Before performing any non-surgical invasive procedures. -Before and after handling invasive devices. -After contact with a resident's intact skin. -After contact with blood or bodily fluids. -After handling used dressings or contaminated equipment. -After removing gloves. *The use of gloves does not replace hand washing/hand hygiene . Review of the provider's (MONTH) 2019 Standard Precautions policy revealed gloves should have been:*Removed promptly after use and before touching non-contaminated items and environmental surfaces. *Changed as needed to prevent cross-contamination. 3a. Observation and interview on 9/30/19 at 5:16 p.m. with CMA C during resident 11's medication administration in the dining room revealed:*She set-up and administered the resident's medications by crushing and mixing them with a spoonful of chocolate pudding. *The container of chocolate pudding had been opened and ready-for-use prior to that and was sitting on top of the medication cart. -The top label had a handwritten note of 9/30 AM on it. *She stated the resident preferred to take her medications with chocolate pudding instead of applesauce. b. Observation on 9/30/19 at 5:20 p.m. with CMA C during resident 2's medication administration in the dining room revealed:*She set-up and administered the resident's medication by putting it whole into a spoonful of applesauce. *The container of applesauce had been opened and ready-for-use prior to that and was sitting on top of the medication cart. -The top label had a handwritten note of 9/30/19 AM on it. *Neither the applesauce nor chocolate pudding had been stored on ice. -They were small single-serving type containers. c. Observation and interview on 10/1/19 at 8:19 a.m. with CMA D during medication administration in the dining room revealed:*The same containers of applesauce and pudding from 9/30/19 were sitting on the cart again. -They were not on ice. *The top label of the chocolate pudding now had a piece of tap holding it down. *She stated she had gotten the opened applesauce and pudding out of the refrigerator that morning to use them up. *She indicated staff dated the containers when they were opened. -If they were not completely used during that medication pass the staff would put them in the refrigerator to use during the next pass. *She was unsure how long the applesauce or pudding remained safe for consumption after it had been opened, or how many times it could have been in and out of the refrigerator before it was considered unsafe to eat. *She felt they were usually used up in one or two medication passes. *She confirmed: -The containers on her cart had been labeled for 9/30/19 morning which was the day before. -If they actually had been refrigerated in-between passes that would mean they had been in and out of the refrigerator at least three times. *The staff had not kept them on ice or kept them cool in-between the refrigeration. *She confirmed the current opened containers felt room temperature to the touch and were no longer cold. *They had several more unopened containers of pudding and applesauce available on the cart. *After questioning the above process she threw those containers away and opened new ones for the rest of her medication pass. d. Interview on 10/1/19 at 8:25 a.m. with the dietary manager regarding the applesauce and pudding used during medication administration revealed:*She was unsure what the facility process was or should have been for those items. *If the staff were putting them in and out of the refrigerator several times and not keeping them on ice during use that was not a good practice. *She was unsure of the stability of those items or how long the applesauce or pudding was good for once it had been opened. -She indicated she would look for that information and bring it to the surveyors when she found it. --No specific information had been received by the end of survey on 10/2/19 at 4:00 p.m. Interview on 10/1/19 at 8:30 a.m. with RN B regarding the applesauce and pudding used during the medication administration process revealed:*She expected the staff to open a new container for each pass. -If it was not all used they should have thrown the rest away. *She was not aware they were using them for more than one pass and putting them in the refrigerator in-between use. *She was unsure if the applesauce or pudding would have been considered safe for consumption when not refrigerated or how long it was safe after opening. Interview on 10/1/19 at 4:25 p.m. with the DON regarding the above concern with the applesauce and pudding revealed:*Her expectation was to label the container with the opened date and specific time. *She expected the applesauce and pudding to be used only for that one medication pass and not kept for future use. *There was no specific policy or guideline about the applesauce and pudding used during medication administration. Interview on 10/2/19 at 11:25 a.m. with the Minimum Data Set (MDS) coordinator/infection control nurse revealed she was unsure if there was a standard process they used for the applesauce and pudding used during medication administration. She would have expected them to open and use the container during one pass only. She was unsure if the applesauce or pudding was safe for consumption after being opened at a certain time or not being cool properly. She indicated she would provide a resource on that if she could locate one. No information was received by the end of survey on 10/2/19 at 4:00 p.m. Review of the provider's 2011 Medication Crushing Guidelines revealed:*Most crushed tablets or emptied capsules may be with mixed with applesauce, pudding, or jelly immediately prior to administration if necessary to improve their palatability . *There was no mention of a process for dating, labeling, storage, or how long to use a container of opened applesauce or pudding. Review of the provider's 5/20/18 Administering Medications policy revealed:*Medications shall be administered in a safe and timely manner, and as prescribed. *Staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable.

Based on record review, observation, interview, and policy review, the provider failed to ensure appropriate steps had been completed to support four of five sampled residents (7, 13, 16, and 22) were able to self-administer their medications. Findings include: 1. Observation and interview on 8/7/18 at 10:55 a.m. of licensed practical nurse (LPN) C while administering a nebulizer (neb) medication (med) to resident 22 revealed he: *Placed the med in the med holding chamber of the neb tube assembly (T-tube). *Placed the neb machine on the seat of her wheelchair, turned it on, and handed the T-tube to the resident. *Left the resident's room and went down the hallway. -The resident was not visible to him when he was down that hallway. *Stated that was his normal routine when he administered nebs to the resident. *Routinely returned to the room after fifteen minutes to make sure she had taken all of the med. *Set the time on his cell phone for fifteen minutes. Continued observation on 8/7/18 at 11:23 a.m. in resident 22's room revealed: *The resident had been in the bathroom. *The T-tube and neb machine had been placed on the window sill. *The med well and T-tube remained intact with some medication still in the holding chamber. Observation and interview on 8/7/18 at 2:10 p.m. with resident 22 revealed: *She confirmed the staff would: -Have set-up the neb med for her to administer on her own. -Not have stayed in the room to ensure she had taken all of the medication. *She stated: -Some times they come back later on to check on me. -I'm not sure what they do with all of it, but I want it put back on the window sill. *The neb machine remained on the window sill with the neb well and T-tube disassembled and placed on a paper towel. *The neb well appeared to have been cleaned out. Review of resident 22's medical record revealed: *She was admitted on [DATE]. *She had [DIAGNOSES REDACTED]. *She had a Brief Interview for Mental Status (BIMS) score of a twelve. -That score indicated she had some memory impairment. *An order on 4/20/17 for [MEDICATION NAME] Solution (neb med) to be given three times a day for shortness-of-breath (SOB). -No order to support she could have self-administered that med. *No assessment was found in her record to support she had been capable of self-administering the [MEDICATION NAME]. Review of resident 22's comprehensive care plan revealed: *The document had multiple revision and review dates on it. *There was no documentation to support she had been capable of self-administering her medications. Interview on 8/8/18 at 1:34 p.m. with the Minimum Data Set (MDS) coordinator regarding resident 22 revealed she: *Had not been aware the staff had been leaving the resident to self-administer the [MEDICATION NAME] med. *Stated: -Resident 22 Will forget to finish it or set it down and refuse to finish it. -They are supposed to be staying with her to make sure she takes all of it. -So no you won't find orders, an assessment, or information on her care plan, because she can't self-administer her neb treatment. 2. Observation on 8/8/18 at 8:48 a.m. of the MDS coordinator while administering neb med to resident 16 revealed she: *Placed the med in the med well of the T-tube. *Handed the T-tube to the resident and said she would return in about ten minutes. *Left the resident unattended and went to another hallway in the building. -The resident was not visible to her when she was in that hallway. *Returned to the room at 9:13 a.m., disassembled the T-tube, rinsed those pieces, and placed them on a paper towel to dry. *Stated that was her normal routine when she administered nebs to resident 16. Review of resident 16's medical record revealed: *She was admitted on [DATE]. *She had [DIAGNOSES REDACTED]. *An order on 4/17/17 for [MEDICATION NAME] Solution to be given twice a day and additionally twice a day as needed. -No order she could self-administer that med. *No assessments were found in her record that would have determined if she was safe to self-administer the [MEDICATION NAME]. Review of resident 16's care plan revealed: *She Has some forgetfulness. *Staff were to: -Cue, reorient, and supervise as needed. -Simple, structured activities that avoid overly demanding tasks. -Keep Routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. -Use task segmentation to support short term memory deficits. Break tasks into one step at a time. *No mention of self-administration of medications on her care plan. Interview on 8/9/18 at 9:40 a.m. with the director of nursing (DON) confirmed the above findings. 3. Observation on 8/7/18 at 4:35 p.m. of LPN C while administering neb med to resident 7 revealed he: *Placed the med in the med well of the neb mask. *Placed the mask strap over her head. *Turned on the neb machine and told her he would be back. *Set the timer on his phone for twelve minutes. *Stated That gives me a cushion to return within fifteen minutes. *Left her unattended in her room and went down the hall. -She had not been visible to him from that hallway. Review of resident 7's 4/30/18 physician's orders [REDACTED]. Interview on 8/9/18 at 9:08 a.m. with the MDS coordinator revealed: *Ordinarily there would be an order from the physician for self-administration of meds. *They completed a self-administration of meds assessment quarterly, on readmission, or with a resident's significant change. *I am usually nearby and didn't realize I needed to be in the room. *I feel that I put the med in, put it on her face, and set it up. I didn't realize that was self-administering. Interview on 8/9/18 at 9:23 a.m. with the DON concerning resident 7 revealed: *She would have accessed her and checked her physician's orders [REDACTED]. *After set-up and completion she would go back, take her mask off, and turn off machine. *Sometimes the resident wanted it, then she did not. *She would want her neb treatments until you came to put it on her. *Employees set a timer on their phones because, she would tell them to make sure they were back in ten minutes. *Sometimes I would come back into her room and, she had already taken her mask off, and the machine had been turned off. *I have trouble with a self-administration order. I've never seen an order that a nurse needs to be in the room. *She agreed there could still be medication in the reservoir when they left the room. *She would set her up with the neb treatment and leave the room as with other residents. Review of resident 7's medical record revealed: *She was admitted on [DATE]. *A 8/7/18 physician's orders [REDACTED]. *There were no assessments documented she was safe to self-administer the Duo-Neb.4. Observation and interview on 8/8/18 at 8:28 a.m. of resident 13 revealed she: *Had knee pain at night. *Had a tube of Biofreeze on the bedside table. -The prescription label applied to tube stated: Apply topically to knees and ankles as needed for pain. (MONTH) keep at bedside and self-administer. Interview on 8/9/18 at 9:15 a.m. with the MDS coordinator concerning resident 13 revealed: *There needed to be a self-administration assessment. *The self-administration needed to be documented. Interview on 8/9/18 at 9:23 a.m. with the DON concerning resident 13 revealed she: *Agreed she needed to have a self-administration assessment. *Stated self-administration of meds should have been care planned.Review of resident 13's medical record revealed:*She was admitted on [DATE].*She has a [DIAGNOSES REDACTED].*There were no assessments documented she was safe to self-administer the Biofreeze. 5. Review of the provider's updated 1/14/16 Administering Medications through a Small Volume (Handheld) Nebulizer policy revealed: *Administering: -Ask the resident to hold the mouthpiece gently between his/her lips (or apply face mask). -Instruct the resident to take a deep breath, pause briefly and then exhale normally. -Encourage the resident to repeat the above breathing pattern until the medication is completely nebulized, or until the designated time of treatment has been reached. -Administer therapy until medication is gone. Review of the provider's revised (MONTH) 2012 Medication Self-Administration policy revealed:*Policy:-Any resident indicating their desire to self-administer medications must demonstrate the ability to cognitively complete the task and must have a written order from their physician.*Procedure:-The DON or MDS Coordinator will evaluate according to resident's last BIMS assessment and initial task analysis assessment to determine if the resident is competent in self-administration of medications.-Obtain order from physician for self-administration of the medication the resident wishes to self-administer.-Care plan that resident will self-administer medication.-The self-administered medication will be stored in a locked box and the resident will have a key as well as the charge nurse.

Based on observation, interview, and policy review, the provider failed to ensure sanitary conditions were maintained for three of four sampled residents (5, 14, and 22) who received personal care by two of two observed certified nursing assistants (CNA) (A and B). Findings include: 1a. Observation on 8/7/18 at 9:45 a.m. of CNAs A and B during personal care with resident 5 revealed: *The resident had been in her room sitting in her wheelchair (w/c). *They had: -Prepared to transfer the resident into the bed and provide personal care for her. -Washed their hands and put on clean gloves. *With those clean gloves on CNA A had: -Touched the handles on the resident's w/c and pushed her closer to the bed. -Moved the resident's foot off of a w/c pedal. -Unlatched the w/c pedal and pushed it to the side of the w/c. -Assisted CNA B with putting a gait belt around the resident and transferring her into the bed. -Opened a dresser drawer twice to get supplies for her personal care. --Those supplies had been perineal wash and an incontinent brief. -Got a roll of toilet paper. *With those soiled gloves on CNA A: -Unrolled several squares of toilet paper from the roll. -Put peri-wash on the toilet paper and performed personal care for the resident. *CNA A: -Had not removed her gloves or sanitized her hands during the entire process of assisting the resident with personal care. -After personal care had been completed she removed her soiled gloves and without washing or sanitizing her hands had put on another pair of gloves. -Assisted CNA B with the resident by putting on a clean incontinent brief, pulling up her pants, and positioning her in the bed. -Removed her gloves and sanitized her hands. b. Observation on 8/7/18 at 10:00 a.m. of CNAs A and B with resident 14 revealed: *The resident had been in her room sitting in her Broda w/c. *They had: -Prepared to transfer the resident into the bed and provide personal care for her. -Washed their hands and put on clean gloves. *With those clean gloves on CNA A had: -Pulled the divider curtain shut for privacy. -Gotten a mechanical lift to assist the resident with transferring her to her bed. -Assisted CNA B with: --The placement of the sling and attached it to the mechanical lift. --Transferring and positioning the resident on her bed. -Removed the outer wrapping on a new roll of toilet paper. -Pulled down the resident's pants and removed a soiled incontinent brief. -Assisted CNA B with personal care for the resident. --That personal care included handling the roll of toilet paper three times to remove bowel movement from her bottom. *CNA A: -Assisted CNA B with putting on a clean incontinent brief and positioning her in the bed. -Removed her gloves and sanitized her hands. c. Observation on 8/7/18 at 11:29 a.m. of CNA A with resident 22 revealed: *The resident had been in her room and was sitting in her w/c. *CNA A: -Prepared to assist the resident with personal care. -Washed her hands and put on clean gloves. *With those clean gloves on CNA A had: -Touched the handles on the resident's w/c and pushed her up to the assist bar in the bathroom. -Pushed the brakes down on the w/c to secure it in the locked position. -Assisted the resident with grabbing the assist bar and standing up. -Touched the handle on the water faucet twice to turn the water on and off. -Got a clean washcloth and laid it in the sink to get wet with water. -Pulled down the resident's pants and incontinent brief. -Got the wet washcloth out of the sink and cleaned the resident's perineal area. -Pulled up the resident's incontinent brief and pants. -Assisted the resident to sit back down in her w/c. -Removed her gloves and sanitized her hands. *CNA A had not removed her gloves or sanitized her hands during the entire process of assisting the resident with personal care. d. Interview on 8/8/18 at 1:15 p.m. with CNA A regarding the above observations of personal care revealed she: *Had not realized her process for providing personal and perineal care had not been performed in a sanitary manner. *Agreed the process had been unsanitary and had created the potential of cross-contamination of bacteria to the residents. Interview on 8/8/18 at 2:00 p.m. with the director of nursing confirmed the above residents' care had been performed by the CNAs in an unsanitary manner. She would have expected the CNA to have removed her gloves and washed her hands after performing a task that had soiled her gloves. She agreed there had been the potential of cross-contamination of bacteria to be transmitted from one resident to another. Review of the provider's 2010 Hand Hygiene/Hand Washing policy revealed: *Purpose: Hand washing continues to be the primary means of preventing the transmission of infection. *Procedures: Hand washing or use of hand sanitizers should be used at a minimum in these situations: -Before and after direct resident contact. -Before and after assisting a resident with personal care. -Upon and after coming in contact with a resident's intact skin (i.e., when checking vital signs, transferring a resident). -After removing gloves. -After contact with a resident's mucous membranes, body fluids, or excretions. -After handling soiled equipment or utensils. -After handling soiled or used linens, dressings, bedpans, urinals, or catheters.

Based on observation, interview, record review, policy and procedure review, the provider failed to ensure medications were appropriately: *Maintained with a legible date one of one unknown residents insulin. *Dated when first opened for use for four of four sampled residents' (1,11, 12, and 13) insulins or eye drops. *Accounted for by signature of two when destroyed for six of fourteen resident (4,10, and 16) medications on the medication destructions sheets. *Stored in a maintained refrigerator when indicated for one of one medication refrigerators. *Separated external from internal route of administration for one of one medication cart and one of one treatment cart. Findings include: 1. Observation and interview on 10/10/17 from 5:55 p.m. to 6:15 p.m. with registered nurse (RN) E while reviewing the treatment and medication carts, revealed: *Resident 11 had opened insulin dated on the treatment cart: -Lantus 10/3/17. -Levimer 10/23/17. -Humolog 10/23/17. --RN E stated the date was to be written on the vial when it had been opened. --The 10/23/17 dates were wrong. --The 10/3/17 date was probably wrong too. *Resident 12 had opened Lantus insulin that was filled on 10/5/17 that had not been dated when it had been opened. *Resident 13 had opened Levimer insulin that did not have an open date. *Resident 12 had opened artificial tears that was filled on 9/18/17 and not dated when opened. *Resident 1 had dry eye relief that was dated 8/3/17. *Novolog insulin had a label that was unreadable, and it had appeared to have been peeled off. -RN E stated I wonder whose that was, someone pulled the label off and used it for someone else. *Nebulizer medications were not labeled from the pharmacy. -Staff had taken them out of their original box from the pharmacy. -No names remained on those medications. -Names were on their section of the cart, but not on the medications in those sections. -Nitro tablets, and prescription creams, eyed drops, and nasal drops were kept in the same treatment cart drawer. *When reviewing the medication cart oral medications, eye drops and ointments, were stored in the same space. -Resident names were printed on the outside of each small drawer. -All of their medications were stored in this drawer. -No dividers were in their drawer separating internal medication from external medication. *She stated she had mentioned the medication storage several times to the director of nursing (DON). 2. Observation and interview on 10/11/17 at 11:58 a.m. in the medication room of licence practical nurse (LPN) G revealed: *Resident 15's Lasix order had been changed from 40 mg (milligrams) twice daily to 60 mg twice daily. *Someone had hand-written the change on the prescription label on the bottle with no initials. *Nursing had been splitting the tablet for the new dose. *He received his medications from the Veterans Administration (VA), those medications came in bottles. Interview with the nurse liaison on 10/11/17 at 2:45 p.m. revealed: *Her job as nurse liaison included; -Receiving medications from the pharmacy. -Assisting with entering new orders and removing old orders. -Scheduling medical appointments, lab work, therapy and assisting with skin tests. -She was also a medication aide and a phlebotomist. -She would check in medications from the pharmacy carrier and fill out paperwork for the nurses to sign. -She would hold them until the nurses were available to sign them in, even if there had been a narcotic in the delivery. *The nurse would have changed the label on medications, because he was a VA resident. *Medications could not be sent back to the VA to be relabeled. 3. Review of the Medication Destruction List revealed the following residents' medications had been destroyed: *On 4/25/17 resident 4: -Lorazepam one tablet. -Clonazepam six half-tablets. -Zolpidem six tablets. *On 9/21/17 resident 10: -Lorazepam forty-two half-tablets. -Tramadol sixty tablets. *On 9/21/17 resident 16: -Tramadol sixty-two tablets: *The above medication had been signed by only the pharmacist and had not had a nurse's signature witnessing the destruction. Interview on 10/11/17 at 3:30 p.m. with the DON revealed she should have signed the Medication Destruction List and been with the pharmacist at the time of destruction of the medications. 4a. Review of the Fentanyl controlled medication patch destruction sheets revealed from: *9/17/17 to 10/8/17 resident 2 had his Fentanyl patch changed nine times. -They were all destroyed in the sharps container. -They were signed by one nurse three times. *9/3/17 to 10/3/17 resident 12 had her Fentanyl patch changed eight times. -They were all destroyed in the sharps container. -They were signed by one nurse five times. *8/1/17 to 10/3/17 resident 4 had her Fentanyl patch changed sixteen times. -Fifteen times they were destroyed in the sharps container. -They were signed by one nurse six times. *9/14/17 to 10/10/17 resident 5 had her Fentanyl patch changed six times. -They were all destroyed in the sharps container. -They were signed by one nurse two times. b. Observation on 10/11/17 at 3:45 p.m. with nurse C in the medication room revealed: *The nurse liaison had received medications from the pharmacy delivery person. *She had taken the medications out of the paper sack. *She had two boxes of Fentanyl patches. *Nurse C and the MDS nurse were in the middle of report in an office right outside the medication room. *The nurse liaison continued to handle the Fentanyl patches and filled out paperwork for the nurses to check in the narcotics. *Nurse C and the MDS nurse had left the area outside the medication room and they were no longer within eye-site of the medication room. *The nurse liaison continued to fill out paperwork with the Fentanyl patches on the counter. *At 4:05 p.m. the MDS nurse had returned and the nurse liaison asked to her sign in the patches. *The MDS nurse then put them in the locked storage cabinet. Observation and interview on 10/11/17 at 4:05 p.m. with nurse C revealed: *The nurse liaison had asked her to sign in the Fentanyl patches. *She agreed they should not have left the area while the nurse liaison handled the Fentanyl patches. c. Interview on 10/11/17 at 4:15 p.m. with the DON revealed: *They had changed the destruction of the Fentanyl patch to use the drug destroyer instead of the sharps container. *When asked when that had taken place she replied A couple months ago. *She stated the sharps containers were stored in the clean utility room and she agreed that every staff member would have had access to that room. *The nurse liaison should not have handled the Fentanyl patches. *She had been Talked to about this before. *She did not know that internal and external medications needed to be separated in the drawers. 5. Observation and interview on 10/12/17 at 12:05 p.m. with LPN F revealed: *The sharps container on the treatment cart was overflowing with used syringes. *The area where the lid snaps shut was filled with used syringes. *She shook the container, and the syringes fell in the container but were over the fill line. *She snapped shut the sharps container and put it in the dirty utility room in a box. *The dirty utility room had a code on the door to get in. *The nurse stated everyone had that code to get in the room *There were seventeen loose used syringes on the bottom of that box. -It was a large cardboard box that was lined with a biohazard bag. -There were six sharp containers already in the container. -One of those had not been snapped shut. -There were visible Fentanyl patches in the sharps containers. 6. Observation and interview on 10/11/17 at 3:40 p.m. with nurse C and the nurse liaison in the medication room revealed: *The medication refrigerator had thick ice buildup around the freezer area. *The nurse liaison was unaware of a defrosting schedule when requested by nurse C. *Nurse C was unaware of a defrosting schedule. *A defrosting schedule could not be found in the medication room nor anywhere else. 7. Interview on 10/12/17 at 4:30 p.m. with the pharmacist revealed: *He did not routinely check the medication carts. *Medications such as eye drops and insulins needed to have been dated when they had been opened. -They also needed to be stored separately from creams and internal medications. *Nebulizer medications should have been labeled from the pharmacy and stored in the original box with the label. *Medications that had been changed, even those filled at the VA, should have been sent back to him to relabel and cut if needed. -Nursing should not have written on the label and should not cut medications. *The DON should have signed the destruction record. *Fentanyl patches should have been destroyed in the drug destroyer and not in the sharps containers. Review of the provider's undated Medication Storage policy revealed: *Drugs for external use should be stored separately from internal medications. Review of the providers June 2004 Medication Destruction policy revealed: *Controlled drug disposal included: -The controlled medication would have been disposed of when the pharmacist came for the monthly pharmacy review. -Both the pharmacist and DON/RN signature needed to have been on the destruction sheets. The provider did not have a specific sharps container policy, a freezer defrosting policy, a specific VA medication, or a Fentanyl policy.

Based on observation, interview, manufacturer's instructions review, and policy review, the provider failed to ensure appropriate infection control practices were followed for room and whirlpool cleaning: *Hand hygiene and glove use for three of three observations by one of one housekeeper (A) and two of two certified nursing assistants (CNA) (B and D). *Manufacturer's instructions were followed for cleaning and disinfecting one of one whirlpool tub for one of two observations by one of two CNAs (B). Findings include: 1. Observation and interview on 10/11/17 from 8:10 a.m. through 8:43 a.m. in resident 3's room with housekeeper A revealed she: *Removed her gloves twice and put on a new pair of gloves while cleaning the room. -No handwashing was observed during that time. *Agreed she should have washed her hands after removing the gloves and before putting a clean pair of gloves on. 2 a. Observation on 10/11/17 from 11:35 a.m. through 12:12 p.m. in the residents' bathing room with CNA B revealed she: *Without performing hand hygiene: -Rinsed the tub and whirlpool chair with water. -Sprayed the disinfectant Vindicator on the tub and whirlpool chair. -Rinsed the tub with water. -Closed the drain and added hot water to the foot well of the whirlpool tub. -Added the Penner whirlpool disinfectant cleaner to the water. -Filled the tub with hot water to cover the arms of the whirlpool chair. -Put gloves on. -Scrubbed the inside of the tub and the whirlpool chair with a long-handled brush. -Drained the water. -Removed her gloves and began the rinsing and disinfectant process. -No hand washing observed during the above process. Interview at the above time with CNA B stated she should have: *Washed her hands after removing the gloves. *Worn gloves during the whole procedure. *Washed her hands after handling soiled equipment. b. Observation on 10/10/17 from 11:35 a.m. through 12:12 p.m. with CNA B in the residents' bathing room while cleaning and disinfecting the whirlpool tub revealed she: *Rinsed the tub and the whirlpool chair with water. *Sprayed Vindicator on the tub and the whirlpool chair. *Rinsed the tub with water. *Closed the drain and added hot water to the foot well of the whirlpool tub. *Added the Penner disinfectant solution to the water. -She had not used a measuring container to add disinfectant solution. -Stated she added approximately two ounces of the disinfectant. *She then: -Filled the tub with hot water to cover the arms of the whirlpool chair. -Scrubbed the inside of the tub and the whirlpool chair with a long-handled brush. -Drained the water. -Rinsed the tub with water. -Pushed and held the disinfect button for one minute. -Pushed and held the rinse button for one minute. *Washed her hands after completed the cleaning process. Interview at that same time with CNA B revealed she: *Had been disinfecting the whirlpool tub that way since March 2017. *Had been trained on whirlpool disinfection by another CNA. *Had not received any further training on whirlpool disinfection. *Worked as a bath aide on Wednesdays and Fridays. *Completed an average of nine whirlpool baths per shift. *Agreed that adding water to the Penner disinfectant solution would dilute it further and would not be effective. *There was no policy and procedure available to her to follow. c. Interview on 10/12/17 at 2:20 p.m. with the DON revealed: *She would have expected the whirlpool tub to have been cleaned and disinfected according to their policy. *There was no orientation or competency checklist for the bath aide position. Review of the Hillyard Vindicator manufacturer's instructions provided by the administrator revealed: *To have disinfected inanimate, hard porous surfaces there needed to have been: -Add one-half ounce of the disinfectant to one gallon of water. -Allowed to remain wet for ten minutes. Review of the Penner Patient Care Whirlpool Disinfectant Cleaner manufacturer's instructions revealed for disinfection there needed to have been: *Two ounces of the disinfectant added to one gallon of water. *Surfaces wetted thoroughly. *Those surfaces had needed to remain wet for ten minutes. Review of the provider's undated System Cleaning (After Every Bath) policy and procedure revealed: *Press the Tub Fill Button and turn the Temperature Control Knob all the way to the left to its warmest level to heat the disinfectant solution and maximize its effectiveness. *On the Aqua-Aire Tubs, press and hold the Disinfect Button located on the left side of the tub. As the button is held down, the properly mixed cleaning solution is running through the air injection system and out all of the air jets. Release the button after you see solution coming out of all the air jets and you have 1 to 1 ½ gallons of disinfectant solution in the foot well of the tub. *Using the long-handled brush, available from your Penner distributor, thoroughly scrub all interior surfaces of the tub with the solution that remains in the foot well of the tub. Let disinfectant stay on surface for 10 minutes. *Press and hold the Rinse button located on the left side of the control panel until clear water runs from all the air jets. Then release the Rinse button. *Start the air blower by pushing the Aqua-Aire Button. Allow it to run for 30 seconds. This pushes the rinse water out of the air injection system. If this was the last bath of the day, allow the blower to run for 2 minutes to dry out the system. Surveyor 3. Observation on 10/11/17 at 1:45 p.m. with CNA D revealed she: *Put on gloves. *Used alcohol to clean the catheter drainage tube. *Drained the urine into a container. *Emptied the container of urine into the toilet. *Rinsed the container in the sink and poured that water in the sink. *Changed her gloves with no hand washing done. *Continued to empty urine from the catheter bag. *Poured the urine in toilet. *Rinsed the container in the sink and poured the water in the toilet. *Took off her gloves and washed her hands at that time.

A. Based on record review, interview, and policy review, the provider failed to ensure: *One of one sampled resident's (1) fall with injury was reported to the physician or her family. *Professional standards were followed for the assessment and documentation for one of one sampled resident's (2) fall with injury in a timely manner. *An accurate and complete assessment and documentation was done for one of one sampled resident's (8) fall. Findings include: 1. Review of resident 1's medical record revealed: *A [DATE] admitted . *Diagnoses: [REDACTED]. *She sustained a fall with a head injury on [DATE]. Review of resident 1's [DATE] at 10:35 a.m. incident report revealed: *Unwitnessed fall. *Resident was attempting to shut her door independently while using her walker but fell and hit her head on the dresser. *Certified nursing assistant (CNA) had just left the room but had closed the door per resident. Resident did not put call light on but attempted to shut the door herself even though she needs assist with ambulation. *Resident was assessed by registered nurse (RN) C for injuries with only a 2.0 centimeter (cm) bump on the back of her head. Resident's bump is a small raised area with no skin discoloration. Skin was intact with no bruising or bleeding to area. *There was no documentation the family or physician had been informed of the fall. 2. Review of resident 2's medical record revealed: *A [DATE] admitted . *Diagnoses: [REDACTED]. *She sustained a fall on [DATE] with head, neck, and hip injuries. *She required an emergency room visit for x-rays of her head, neck, and hip. *There was no documentation in the nursing progress notes at the time of the fall. Review of resident 2's [DATE] at 8:45 a.m. nursing progress notes by RN C revealed: *It was reported to the charge nurse B and this RN by several day shift certified nursing assistants that the resident stated she had a fall in the night and was helped up by three night shift staff. *Phone calls to the 3, licensed practical nurse (LPN) A, CNA H, and CNA I. Left messages with no response. *Depression in the top of left side of scalp is noted. Resident complains of pain to left side of head, neck, and left hip. Rates pain 10 out of 10 on a 1 to 10 scale (1 being minimal pain and 10 being severe pain). Scheduled [MEDICATION NAME] was administered at 7:38 a.m. *Neurological and vital signs are all within normal limits (WNL). *Resident is answering appropriately. She stated her legs gave out and I fell cracking my head. *Phone call to clinic for orders to transport via ambulance to hospital. Review of resident 2's [DATE] at 12:35 p.m. nursing progress notes by RN J revealed: *Resident returned from hospital emergency room visit with her son. *Spoke with emergency room doctor and he gave verbal order for Tylenol 650 milligrams every six hours as needed for aches or fever. Encourage resident to drink as she may have been slightly dehydrated. Have provider evaluate blood pressure medications for possible reduction. Hold Lorsartan for two days, and she was given 500 milliliters normal saline per intravenous. Review of resident 2's [DATE] emergency room notes revealed: *Heard a crack when hitting head and has head and neck pain. Collar placed upon admission. *X-rays of head, neck and left hip reviewed and negative. Review of resident 2's incident report dated [DATE] at 4:15 a.m. with a revision date of [DATE] by LPN A revealed: *Unwitnessed fall. *Found resident sitting on floor next to bed. States she was standing next to her bed and her legs gave out causing her to fall to the ground. *Injury assessment done. Resident denied pain or discomfort. Lifted to standing position by two assist. Reassessed resident for injury. Helped into bedside recliner. *Level of pain 0 out of 10. *There was no documentation the family or physician had been contacted. Interview on [DATE] at 11:25 a.m. with LPN B regarding resident 2 revealed: *She confirmed there had been no incident report, no nursing documentation, or any communication to the day shift on [DATE] by the night shift nurse regarding her fall. *LPN A had been the nurse on duty when she had fallen. LPN A was a temporary nurse at their facility. *She had been asked by the administrator and interim director of nursing to re-educate LPN A on their fall policy and procedure. She reviewed the information with LPN A on [DATE]. *She thought she had been asked to re-educate LPN A, because she also was the training coordinator for the facility. *LPN A had given her no explanation regarding why she had not assessed, documented, and communicated the resident's fall in a timely manner. Interview on [DATE] at 4:00 p.m. with RN C regarding resident 2 revealed she: *Had the role of Minimum Data Set (MDS) coordinator and had recently been assisting with the director of nursing (DON) duties due to a medical illness. *Had oriented LPN A on her first night shift on [DATE]. LPN A stated she was familiar with the computer charting system and had no questions when the fall policy was reviewed with her. *Confirmed LPN A should have at the time of the resident's fall: -Completed an incident report. -Documented in the nursing progress notes. -Initiated and documented neurological and vital signs. -Communicated to the on-coming shift the fall and the need to notify the physician and her family. *LPN A had called her back later in the day on [DATE] and told her she had not documented the fall or passed the fall onto the day shift, because she had been worried about the weather. LPN A had told her the resident had denied any pain or had any injury at 4:00 a.m. on [DATE] when she fell . *Had communicated her concerns with LPN A to the administrator. Interview on [DATE] at 4:30 p.m. with the interim DON and the administrator regarding resident 2 revealed: *The interim DON was not on duty on [DATE] when the resident had fallen. She had been updated of the concerns with LPN A by RN C and the administrator. *The administrator had sent an e-mail to LPN A's supervisor at the temporary staffing agency. They had responded they were going to talk to her. *The administrator had asked LPN B to re-educate LPN A regarding their fall policy on [DATE] since LPN B was their training coordinator. *They both felt the re-education to LPN A had helped. LPN A had completed the assessment and documentation correctly on [DATE] for another resident who had fallen and hit her head. Interview on [DATE] at 6:00 p.m. with LPN A regarding resident 2 revealed she: *Confirmed she had not documented her fall or passed the fall onto the day shift and should have. *Stated she had assessed the resident when she had fallen on [DATE] at about 4:00 a.m. and found her to be without injury or pain. *Felt she was worried some about adverse driving conditions when she got off duty due to the weather, but that was not why she had failed to document her assessment. *I simply forgot. *She stated she left the resident's room and went about her other night duties. The fall just slipped out of her mind since the resident had not been hurt. Review of the [DATE] contract between the provider and LPN A's temporary staffing agency revealed Staff will comply with standard policy and procedures of client's (resident's) facility. Review of the provider's [DATE] Emergency Care of Residents with Sudden Illness, Change of Condition or Incapacity policy revealed: *Residents becoming suddenly ill, change of condition or incapacitated by accidents will be assessed by the licensed nurse. *Assessment including vital signs, neurological assessment (when indicated) and other symptoms will be done by licensed nurse and documented. *Notify the resident's physician or on-call physician. *Notify resident's family or responsible party of the resident's change in condition. *Licensed nurse will document the event in the nurse's notes including witnesses (if any), date, time, family (who and where contacted), physician (who and where contacted), circumstances under which it occurred, and action taken. Review of the provider's [DATE] Emergency/Fall policy revealed: *Notify physician for further orders and follow-up. May use facsimile (fax). *Notify family or guardian. *Document details in nurse's notes. All shifts will write follow-up notes for at least twenty-four hours, longer if needed. *Fill out incident form. Review of the provider's [DATE] Neurological Assessment policy revealed: *Neurological assessments are indicated following an unwitnessed fall. *Neurological assessments are indicated following a fall or other accident/injury involving head trauma. *A neurological assessment should be completed in Point Click Care. *All assessment data obtained during the procedure should be entered into the assessment. 3. Review of resident 8's medical record revealed: *A [DATE] admitted . *Diagnoses: [REDACTED]. *She sustained falls on [DATE] and on [DATE]. *She was sent to the hospital on [DATE] after her fall with injury. *She died at the hospital on [DATE]. Review of resident 8's [DATE] at 5:30 a.m. incident report by LPN A revealed: *Unwitnessed fall. *Resident states she was trying to sit down when she slid to the floor before she could get the chair to go back. *No injuries observed. *No predisposing factors (includes recent change or new medications). *No notifications found for agencies and people notified (would include physician and family. Review of resident 8's [DATE] investigation of occurrence of fall on [DATE] completed by LPN B revealed: *Frequent safety checks every thirty minutes and as needed. *Staff to anticipate needs and if resident needs assist with anything. *Encourage compliance with seeking assist and utilizing call light. Review of resident 8's [DATE] physician's progress notes revealed: *Long-standing [MEDICAL CONDITION] with acute escalation or exacerbation. *Dementia. *[MEDICATION NAME] 10 milligrams (mg) every bedtime for [MEDICAL CONDITION] (new medication for resident). *Topical [MEDICATION NAME] gel three times a day as needed (PRN) for hyper-sensitive areas. *[MEDICATION NAME] 5 mg every four hours PRN pain (medication had been scheduled only once a day at bedtime). Review of resident 8's [DATE] physician's orders [REDACTED]. Review of resident 8's [DATE] through [DATE] Medication Administration Record [REDACTED] *Eleven doses of [MEDICATION NAME]. *Six doses of [MEDICATION NAME]. *Three PRN doses of [MEDICATION NAME] on [DATE]. *Five doses of scheduled [MEDICATION NAME] at bedtime ([DATE] through [DATE]). *Six doses of [MEDICATION NAME] gel. Review of resident 8's [DATE] and [DATE] nursing progress notes revealed: *[DATE] at 11:31 a.m.: Increased pain from shingles exacerbation. Using wheelchair related to increased [MEDICAL CONDITION] in bilateral lower extremities. *[DATE] at 10:30 p.m.: No signs of acute injury from fall. Pain related to shingles in left shoulder and chest. Ankles swollen, resident is not as sedated by medications as she was yesterday. No other complaints at this time. *[DATE] at 9:40 a.m.: Resident does not complain of increased pain or discomfort when she is lying still. If right upper extremity is palpated slightly she cries out. Her vital signs are stable. She reports that no other acute pain or discomfort to any other portion of her body. *[DATE] at 7:45 p.m.: Called to resident's room by another resident. Resident found laying on her right side next to the wall. States she was trying to get her wheelchair. Unable to get resident to move onto her back due to hollering out in pain. Unable to feel any bumps on her head however every time head felt hollered out in pain. Granddaughter notified of fall and desire to send resident to hospital for x-rays. 911 activated. Once emergency medical personnel (EMS) arrived resident was lifted onto stretcher via blanket hold and six assist. Resident left facility via stretcher with three EMS technicians at 7:35 p.m. *[DATE] at 9:15 p.m.: Call from emergency room with report on resident. Resident being admitted for massive brain bleed. Hip x-ray negative. *[DATE] at 3:09 a.m.: Received call from nurse at hospital. Resident expired at 2:05 a.m. Granddaughter was there. *There was no documentation of any safety checks or what assistance the resident needed with activities of daily living (ADL) from her fall on [DATE] at 5:46 a.m. to her fall on [DATE] at 7:45 p.m. Interview on [DATE] at 4:30 p.m.with RN C regarding resident 8 revealed: *She confirmed the physician and family had not been contacted after her [DATE] fall and should have been. *There was no documentation of any safety checks or needed ADL assistance from her [DATE] fall to her [DATE] fall. *No one had put the safety checks into the computer for the CNAs to document they had been done. *She agreed LPN A had not assessed the [DATE]s fall of predisposing factors. The resident had started on new medications and was having an acute flare-up of her shingles and [MEDICAL CONDITION] pain. *The resident had been at supper on [DATE] but during the investigation into her fall no one could recall when they had last observed her or assisted her with any ADL. B. Based on record review, interview, and policy review, the provider failed to ensure one of nine sampled residents (3) had documentation of an incident report having been completed by one of one registered nurse (RN) (G). Findings include: 1. Review of resident 3's medical record revealed: *He had been admitted on [DATE]. *He had [DIAGNOSES REDACTED]. *The [DATE] at 8:17 a.m. progress note completed by RN G confirmed resident 3 had been found sitting on the floor in front of his recliner. *The [DATE] unwitnessed incident report had not been completed. Interview on [DATE] at 11:25 a.m. with licensed practical nurse (LPN)/nursing education coordinator B regarding resident 3's [DATE] incident report revealed: *She confirmed RN G had not filled out an incident report and should have. *Incident reports were filled out on the electronic medical record (EMR). *She reviewed all the incident reports. *She would inform the interim director of nursing (DON) and the interim administrator about the incident reports by email or voice mail. *Sometimes the incident reports would not be reported to the interim DON or the interim administrator until a few days following an incident depending on her schedule. Interview on [DATE] at the following times regarding resident 3's [DATE] incident report revealed at: *4:30 p.m. with RN/Minimum Data Set coordinator C agreed an incident report should have been filled out. *4:45 p.m. with the interim DON an incident report should have been filled out. *5:00 p.m. with the interim DON, the interim administrator, and RN/MDS coordinator C: -The nurses should have informed the interim DON or the the interim administrator via text if they were not in the building. -The interim administrator had been informing the interim DON of the incidents. -The nurses informed the interim administrator if LPN/nursing education coordinator B had not been at the facility to review the incidents. Review of the provider's [DATE] Incident Reports (Resident) policy revealed: *Policy: When an incident involving a resident occurs any witnessing staff will offer immediate assistance. An incident report and the appropriate documentation will be completed by the end of the shift. *Purpose: To assure appropriate follow-through on all incidents. *Essential points: Fill out the incident Report completely. Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 9th Ed., St. Louis, Mo., 2017, p.367, revealed: An incident or occurrence is any event that is not consistent with the routine, expected care of a patient (resident) or the standard procedures in place on a health care unit. You complete incident (or occurrence) reports whenever an incident occurs.

Based on observation, record review, and interview, the provider failed to ensure the appropriate documentation for: *Five of nine sampled residents (1, 2, 3, 4, and 5) who had a history of [REDACTED]. *One of one sampled temporary staff nurse (A) for general orientation. Findings include: 1. Review of resident 1's medical record revealed: *A 2/25/16 admitted . *Diagnoses: [REDACTED]. *She sustained a fall with a head injury on 1/7/17. Review of resident 1's 11/9/16 revised care plan revealed she: *Had limited mobility of her right hip and knee. *Needed one to two staff assistance when using her walker. *Required limited to extensive assistance of one staff person with a gait belt to move between surfaces. *Had short term memory loss and forgetfulness. *Was at high risk for falls related to pain and gait/balance problems. Interview on 1/17/17 at 3:45 p.m. with resident 1 revealed she: *Thought her fall was on 1/13/17. *Used her walker on her own in her room to walk to and from the bathroom. *Did not think she needed anyone to be with her when she walked in her room. *Did feel unsteady at times and her legs gave out causing her to lose her balance. Observation on 1/17/17 at 3:50 p.m. on the outside of her room door revealed no documentation of a falling star. 2. Review of resident 2's medical record revealed: *A 12/26/16 admitted . *Diagnoses: [REDACTED]. *She sustained a fall on 1/9/17 with head, neck, and hip injuries. *She required an emergency room visit on 1/9/17 for x-rays of her head, neck, and hip. Review of resident 2's 1/10/17 revised care plan revealed she: *Required extensive assistance of one staff person to move between surfaces as necessary. *Had short term memory loss, loses train of thought, and easily gets distracted. *Was at risk for falls related to gait and balance problems, antidepressant use, and history of frequent falls at home. Interview on 1/17/17 at 3:30 p.m. with resident 2 revealed she: *Stated she had a bad fall a week or two ago. *Had hit her head and left hip. *Stated both her head and her left hip still bothered her from the fall. *Was taking some pain pills that helped the pain. *Stated she had a new left hip, but she was unable to recall when. *Felt she could stand up on her own. *Felt when she stood up she often felt she was going to fall forward. *Had recently fell forward onto her face. Observation on 1/17/17 at 3:35 p.m. on the outside of her room door revealed no documentation of a falling star. 3. Interview on 1/18/17 at 3:55 p.m. with the registered nurse (RN) Minimum Data Set coordinator (MDS) C regarding the above residents revealed she: *Stated they should have had a falling star on their room doors to alert the staff of their fall risks. *Stated both residents had been identified according to their fall risk assessments as high risk individuals. *Usually was the one who put up the falling stars on residents' room doors when they were a fall risk. *Stated any resident identified at being as a high fall risk on their care plan should have been identified with a falling star on their room door. 4.Observation on 1/17/17 at 5:32 p.m. outside of resident 3's room revealed there had not been a falling star posted on his door. Review of resident 3's medical record revealed: *He had a history of [REDACTED]. *The 1/17/17 revised care plan stated he had been a high fall risk related to an unsteady gait, and [MEDICAL CONDITION] episodes. *The certified nursing assistant (CNA) pocket care plan had listed him as a fall risk. *The 12/29/16 at 8:17 a.m. progress note completed by RN G confirmed resident 3 had been found sitting on the floor in front of his recliner. 5. Observation on 1/18/17 at 10:00 a.m. of resident 4 revealed: *Outside of her room was a falling star on the door. *She had been asleep in a recliner Broda chair with a padded thigh belt on her upper thighs. *The room had a low bed and a mat up against the wall. Review of resident 4's medical record revealed: *She had a [DIAGNOSES REDACTED]. *The 1/17/17 revised care plan stated she was at a high risk for falls related to Hungtington's disease with chorea movement, use of [MEDICAL CONDITION] medications, and mood disorder. *The CNA pocket care plan had not listed her as being a fall risk. 6. Review of resident 5's medical record revealed: *He had [DIAGNOSES REDACTED]. *The 1/2/17 revised care plan stated he was a high risk for falls related to a history of falls and [MEDICATION NAME] degeneration. *The CNA pocket care plan had not listed him as being a fall risk. Observation on 1/17/17 at 5:30 p.m. outside of resident 5's room revealed there had not been a falling star posted on his door. Interview on 1/17/17 at 5:20 p.m. with CNA F revealed: *She had been employed at the facility around one year. *She knew a falling star on a residents' door indicated they had been at risk for falls. *The CNA pocket care plan had not included information on what residents were considered a risk for falls. *She had relied on the falling star on the resident's door to inform her who was at risk for falls. Interview on 1/18/17 from 4:25 p.m. through 4:45 p.m. with the interim DON, RN/Minimum Data Set (MDS) coordinator C and the interim administrator regarding the above revealed: *Residents who were at risk for falls should have been indicated on the CNA pocket care plan. *Residents who were at risk for falls should have had a falling star on their door to alert the staff. *Confirmed residents' 3 and 5 had not had a falling star on their doors and should have. *Confirmed residents' 4 and 5 had not indicated they were a high fall risk on the CNA pocket care plans and should have. *RN/MDS coordinator C was responsible to put the falling star on residents' doors who were at a fall risk. *It had been a group effort to update the CNA pocket care plan with residents who were at a fall risk. *At a minimum the CNA pocket care plan was updated weekly. *They tried to update the CNA pocket care plan after the risk management meetings. *CNAs were informed of residents who were at a risk of falls through the falling star on the door and the CNA pocket care plan. *There was not a policy for the falling star on residents' doors. *There was not a policy for the CNA pocket care plan. 7. Review of licensed practical nurse (LPN) A's employee file revealed: *She was a contracted nurse from a contracted/temporary (temp) staffing agency. *Her first day of employement had been on 12/28/16. *There was a typed note indicating On 12/28/16 LPN A had stopped into the nursing home before her shift that evening. I gave her a tour of the building. The things I showed her were:-The location of the gas turn off valve. -The location of the fire extinguishers, fire pulls, and eyewash stations. -The fire panel and how to operate it. -How to turn the water off. -The supply room with the location of the oxygen. -The automated external defibrillator (AED). -The spill kit. -The suction machine. -The crash cart. -The laundry room. -The clean and dirty utility room. -The location of the material safety data sheets (MSDS) books. -The location of the furnace and hot water heater. -The location of the electrical panel. -The location of the whirlpool and the location of the scale. -The magnets located on the outside of the residents rooms indicting if they are at risk. -The evacuated magnets inside the door. -The note had been signed by the human resource director but not dated or timed when completed. *There had been no documentation of general orientation training for a licensed nurse in her employee file. Interview on 1/18/17 at 5:00 p.m. with the interim DON, RN/MDS coordinator C, and the interim administrator regarding LPN A's general orientation for a licensed nurse revealed: *LPN A's first day of work was 12/28/16. *LPN A had been employed with a contracted staffing agency. *The human resource director had gone through papers with LPN A. *RN/MDS coordinator C had trained LPN A the night of 12/28/16. *LPN A had needed very little training on the electronic medical record (EMR) and point click care (PCC). *RN/MDS coordinator C had gone over PCC with LPN A but had not documented that. *LPN A had been shown the risk management portion of the EMR that included incident reports and fall reports. *There had not been a general orientation for licensed nurse document completed for LPN A. *They had not documented any general orientation training for LPN A. *There was not a general orientation policy for licensed nurses from temporary staffing agencies. Review of the contract between the facility and the contracting temporary staffing agency signed by the interim administrator on 9/6/16 revealed: *Client Facility Responsibilities: -D. Client Facility agrees that a proper orientation will be conducted to ensure a safe working environment.

Based on observation, interview, record review, policy review, and manual review, the provider failed to ensure the Minimum Data Set (MDS) assessment had been coded accurately for one of one sampled resident (4) with a restraint. Findings include: 1. Observation and interview on 1/18/17 from 10:00 a.m. through 10:15 a.m. in resident 4's room revealed at: *10:00 a.m. she was asleep in a recliner Broda chair. There was a strap extending over both upper thighs to the back of that chair. *10:15 a.m. she remained in the same position. Interview at that time with registered nurse (RN)/MDS coordinator C revealed the resident: -Had the padded thigh belt on when up in the Broda chair to prevent sliding. -Was unable to release the padded thigh belt. Review of resident 4's medical record revealed: *She had [DIAGNOSES REDACTED]. *A 5/19/16 physician's orders [REDACTED]. Ensure belt is released every 2 hours. *The revised undated care plan revealed she: -Was a high risk for falls related to [MEDICAL CONDITION]'s with chorea movements. -Used a padded thigh belt for positioning in the Broda chair. -Was totally dependent on staff for transferring, dressing, eating, toileting, and personal hygiene. *The 12/1/16 quarterly restraint assessment revealed: -Prompted continued need for restraint: [MEDICAL CONDITION]'s chorea movements, resident is unable to maintain position while in Broda chair. Padded thigh belt need for positoning only while up in Broda chair. -Attempts to reduce restraint use over the past quarter: NA (non-applicable). -The restraint was considered effective. -Interdisciplinary team review summary: Continued need for padded thigh belt while in Broda chair for positioning. Review of the 12/1/16 quarterly MDS assessment revealed: *Brief Interview for Mental Status examination had not been coded indicating severe cognition impairment. *Required: -Extensive assistance with bed mobility. -Total assistance with transfer, locomotion, dressing, eating, toileting, personal hygiene, and bathing. -Was impaired on both sides for upper and lower body range of motion. -Section P, P0100, Physical Restraints, had been coded as not being used for trunk restraint in chair or out of bed. Interview on 1/18/17 at 11:20 a.m. with RN/ MDS coordinator C regarding the padded thigh belt for resident 4 revealed: *She had not coded the 12/1/16 MDS assessment correctly. *She had used the Resident Assessment Instrument (RAI) manual 3.0 as her resource for documenting the MDS assessments. *The padded thigh belt should have been coded as a restraint. Interview on 1/18/17 at 4:45 p.m. with RN/MDS coordinator C, the interim administrator, and the interim director of nursing regarding resident 4's padded thigh belt revealed they agreed the 12/1/16 MDS assessment should have been coded as a restraint. Review of the provider's October 2008 Restraint/Positioning Device policy revealed: *A positioning device is defined as any manual method, physical or mechanical device, to assist in body positioning or support, such as lap trays, thigh belts, and self release belts. *A physical restraint is defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to ones' body. Review of the RAI manual, MDS 3.0, Version 1.13, pages 1 through 8, revealed, An accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT (interdisciplinary team) completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment.

Based on interview, record review, and policy review, the provider failed to ensure: * A thorough and timely investigation had been completed for one of one sampled resident (1) who had obtained a bruise of unknown origin. *Policies and procedures were developed to protect all residents from abuse and to guide staff to complete an appropriate and thorough investigation. *Management staff appropriately identified direct care staff concerns related to one of one certified nursing assistant (CNA) C who had been involved in the bruise of unknown origin. Findings include: 1. Review of resident 1's medical record revealed: *She had been admitted on [DATE]. *She had the following Diagnoses: [REDACTED]. -Dementia with behavioral disturbances. -Major [MEDICAL CONDITION]. *She had been placed on Hospice services on [DATE] due to declining health issues. *There had been an incident of a noted bruise to her left thumb on [DATE] during the morning breakfast meal. The charge nurse was notified immediately. Review of resident 1's [DATE] significant change Minimum Data Set assessment revealed: *She could make her needs known. *She had a Brief Interview for Mental Status (test to measure ability to think and remember) score of six out of fifteen indicating being cognitively impaired. *She had mood and behavioral concerns. *She required extensive assistance of two staff for physical assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. *She was always incontinent of bowel and urine. Review of resident 1's [DATE] current care plan revealed: *She required assistance of two staff for toileting. *She required assistance of two staff and a gait belt to perform a pivot transfer. *The staff were to have provided a non-confrontational approach to provide cares as she had anxiety and behaviors related to dementia. *She was placed on Hospice services on [DATE]. Interview on [DATE] at 10:05 a.m. with the administrator regarding CNA C and the incident involving resident 1 on [DATE] revealed: *CNA C had been offered the Employee Assistance Program several times in the past few months. He had declined the assistance and had stated he had been working with his minister. *She felt he had some mental issues, but there had been no official diagnosis. *He was terminated on [DATE]. Review of resident 1's nursing progress notes from [DATE] revealed there was minimal documentation of the bruising. There had been no measurements or description of the bruise. There was no documentation of the physician being notified of the bruise. Review of the provider's initial and on-going investigation of resident 1's bruise of unknown origin involving CNA C revealed: *There was a Leave Request slip of paper that had CNA Cs name at the top. It was dated [DATE] handwritten on the leave slip by CNA C: At home sick do to work stress vomiting and diarrhea someone should care!!!! *Review of the Assignment Daily Log sheet dated [DATE] revealed a handwritten note from CNA C CNAS are nobodys! *On [DATE] CNA H hand wrote the following on a Concern Form (Name of a CNA) told me that (CNA name) that one of these days he is afraid that he is going to strike out on (name of resident 1) that event happened on [DATE]. The rest of the handwritten note went on to state, The last time I worked with (name of CNA C) we walked in to (name of resident 1) room together. (resident 1 name) looked at (CNA C name) and said don't touch me. (name of CNA C) stated, what are you going to do hit me. Come on hit me. We got her into bed and he was being rough with her when he lifted up her gown to change the brief he threw it over her face and didn't bother to say I'm sorry or take it off her face. *Multiple interviews with staff revealed the story had been consistent with the fact that CNA C was providing toileting for resident 1 by himself and had not been following the care plan. *On [DATE] there was an interview conducted regarding the incident with resident 1 with CNA C that revealed: -He had taken the resident to the bathroom by himself. The resident had been striking out at him. He had denied injuring resident 1. Interview on [DATE] at 10:30 a.m. with the chief of police regarding the incident of a bruise of unknown origin for resident 1 revealed he: *Had not been notified of the incident until [DATE]. *Instructed the management staff to obtain pictures of the bruise. *Would speak with CNA C after the investigation had been completed on [DATE]. Interview on [DATE] at 10:40 a.m. with licensed practical nurse G regarding resident 1's bruise of unknown origin revealed: *She was the charge nurse on [DATE]. *At 9:00 a.m. the restorative aide working the day shift notified her there was a bruise noted to the resident's left thumb. *When the nurse asked the resident what had happened the resident had stated, The big guy came in and broke my thumb. He did it. *She confirmed there were no other male CNAs that worked with the resident. *She notified the director of nursing (DON) immediately. *CNA C had worked the evening shift on [DATE]. The CNA was off on [DATE]. *She had interviewed CNAs H and I when they returned to work on [DATE] who had worked the night before. *The CNAs had discovered: -CNA C had been in resident 1's room alone on the evening of [DATE]. *Resident 1 was confused and combative at times. *The resident had been placed on Hospice for failure to thrive due to her advancing dementia. *The resident was very limited with any movements of her extremities. *The resident was unable to reposition herself and would not have been able to move her arms. *The resident required two staff assistance with all transfers. *The bruise was described as a wrap-around dark purple bruise on to the resident's left thumb area. *She had not notified the physician, had given the resident Tylenol for pain, she had assessed the thumb, and did not believe there was any broken bones. *She agreed there should have been an incident form completed, and the physician should have been notified about the bruise. Telephone interview on [DATE] at 11:15 a.m. with CNA I regarding resident 1 and the evening of [DATE] revealed: *She was working 2:00 p.m. to 10:00 p.m. on [DATE]. *She had only been working at the facility for two weeks and had been orientating with CNA H. *She had watched a video in regards to Abuse and Neglect prior to working on the floor. *Both her and CNA H noticed the door was closed to resident 1's room on the evening of [DATE]. She just figured someone was in working with the resident. *On [DATE] afternoon during her shift resident one stated to her, The big man did it. After she, CNA H, and another unidentified CNA had shown a picture of CNA C and had asked the resident who had done this. Telephone interview on [DATE] at 11:32 a.m. with CNA H regarding resident 1 and the evening of [DATE] revealed: *On the evening of [DATE] she and CNA I had noticed the door to resident 1's room was closed. *She knocked and opened the door and saw CNA C sitting in resident 1's wheelchair outside the bathroom while the resident was sitting on the toilet in the bathroom. *She stated, We should have stayed in the room because the residents care plan indicated there should always be two persons assisting with transferring and toileting. *She has only been employed for two months with the provider. *On [DATE] she and another unidentified CNA asked the resident what had happened to her thumb, and the resident had replied, The big man did it. *She was unsure as to why she did not inform the charge nurse that CNA C had been assisting resident 1 alone. Interview on [DATE] at 1:20 p.m. with the DON and registered nurse (RN) J regarding CNA C and the incident on [DATE] involving resident 1 revealed: *CNA C had been texting RN J for several months with explicit comments. She had to block him from her phone. *They felt as though CNA C had been depressed. *CNA C had been offered the Employee Assistance Program several times in the past several months. His mother had died [MEDICAL CONDITION] three months ago, and he was estranged from two adopted brothers. *He was described as a loner. *They both had feared retaliation after he had been fired on [DATE]. *His co-workers started revealing concerns of CNA C to the DON after the incident had happened to resident 1. Some staff thought he was unstable. *The DON had felt sorry for him because of his situation and felt as though that might have clouded her judgement to take action prior to the incident on [DATE]. He had refused the employee assistance program several times. *The DON agreed it was the provider's responsibility to protect all the residents in the facility. *The DON was unsure as to the reason staff would not come to management staff with their concerns of CNA C. *CNA C had not followed resident 1's plan of care, and that was the reason he had been terminated. Review of resident 1's nursing progress notes from [DATE] revealed there was minimal documentation of the bruising. There had been no measurements or description of the bruise. There was no documentation of the physician being notified of the bruise. Interview on [DATE] at 2:45 p.m. with CNA L regarding CNA C revealed: *Resident 1 would sometimes hit at staff. *She stated approximately one month ago everyone (two or three other CNAs and the charge nurse for the shift) were sitting in report before work and CNA C made the comment I hope I never get upset with her (resident 1). *When asked why she had not reported that to management, she stated, She thought the charge nurse would have reported it. *Resident 1 was supposed to have been a two person transfer at all times. Interview on [DATE] at 3:00 p.m. with the DON regarding the incident with resident 1 and CNA C revealed: *She was unable to find the Abuse and Neglect policy that had the required seven components which included: -Screening of employees. -Training of employees. -Protection of residents. -Prevention of abuse. -Identification of abuse. -Investigation. -Reporting. *She agreed the Abuse policy should have been more comprehensive to include the above components to ensure the protection of all residents residing in the facility. *The investigation into resident 1's incident should have been started immediately after the charge nurse had become aware of the incident. Review of the provider's [DATE] Certified Nursing Assistant Job Description revealed Fully understands all aspects of residents' rights, including the right to be free of restraints and free of abuse. Is responsible for promptly reporting to the charge nurse or administrative staff incidents or evidence of resident abuse or violation of residents' rights. Review of the provider's undated Director of Nursing Job Description revealed: Monitors complaint reports daily for allegations of potential abuse or neglect, and participates in these investigations. Review of the provider's undated Charge Nurse RN/LPN Job Description revealed: Maintains accurate and complete records of nursing observations and care. Review of the provider's undated Administrator Job Description revealed: The primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with current federal, sate, and local standards, guideline, and regulations that govern long-term care facilities to assure that the highest degree of quality of care can be provided to our residents at all times. Review of the provider's [DATE] Resident Abuse and/or Neglect policy revealed: *The seven components mentioned above were absent from the policy. *The purpose of the policy was to ensure the facility had in place an effective system that regardless of the source prevented mistreatment, neglect, and abuse of resident or misappropriation of their property. *To ensure all residents were not subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends, or other individuals. *To ensure all identified incidents of alleged or suspected abuse/neglect were promptly investigated and reported. *To ensure all identified injuries of unknown origin were promptly investigated to determine probable cause of unknown origin injuries and were reported. *To identify and remedy any abusive situations. *To prevent future injuries. *To ensure a complete review of existing incidents were documented. *To identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that might constitute abuse and to determine the direction of the investigation. Observation on [DATE] at 8:35 a.m. in resident 1's room revealed she was lying on her back in bed. The bed had been lowered to a low position, the room was dark, and there was a mat on the floor next to the bed. Observation and interview on [DATE] at 12:45 p.m. in resident 1's room with the director of nursing (DON) revealed: *Resident 1: -Had been sitting up in her wheelchair with the television on. -Had her left hand positioned on her lap. *The DON took the resident's left hand and held it out for the surveyor to look at it. *Resident 1's left hand revealed areas of light to dark purple bruising extending over most of the thumb and radiating down over the inner aspect of the palm and wrapping around to the front of the thumb. *The DON confirmed the light to purple bruising to the residents left hand thumb region was larger than on Monday. Observation and interview on [DATE] at 3:30 p.m. in resident 1's room with certified nursing assistants (CNA) J and K revealed: *They had placed a portable commode (stool) next to the resident's bed. *They placed a gait belt around the resident and assisted her with doing a pivot transfer from the bed to the commode. *They cleaned the resident's glasses and placed the glasses on her face. *CNA A revealed: -They had a difficult time trying to get the resident into the bathroom, so they had been using the commode for quite awhile. -They were to always use two staff when transferring the resident.