Every finding on record at Mount Carmel Rehabilitation and Nursing Center

Based on observation, interview and record review, the facility failed to store food in accordance with professional standards for food service safety in 3 of 5 kitchenette refrigerators and 1 of 3 dining room refrigerators observed for a facility census of 109 residents. Findings include:Review on 7/22/26 of kitchenette and dining room refrigerator temperature logs revealed the following temperature that were out of range:2nd Floor Annex refrigerator:July 7th 43 degrees Fahrenheit (F) July 8th 48 degrees FJuly 9th 45 degrees FJuly 10th 48 degrees FJuly 11th 42 degrees FJuly 20th 45 degrees FJuly 21st 45 degrees F 2nd floor East Refrigerator:July 1st 45 degrees FJuly 5th 43 degrees FJuly 7th 45 degrees FJuly 8th 44 degrees FJuly 9th 43 degrees FJuly 10th 45 degrees FJuly 20th 46 degrees FJuly 21st 45 degrees F 4th floor Resident Dining Room:July 3rd 45 degrees FJuly 4th 45 degrees FJuly 5th 48 degrees FJuly 6th 45 degrees FJuly 7th 45 degrees FJuly 8th 45 degrees FJuly 16th 45 degrees FJuly 18th 50 degrees F. 4th Floor KitchenetteJuly 5th 57 degrees FJuly 12th 45 degrees FJuly 15th 45 degrees FJuly 16th 45 degrees F Interview on 7/23/26 at approximately 11:00 a.m. with Staff A (Dietary Manager) confirmed the above findings and revealed there was no documentation that temperatures were rechecked on the above noted days. Review on 7/24/26 policy titled Use and Storage of Food and Beverage Brought in for Residents, dated 10/11/17, revealed, . (6) All refrigerators will be at or below 41 degrees F. Review on 7/24/26 of the U.S. Food and Drug Administration- Refrigerator Thermometers-Cold Facts About Food Safety, dated 3/5/2024, revealed, .To ensure that your refrigerator is doing its job, it's important to keep its temperature at 40 F or below .

Based on observation, interview, and record review, the facility failed to ensure that a resident was assessed to self-administer medications for 1 of 1 resident reviewed for choices in a final sample of 22 residents. (Resident identifier is #5.)Findings include: Observation on 7/22/26 at approximately 2:03 p.m. of Resident #5's room revealed that there was a prescription inhaler, Albuterol Sulfate HFA (hydrofluoroalkane)108 (90 Base) MCG/ACT (micrograms per actuation), located on top of the resident's bedside table. Interview on 7/22/26 at approximately 2:03 p.m. with Resident #5 revealed that he/she kept the inhaler at bedside to self-administer daily. Interview on 7/24/26 at approximately 8:22 a.m. with Staff F (Registered Nurse) confirmed that Resident #5 keeps his/her inhaler at bedside to self-administer daily. Review on 7/24/2026 of Resident #5's assessments and care plan revealed there was no assessment and care plan done for Resident #5 to self-administer medications. Observation on 7/24/26 at approximately 8:49 a.m. of Resident #5's room revealed that there was a bottle of antacid chewable tablets located inside the resident's bedside table drawer. Interview on 7/24/26 at approximately 8:49 a.m. with Resident #5 revealed that he/she kept the antacid chewable tablets at beside to self-administer daily. Interview on 7/24/26 at approximately 8:49 a.m. with Staff G (Assistant Director of Nursing) confirmed that Resident #5 kept his/her antacids at bedside to self-administer daily and that there was no assessment done for Resident #5 to self-administer medications. Review on 7/24/26 of the facility policy titled, Residents Right to Self-Administer Medications, policy established date 11/5/21, revealed, . residents right to self-administer medications if the IDT [Interdisciplinary Team] has determined that it is clinically appropriate and safe for the resident to do so . 2. Self-administration assessment is completed to ensure resident has the physical and cognitive ability to safely administer the chosen medications, record the meds and times taken on a sheet provided by nursing and is capable of safely storing the medications in a locked box .

Based on observation, interview, and record review, the facility failed to implement infection control policies for 1 of 2 medication carts observed and for 1 of 2 residents reviewed for Transmission Based Precautions (TBP) in a final sample of 22 residents. (Resident identifiers is #5.) Findings include:Medication Cart (fourth floor back) Observation on 7/23/26 at approximately 8:02 a.m. revealed two personal beverages on the fourth floor back medication cart. Interview on 7/23/26 at approximately 8:16 a.m. with Staff J (Licensed Practical Nurse) confirmed the above findings. Observation on 7/23/26 at approximately 11:57 a.m. revealed Staff J eating a personal meal on top of the fourth floor back medication cart. Interview on 7/23/26 at approximately 11:59 a.m with Staff J confirmed the above finding. Interview on 7/24/26 at approximately 11:13 a.m with Staff D (Infection Preventionist) confirmed that personal items should not be placed on medication carts. Review on 7/24/26 of the facility's Infection Control Practices with Medication Administration policy, undated, revealed that, . no personal drinks/food/handbags/etc. should be stored on the medication cart. Review on 7/27/26 of the Centers for Disease Control and Prevention's (CDC) standards of care document titled, Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 4/12/24, revealed, . 5c. Injection and Medication Safety . 1. Prepare medications in a designated clean medication preparation area that is separated from potential sources of contamination. Resident #5 Observation on 7/22/26 at approximately 12:35 p.m. of Resident #5's room revealed an On Precautions sign posted outside of the door. A precautions cart, located outside of Resident #5's room door, contained an enteric precaution sign that indicated staff to always wear gown and gloves. Further observation revealed Staff I (Licensed Nursing Assistant) entered Resident #5's room carrying Resident #5's meal tray without wearing gloves and a gown. Interview on 7/22/26 at approximately 12:41 p.m. with Staff I confirmed that he/she did not wear a gown and gloves before entering Resident #5's room to deliver their meal tray. Review on 7/24/26 of Resident #5's physician orders revealed an order for, . cdiff [Clostridium difficile] enteric contact precautions . Date Initiated 5/14/26. Interview on 7/23/26 at approximately 12:35 p.m. with Staff D (Infection Preventionist) revealed that enteric precaution was a form of contact precaution, so the facility followed its contact precaution policy when implementing enteric precautions. Staff D was unable to provide a policy specific for enteric precautions. Review on 7/23/26 of the facility's policy Contact Precautions, 2012 revealed, II. Gloves . B. Gloves should be worn when entering the room . III. Gowns A. A gown should be donned prior to entering the room . The policy did not specify additional enteric precautions. Review on 7/23/26 of the CDC website titled, Appendix A: Type and Duration of Precautions Recommended for Selected Infections and Conditions, dated 2/7/25, retrieved from https://www.cdc.gov/infection-control/hcp/isolation-precautions/appendix-a-type-duration.html revealed, .Infection/Condition.Clostridium difficile.Type of Precaution.Contact +[plus] Standard. Review on 7/23/26 of the CDC website titled, Transmission-Based Precautions, dated 4/3/24, retrieved from https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html revealed, .Use of Contact Precautions for patients with known or suspected infections that represent an increased risk for contact transmission .Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens .

Based on observation, record review, and interview, the facility failed to ensure medications were properly labeled with opening and discard dates to maintain safety and effectiveness for 2 of 3 medication carts observed. Findings include:Observation on 7/22/26 at approximately 9:00 a.m. of the 2nd floor [NAME] medication cart with Staff L (License Medication Nursing Assistant) revealed a Budesonide and Formoterol Fumarate Dihydrate inhalation Aerosol and one Incruse Ellipta inhalation without an open date or an open discard date. Review on 7/22/26 of the manufacturer's instruction for Budesonide and Formoterol Fumarate Dihydrate inhalation Aerosol revealed that when the counter shows zero (0) or 3 months after you take it out of its foil pouch, whichever comes first. Review on 7/22/26 of the manufacturer's instruction for Incruse Ellipta revealed, Safely throw away INCRUSE ELLIPTA in the trash 6 weeks after you open the tray or when the counter reads 0, whichever comes first. Write the date you open the tray on the label on the inhaler. Interview on 7/22/26 at 9:05 a.m. with Staff L confirmed the above findings.

Based on interview and record review, it was determined that the facility failed to implement the facility's policy on COVID-19 immunizations for 2 of 5 residents reviewed for immunizations. (Resident identifiers are #48 and #79.)Findings include:Review on 7/24/25 of the facility policy titled, 2025 Updated Covid-19 Vaccination for Nursing Home Residents and Healthcare Personnel, Dated 3/1/25 revealed .14. People Ages 65 Years and Older: You are up to date when you have received: 1. 2 doses of any 2024-2025 COVID-19 vaccine 6 months apart .Resident #48Review on 7/23/25 of Resident #48's COVID Vaccine Consent - 2024-2025 revealed, the resident gave consent for the immunization on 7/4/25. Review on 7/23/25 of Resident #48's Immunization Report revealed that Resident #48's birth year was in 1938 ([AGE] years old). Further review revealed Resident #48's last COVID immunization was administered on 10/1/24, Resident #48 had not received another dose after they consented on 7/4/25.Resident #79Review on 7/23/25 of Resident #79's COVID Vaccine Consent - 2024-2025 revealed, the resident gave consent for the immunization on 6/23/25.Review on 7/23/25 of Resident #79's Immunization Report revealed that Resident #79's birth year was in 1944 ([AGE] years old). Further review revealed Resident #79's last COVID immunization was administered on 11/8/24 and Resident #79 had not received another dose after they consent on 6/23/25. Interview on 723/25 at approximately 10:30 a.m. with Staff A (Director of Nursing) confirmed Resident #48 and Resident #79 had not received a dose of the COVID-19 vaccine after consenting.Interview on 7/24/25 at approximately 10:45 a.m. with Staff C (Infection Preventionist) confirmed the above findings.

Based on record review and interview, it was determined that the facility failed to inform the resident or the resident representative of the risk and benefits of psychotropic medications in 1 of 5 residents reviewed for unnecessary medications in a final sample of 22 residents (Resident identifier is #121).Findings include: Review on 7/23/25 of Resident #121's physician's orders revealed the following prescribed medications: Ativan 0.5 milligram (mg) 1/2 tablet twice a day and 1 tablet as needed for anxiety and restlessness (the as needed order was for 14 days only), Cymbalta 30 mg in the evening and 60 mg in the morning for depression, and Lexapro 10mg daily for depression, all orders dated 7/18/2025.Review on 7/23/25 of Resident #121's medical record revealed no documentation that Resident #121 or his/her representative was informed of the risk and benefits of the above-mentioned psychotropic medications. Interview on 7/24/2025 at approximately 9:00 a.m. with Staff A (Director of Nursing) confirmed that the Resident #121 or his/her representatives was not informed of the risk and benefits of the above-mentioned psychotropic medications.

Based on observation and interview, it was determined that the facility failed to ensure that medications were secured for 1 of 4 medication carts observed. Observation on 5/20/24 at 8:20 a.m. of the third floor Westside Medication Cart revealed it was unlocked with no staff within sight. There were 4 residents seated at tables and eating breakfast within 10 feet of the unlocked medication cart. Interview on 5/20/24 at 8:24 a.m. with Staff J (Medication Nursing Assistant (MNA)) confirmed the cart was unlocked while he/she stepped away for a few minutes. Review of facility policy, Medication Storage, dated 01/2021, revealed: .Procedures: .3. In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allow access to medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access .

Based on interview and record review, it was determined that the facility failed to follow physician orders for 1 resident out of 5 residents reviewed for unnecessary medications and for 1 of 31 medications observed for medication administration in a final sample of 23 residents (Resident Identifier #157 and #65). Standards: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336- Physicians' Orders .The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Review on 5/21/24 of Resident #157's May 2024 Medication Administration Record (MAR) revealed the following physician's order: Midrodrine HCL [Hydrochloric Acid] Tablet 10 mg [milligrams], Give 1 tablet by mouth three times a day for BP [Blood Pressure] hold for SBP [Systolic Blood Pressure] greater than 160. Do not give after 6 pm., Start Date 5/7/24. Further review revealed that the medications were held with the following blood pressures: 5/17 SBP 151; 5/18 SBP 143. Interview on 5/21/24 at approximately 1:30 p.m. with Staff F (Director of Nursing) confirmed the above findings. Resident #65 Review on 5/20/24 of Resident #65's medication orders revealed an order for Midodrine 5mg, take by mouth three times per day related to orthostatic hypotension. Hold for SBP > (greater than symbol) than 110. Observation on 5/20/24 at approximately 8:30 a.m. with Staff H (Licensed Practical Nurse) revealed Staff H obtained Resident #65's SBP reading of 149. Staff H then poured Midodrine (medication to prevent blood pressure from dropping) to be administered to Resident #65. Interview on 5/20/24 at approximately 8:35 a.m. with Staff H confirmed that medication should not be administered as Resident #65's SBP was 149, which is greater than 110. Interview further revealed that Staff H did not understand the symbols used to indicate greater than in the physicians' order. Review on 5/20/24 of Resident #65's MAR for May 2024 revealed that 5 doses of Midodrine were given with a SBP greater than 110. The doses were as follows: On 5/2/24 the evening dose was administered with a SBP of 162; On 5/5 24 the evening dose was administered with a SBP of 126; On 5/7/24 the evening dose was administered with a SBP of 154, On 5/16/24 the afternoon dose was administered with a SBP of 148; On 5/16/24 the evening dose was administered with a SBP of 147. Review on 5/20/24 of Resident #65's May 2024 MAR revealed the following physician's order: Lutein Oral Capsule 6 mg, Give 1 capsule by mouth in the morning for supplement, Start Date 11/1/23. Further review revealed that on 5/2, 5/3, 5/4, 5/6, 5/8, 5/9, and 5/10 the medication was indicated as not being available. Interview on 5/21/24 at approximately 1:30 p.m. with Staff F confirmed the above findings. Interview on 5/21/24 at approximately 1:50 p.m. with Staff K (Nurse Practitioner) revealed that he/she was not notified of the medication not being available. Review on 5/21/24 of the facility policy titled, 3.12 Medication Shortages, dated 9/10 revealed: .2. Nursing staff shall, if the shortage will impact the patient's immediate need of the ordered product: a. Notify the attending physician of the situation, explain the circumstances, expected availability and optional therapy(ies) that are available. b. Obtain a new order and cancel/discontinue the order for the non-available medication .

Based on interview and record review, it was determined that the facility failed to report an allegation of misappropriation to the State Survey Agency (SSA) for 1 out of 9 allegations reviewed (Resident Identifier #42). Findings include: Review on 5/20/24 of the facility grievance log revealed the following allegation of misappropriation that was not reported to the SSA: Resident #42 Review on 6/4/23 a grievance was filed by Resident #42's Durable Power of Attorney (DPOA) for Resident #42's missing gold and diamond wedding ring set. Interview on 5/20/24 at approximately 12:00 p.m. with Staff A (Social Worker) revealed that the missing items were not reported to the SSA or the local police. Interview on 5/21/24 at approximately 8:45 a.m. with Staff D (Administrator) confirmed the above findings. Review on 5/20/24 of the facility policy titled, Abuse Prevention and Reporting, Revision Date 10/24/22 revealed: .3. All alleged violations involving abuse, neglect or mistreatment, including injuries of unknown source and misappropriation of resident property, will be reported immediately after the incident is discovered or observed by the employee to the employee's supervisor on duty. The supervisor on duty has the responsibility to report same immediately to the facility Administrator (or designee). The facility will investigate and report all allegations of abusive conduct to the state agency. 4. Initial Report The administrator or designee will report alleged violations involving abuse, neglect or mistreatment, including injuries of unknown source and misappropriation of resident property, and exploitation to the . the State Agency through the Ombudsman's Office reporting system immediately .

Based on interview, observation, and record review, it was determined that the facility failed to ensure that a resident was clinically appropriate to self-administer their medications for 1 of 3 residents reviewed for choices in a final sample size of 23 residents (Resident Identifier #4). Findings include: Observation on 5/20/24 at approximately 9:15 a.m. in Resident #4's room revealed the following medications on a shelf near the resident sitting in his/her recliner: 1 bottle of Biotics Calcium; 1 bottle of Turmeric m1670; 1 bottle of Vitamin C 500 milligrams (mg); 1 bottle of [NAME] Liquid. Interview on 5/20/24 at approximately 9:15 a.m. with Resident #4 revealed that he/she takes the medications on his/her own. Further interview revealed that Resident #4 administers: [NAME] liquid -daily for his/her blood pressure; Turmeric m1670- as needed for pain; Vitamin C -1 or 2 times per week; Biotics Calcium -daily. Observation and interview on 5/21/24 at approximately 8:30 a.m. with Staff E (Licensed Practical Nurse) of Resident #4's room revealed the above medications on a shelf near the resident sitting in his/her recliner. Staff E confirmed the findings. Review on 5/21/24 of Resident #4's May 2024 Medication Administration Record (MAR) revealed the following physician order's: [NAME] Oral Capsule 150 mg ([NAME]) Give 1 capsule by mouth in the morning every 2 day(s) for supplement. Unsupervised self-administration, family provides. Start Date 12/30/23. Further review of Resident #4's MAR revealed that he/she did not have physician's order for Turmeric m1670, Vitamin C 500 mg and Biotics Calcium. Review on 5/21/24 of Resident #4's medical record revealed that there was no assessment for self administering medications done with Resident #4. Interview on 5/21/24 at approximately 12:30 p.m. with Staff F (Director of Nursing) confirmed that Resident #4 was not assessed for the ability to self administer medications. Interview on 5/21/24 at approximately 1:50 p.m. with Staff K (Nurse Practitioner) revealed that he/she was not aware of Resident #4 administering his/her medication. Staff K also revealed that they were not aware of Resident #4 administering the [NAME] liquid every day instead of every other day. Review on 5/21/24 of the facility policy titled, Self-Administration By Resident, Dated 11/17 revealed: .Procedures: 1. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility, during the care plan process .

Based on interview and record review, it was determined that the facility failed to ensure that the residents' Minimum Data Set (MDS) accurately reflected the resident's status for 3 residents in a final sample of 22 residents (Resident Identifiers #83, #89 and #103). Findings include: Resident #103 Review on 5/22/24 of Resident #103's MDS within an Assessment Reference Date (ARD) date of 2/25/24, section A2105: Discharge Status, revealed that Short-Term General Hospital (acute hospital, IPPS) was selected. Review on 5/22/24 of Resident #103's Notice of Transfer/ Discharge revealed that Resident #103 was discharged home on 2/23/24. Interview on 5/22/24 at 9:44 a.m. with Staff G (Clinical Assessment Manager) confirmed the above MDS was incorrect and Resident #103 was discharged home. 47129 Resident #83 Review on 5/21/24 of Resident #83's progress note dated 12/23/23 revealed that Resident #83 was being discharged to home. Review on 5/21/24 of Resident #83's MDS with an ARD date of 12/28/23 revealed under section A0310F, Type of Assessment - entry/discharge reporting, revealed that 99, None of the above, was coded. Interview on 5/21/24 at 1:00 p.m. with Staff G confirmed the above finding. Staff G stated that the MDS was coded incorrectly and that the MDS should have been coded as a Discharge assessment - return not anticipated. Resident #89 Review on 5/21/24 of Resident #89's quarterly MDS with an ARD of 4/11/24 revealed under section N0415 Medications: High-Risk Drug Classes: Use and Indication A. Antipsychotic was coded indicating that Resident #89 had received an antipsychotic medication during the last 7 days. Review on 5/21/24 of Resident #89's Medication Administration Record for April revealed that no antipsychotic medication was ordered or administered for April 4 through April 11, 2024. Review on 5/21/24 of Resident #89's medical record revealed that there was an order for an antipsychotic (Olanzapine) that was discontinued on 11/9/23. Interview on 5/21/24 at 1:42 a.m. with Staff G confirmed the above findings and that the MDS dated [DATE], was coded incorrectly.

Based on observation, interview, and policy review it was determined that the facility failed to ensure expired medications were properly disposed of in 1 of 3 medication rooms and on 1 of 6 medication carts (Resident identifiers are #67 and #87). Findings Include: Second Floor Medication Room Observation on 4/25/23 at 8:45 a.m. of the second floor medication room revealed a bottle of Pantoprazole Sodium 40 milligram (mg) tablets, expired 1/2023, and a bottle of Levothyroxine Sodium 75 microgram (mcg) tablets, expired 10/30/22, available for use for Resident #67. Interview on 4/25/23 at 8:45 a.m. with Staff G (Registered Nurse) and Staff H (Licensed Practical Nurse) confirmed Resident #67 was prescribed the above medications and confirmed the finding. Review of facility's Medication Storage policy revealed: Outdated, contaminated, discontinued or deteriorated medications .are immediately removed from stock, disposed of . Fourth Floor Medication Cart Observation on 4/25/23 at 9:15 a.m. of the fourth floor medication cart revealed a vile of Insulin Aspart 100 units/milliliter (ml) in use with an open date of 3/18/23 (open expiration date of 4/15/23) for Resident #87. Interview on 4/25/23 at 9:15 a.m. with Staff I (Registered Nurse) and Staff J (Assistant Director of Nursing) confirmed the finding. Review of Insulin Aspart manufacturer specifications revealed: Throw away all opened insulin aspart vials after 28 days, even if they still have insulin left in them.

Based on interview and record review, it was determined that the facility failed to notify the provider of a change in residents' condition and failed to assess and monitor identified areas of concern for 1 of 2 residents reviewed for abuse out of a final sample of 18 residents (Resident identifier is #32). Findings include: Resident #32 Observation on 4/25/23 at approximately 12:14 p.m. of Resident #32 revealed a large discolored area to their right outer wrist going from under the wrist, at mid-circumference, extending around to the top of wrist and going up to the pinky finger. The area appeared to be slightly swollen compared to left hand and the surrounding skin was slightly darker pink in color than the left hand. Review on 4/26/23 of Resident #32's medical record revealed no documentation regarding Resident #32's bruised right wrist and hand until a note dated 4/25/23, with an entry time of 1:29 p.m., stated that a bruise of unknown origin was noted to right hand. Blueish in color swelling and pain noted. Nurse Practitioner and DPOA [Durable Power of Attorney] notified at that time and [an] x-ray ordered., Further review of Resident #32's medical record revealed the x-ray of the right wrist and hand showed evidence of a right fractured 5th finger. Interview on 4/26/23 at approximately 9:00 a.m. with Staff A (Nurse Manager) confirmed the above areas and stated he/she was not aware of the areas on Resident #32's right hand and wrist. Interview on 4/27/23 at approximately 9:05 a.m. with Staff F (Registered Nurse) revealed he/she had been made aware of the discolored area to the right hand on 4/19/23, but at the time was only discolored on the top of the hand. Staff F stated he/she reported this to Staff A at the daily meeting and initiated a treatment order to monitor the area twice a day. Staff F confirmed he/she did not write a note or call a provider about the area.

Based on interview, observation, and record review, it was determined that the facility failed to ensure that all alleged violations of abuse, neglect, exploitation or mistreatment were thoroughly investigated for 1 of 2 residents reviewed for abuse in a final sample of 18 residents (Resident identifier is #32). Findings include: Resident #32 Observation on 4/25/23 at approximately 12:14 p.m. of Resident #32 revealed a large greenish purple area to their right wrist going from under the wrist, at mid-circumference, extending around to the top of wrist and going up to the top of the pinky finger. The top of the hand appeared to be slightly swollen compared to the left hand and surrounding skin was slightly darker pink in color than the left hand. Interview on 4/25/23 at approximately 12:20 p.m. with Staff D (Licensed Nursing Assistant) confirmed the discolored area on Resident #32's right wrist and hand. Staff D stated he/she had seen the areas last Wednesday [4/19/23] and reported this finding to Staff F (Registered Nurse). Interview on 4/25/23 at approximately 12:30 p.m. with Staff A (Nurse Manager) revealed he/she was unaware of this area to Resident #32's wrist and hand and there was no investigation of the injury of unknown orgin.

Based on observation, interview and record review, the facility failed to adhere to infection control practices regarding wearing eye protection per the Centers for Disease Control and Prevention (CDC) guidelines during the COVID-19 pandemic in a community with high transmission on 3 of 3 units observed. Findings include: Review on 10/7/21 of CDC website titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 9/10/21, retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html revealed, .1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic .Implement Universal Use of Personal Protective Equipment for HCP [Healthcare Personnel]. If [CONDITION(S)]-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP working in facilities located in counties with substantial or high transmission should also use PPE [personal protective equipment] as described below: .Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters . Interview on 10/7/21 at 11:45 a.m. with Staff A (Administrator) and Staff B (Director of Nursing) revealed that only face masks were needed when on the resident units. Observation on 10/7/21 at 12:00 p.m. of the 2nd floor unit revealed approximately 5 staff were assisting approximately 10 residents with eating their lunch. There were no staff observed wearing eye protection. Interview on 10/7/21 at 12:00 p.m. with Staff C (Registered Nurse) revealed that it was his/her understanding that staff only had to wear a face mask. Observation on 10/7/21 at 12:10 p.m. of the 4th floor revealed approximately 5 staff assisting approximately 10 residents with meals, medications and/or were observed walking in and out of resident's rooms. There were no staff observed wearing eye protection. Interview on 10/7/21 at 12:15 p.m. with Staff D (Unit Manager) revealed that it was his/her understanding that staff only needed to wear eye protection on the resident unit if the resident was on quarantine or during nebulizer treatments. Observation on 10/7/21 at 12:20 p.m. of the 3rd floor revealed staff assisting residents in the dining room to eat. Staff were not wearing eye protection. Interview on 10/7/21 at 12:20 with Staff E (Unit Manager) revealed that that it was his/her understanding that staff only needed to wear a mask on the resident unit. Review on 10/7/21 of the facility's policy titled Updated Mask Guidance for Healthcare Personnel dated 5/19/21 read, in part, .Eye protection: All staff will wear eye protection on the resident units while the community is in substantial or moderate transmission Interview on 10/7/21 at 1:25 p.m. with Staff F (Infection Preventionist) confirmed that the county was in high transmission of COVID-19 and that the staff should be wearing eye protection. Interview on 10/7/21 at 2:15 p.m. with Staff B confirmed that staff should be wearing eye protection during resident care. Review on 10/15/21 of the CDC website COVID Data Tracker retrieved from https://covid.cdc.gov/covid-data-tracker/#county-view|New%20Hampshire| |Risk|community_transmission_level revealed that on 10/7/21 Hillsbourgh County was in high community transmission.

Based on observation and interview, it was determined that the facility failed to follow the Centers for Disease Control and Prevention (CDC) guidelines for universal masking and staff screening during the COVID-19 pandemic in 1 of 1 therapy gyms, 1 out of 3 nursing stations and 1 out of 2 screening stations. The facility had a census of 95 residents that potentially could be put at risk to COVID-19 exposure during the COVID-19 pandemic due to these practices. Findings include: Universal Masking Observation on 4/20/21 at approximately 11:45 a.m. in the nursing station on the 4th floor revealed Staff A (Licensed Practical Nurse) was on the telephone with his/her surgical mask around his/her chin in the nursing station with the door open. The surgical mask was not covering Staff A's mouth or nose. Staff A was in the nursing station with 2 other staff members within approximately 3 feet from each other. Interview on 4/20/21 at approximately 11:45 a.m. with Staff A revealed that this is not his/her normal practice. Observation on 4/21/21 at approximately 12:45 p.m. in the therapy gym revealed Staff B (Physical Therapy Assistant) sitting at a table drinking a drink without a surgical mask on. Two other staff members were within 3 feet of Staff B in the therapy gym. Staff C (Rehabilitation Director) came out of his/her office and entered the therapy gym with a surgical mask below his/her chin. The surgical mask was not covering his/her mouth or nose. Interview on 4/21/21 at approximately 11:45 a.m. with Staff A and Staff C revealed that the therapy department has been taking their lunch breaks in the therapy gym. The gym is closed to residents from 12:00 p.m. until 1:00 p.m. Staff C revealed that only the tables are disinfected after their breaks. The therapy gym has multiple items in it for resident use. Interview on 4/21/21 at approximately 12:45 p.m. with Staff E (Director of Nursing) revealed that the therapy gym is not considered to be a demasking area for staff. Interview on 4/22/21 at approximately 9:15 a.m. with Staff D (Infection Preventionist) revealed that the facility did know that therapy staff were utilizing the therapy gym as a break area and staff were disinfecting the tables prior to residents entering. The facility is currently trying to set up a demasking area on each floor for staff. Staff D's expectation of Staff removing masks in the nursing station would be that the staff member would be in the nursing station alone and the door would be closed. Staff D's expectation is that any staff that removes masks in a designated area of the facility would be 6 feet apart. Employee Screening Observations on 4/20/21 and 4/21/21 of employee screenings revealed that the Staff F (employee screener) was aiming the thermometer at employees necks to obtain a reading. Review on 4/21/21 of the thermometer manufacturers instructions, date modified 2020-04-17 revealed: Intended use .The correct measurement method to follow: Measure the forehead. Distance 15 (millimeter (mm)) to 50 mm Review on 2/22/21 of the CDC (Center for Disease Control) titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Updated Feb. 23, 2021 revealed: Implement Universal Source Control Measures Screen and Triage Everyone Entering a Healthcare Facility for Signs and Symptoms of COVID-19 .Obtaining reliable temperature readings is affected by multiple factors, including: .Proper usage and reading of the thermometers: Non-contact infrared thermometers frequently used for health screening must be held at an established distance from the temporal artery in the forehead to take the temperature correctly. Holding the device too far from or too close to the temporal artery affects the reading. .-HCP should wear well-fitting source control at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers

Based on observation, interview, record review and policy and procedure review it was determined that the facility failed to follow the manufacturer's specifications regarding the preparation and administration of 1 resident that was observed receiving insulin during medication pass. (Resident identifier is #73.) Findings include: Observation on 6/26/19 at approximately 7:40 a.m. during medication pass with Staff A, RN (Registered Nurse) revealed that Resident #73 had an order for [REDACTED]. Staff A was stopped prior to administering the 10 units, I never prime it before administering. I was not taught to do that. Interview on 6/26/19 at approximately 7:45 a.m. with Staff B (Unit Manager) revealed that Staff B does not turn the flex pen dose selector to 2 units prior to administering insulin, I only prime the pen if it is the first dose. Review on 6/26/19 of the manufacturer's instructions titled [MEDICATION NAME], dated 5/2015 revealed: . Instructions for Use . Giving the airshot before each injection Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: E. Turn the dose selector to select 2 units. F. Hold your [MEDICATION NAME] with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. G. Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to 0. A drop of insulin should appear in the needle tip . Review on 6/26/19 of the facility policy and procedure titled, Medication Administration Subcutaneous Insulin, Section 7.23, dated 5/16 revealed: . Procedures . 5.Review manufacturer specific administration and storage instructions for pen devices. . 22 Always perform the safety test before each injection. Performing the safety test ensures that you get an accurate dose by: ensuring that the pen and needle work properly. removing air bubbles.

Based on interview, observation, and record review, it was determined that the facility failed to maintain a complete medical record of medication administration and self administrations assessment for 1 of 1 resident who self-administer medications in a final sample of 27 residents (Resident identifier #104). Findings include: Observation on 6/25/19 at 10:52 a.m. of the Resident #104 in their room revealed 3 bottles of nasal spray ([MEDICATION NAME], and Afrin) on the night stand. Interview with Resident #104 during observation revealed that the resident self-administers nasal sprays each evening. Review on 6/27/19 of physician orders [REDACTED]. Instructions for orders indicate medication can be kept at bedside. Review on 6/27/19 of resident assessments revealed a Medication Self-Administration Evaluation performed on 5/2/19 that indicates the resident is fully able to administer medications but did not indicate which medications. Review on 6/27/19 of Resident 104's Medication Administration Record [REDACTED]. Further review revealed that the resident had orders for oral, suppository, intramuscular, intranasal, and topical medications. Observation on 6/27/19 at 1:05 p.m. with Staff C (Director of Nursing) revealed the above 3 nasal sprays in Resident #104's room. Interview with Resident #104 at that time revealed the resident has been using one nasal spray every night and the resident is not [MEDICATION NAME] longer. Interview on 6/27/19 at 1:35 p.m. with Staff C revealed that there was no record of Resident 104's self -administration of medications in (MONTH) or (MONTH) 2019.

Based on observation, interview and policy and procedure review it was determined that the facility failed to ensure that residents are free from significant medication errors and failed to dispose of an expired medication for 1 out of 7 medication carts. (Resident identifiers are #8 and #37.) Findings include: Observation on 8/3/18 at approximately 12:35 p.m. of the medication cart on the second floor revealed Resident #37's [MEDICATION NAME] Extended Release 75 mg had expired on 6/7/18. Interview on 8/3/18 at approximately 12:40 p.m. with Staff B Licensed Practical Nurse revealed that the expired [MEDICATION NAME] was administered on 8/3/18 to Resident #37. Interview on 8/3/18 at approximately 2:00 p.m. with Staff C (Director of Nurses) revealed that when the expired medication was brought to the facility's attention it was revealed that the expired medication had been administered to the Resident #37 by different staff members daily. Review on 8/7/18 of the facility's policy and procedure titled Disposal of Medications, Syringes and Needles. Disposal of Medications, dated (MONTH) 5, (YEAR) revealed: . Section 5.4 . 7. Outdated medications, contaminated or deteriorated medications, and the contents of containers with no label shall be destroyed according to the above policy. Review on 8/7/18 of the facility's policy and procedure titled Medication Administration, General Guidelines, dated 12/12 revealed: . Medication Administration . 8. Check expiration date on package/container. No expired medications will be administered to a resident.

Based on observation, interview and policy and procedure review it was determined that the facility failed to follow professional standards of practice for expired medications in 1 out of 5 medication rooms. (Resident identifiers are #8 and #37.) Findings include: . It is important to know and stick to the expiration date on your medicine. Using expired medical products is risky and possibly harmful to your health Expired medical products can be less effective or risky due to a change in chemical composition or a decrease in strength (https://www.fda.gov/Drugs/ResourcesForYou/SpecialFeatures/ucm 9.htm accessed on 8/14/18.) Observation on 8/3/18 at approximately 12:30 p.m. of the second floor medication storage room revealed the following expired medications: [REDACTED] Resident #8 Prevnar expiration date 3/18. Resident #37 [MEDICATION NAME] 20 mg (milligram) expiration date 7/31/18 Resident #37 Pioglitazone 45 mg expiration date 7/31/18 Resident #37 [MEDICATION NAME] Extended Release expiration date 6/7/18 Interview on 8/3/18 at approximately 12:30 p.m. with Staff A (UM) Unit Manager confirmed that the above medications were expired. Review on 8/7/18 of the facility's policy and procedure titled Disposal of Medications, Syringes and Needles. Disposal of Medications, dated (MONTH) 5, (YEAR) revealed: . Section 5.4 . 7. Outdated medications, contaminated or deteriorated medications, and the contents of containers with no label shall be destroyed according to the above policy.

Based on record review and interview the facility failed to supervise the resident and reassess alarm removal to prevent a second fall with injury for 1 resident in a standard survey sample of 23 residents. (Resident identifier is #7.) Findings include: Resident #7. Record review was conducted between 2/22/12 -2/24/12. Record review of the nurses notes and the physician's progress notes revealed that Resident #7 sustained a witnessed fall with subsequent left hip fracture on 7/20/11. Resident was admitted to the hospital on [DATE], the hip was surgically repaired and the resident returned to the facility on [DATE]. Review of the "Physical Therapy Discharge Summary" with dates of service from 7/25/11- 9/23/11 revealed that the resident was a "Maximal Assistance" with "sit to stand transfers...ambulation.... and transfers..." on 7/25/11 and graduated to "Contact Guard up to 300 feet on discharge 9/23/11" for ambulation and "Supervision for transfers..." and "...sit to stand transfers" for the 9/23/11 discharge date . Interview on 2/24/11 in the late morning with Staff E (Rehab manager) revealed that these were the discharge notes from Physical Therapy summarizing the services from July through the 23rd of September. Staff E stated that there was no documentation stating that this resident was cleared by therapy to transfer or walk independently as of 9/23/11. This resident was still a contact guard and required supervision as stated above. Record review and review of the Incident/Accident Report dated 9/25/11 revealed that Resident # 7 fell at 11:30 a.m., "Resident ambulated independently to room/bathroom. Found sitting on floor. Back/head against wall. Externally rotated RLE (right lower extremity.)" The report indicated no alarm was in use. Record review revealed a skilled nurses note dated 9/25/11, 7-3 shift "...resident was sitting in T.V. room, in front of T.V. in wheel chair. got up unnoticed and ambulated to room bathroom. Staff noticed empty chair. (Resident #7) had been @ ( at) chair @ 11:15. Sitting in bathroom in front of toilet. back and hand against wall..." Nurses note continued to say that Resident #7 was transported to hospital and was admitted for a hip fracture. Further review of the medical record hospital discharge summary dated 9/29/11 revealed that the reason for admission was: status [REDACTED]. Fracture was surgically repaired and Resident #7 returned to the facility on [DATE]. Review of facility "Fall Prevention Program" dated as revised 8/24/04 under "PURPOSE" revealed: "1) To identify and monitor residents who are at risk for falling. 4) To reduce the risk of future falls. 5) To ensure that the cause(s) of the accident/incident can be investigated and evaluated and that corrective measures are ` implemented to prevent reoccurrence." And under "PROCEDURE" revealed: "The falls Committee shall review the Alarm Audit to ensure timely sensor pad changes, alarm in working order, and necessity to continue alarm use." Interview with Staff B (LPN/Unit Manager) on 2/22/12 at 2:15 p.m. confirmed Resident #7 had been found on 9/25/11 in the resident's own bathroom on the floor. "No on saw (Resident #7) leave this (signaled to the T.V. area)." Staff B also confirmed that the ambulance came and that the staff transported this resident to the Hospital immediately. Staff B also stated that on 9/25/11, at the time of the fall, there were "....no alarms on (name omitted) (Resident #7)" as they had been removed earlier in the month. In an interview with Staff A (ADON) on 2/24/12 in the morning, Staff A stated that the facility had done an Alarm reduction program and Resident #7's alarm had been removed on 9/7/11 after a discussion with the falls committee. Review of the list of residents given to this surveyor by Staff A revealed that 9/7/11 was the date Resident #7's alarm was removed. Staff A was unable to locate any documentation of an assessment or evaluation or follow-up nurses notes confirming the decision to remove this alarm. Review of the above list of residents and Falls committee notes dated 9/7/11 given to this surveyor by Staff B revealed, by floor, the list of "Alarms discharged " with Resident #7's name on this list with no reason, justification or assessment for the "discharge"/removal of alarms noted on the list. Review of the medical record, nurses notes, physicians progress notes, social service notes, and IDT notes revealed no documented evidence that this resident was an independent walker at the time of the 9/25/11 fall or that Resident #7 was a safe candidate for Alarm removal on 9/7/11. Review of the active and back up medical record revealed no documented evidence of Alarm monitoring sheets to corroborate the decision to remove Resident #7's alarm. During an interview with Staff F (DON) on 2/24/11 in the afternoon, Staff F confirmed that there was no documented evidence of any of the conversations regarding the removal of Resident #7's alarm on 9/7/11 and no documented evidence of the alarm monitoring sheets.