Every finding on record at NHC Place at the Trace

Based on policy review, medical record review, observation, and interview, the facility failed to store medications in accordance with facility policy when 1 of 2 nurses (Licensed Practical Nurse (LPN) A) left medications unsecured and unattended for 1 of 5 (Resident #60) sampled residents observed during medication administration and when medications were found unsecured and unattended for 1 of 83 (Resident #61 ) sampled residents. The findings include: 1. Review of the facility policy titled, Medication Storage In The Facility, dated 2/25/2025, revealed .Medications and biologicals are stored safely, securely, and properly.The medication supply is only accessible to licensed nursing personnel.authorized to administer medications. 2. Review of the medical record revealed Resident #60 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease and Parkinsons. Review of the Physician's Orders dated 11/21/2025, revealed orders for the following medications: a. Ipratropium-albuterol solution (used to treat and prevent symptoms of wheezing and shortness of breath that is caused by ongoing lung disease) for nebulization, 0.5 mg (milligram)-3mg, Three Times A Day b. Clear Lax (a laxative) powder 17 gram oral, give 17 grams, Once A Day c. Guaifenesin (an expectorant) liquid 100mg/5ml (milliliter), give 5ml (100mg) oral, four times a day d. Bupropion HCI (antidepressant) tablet (tab) extended release 24 hr (hour) 150 mg, give 1 tab oral, Once A Day e. Carbidopa-Levodopa (a medication to treat Parkinson's disease) tablet 25-100 mg, give 1.5 (one and a half) tabs (37.5-150mg) oral, Three times A Day f. Aspirin (used to treat fever, pain, inflammation, and to thin blood) tablet chewable 81mg, 1 tab oral, once a day Review of the Physician's Order dated 2/9/2026, revealed .furosemide [ a diuretic] tablet; 20 mg; 1 tab; oral once a day . Review of the Physician's Order dated 2/18/2026, revealed .Pataday [an antihistamine] Once Daily Relief .drops; 0.2% [percent]; amt [amount]: 1 drop; ophthalmic (eye) Once A Day . Review of the Physician's Order dated 4/9/2026, revealed .loratadine [an antihistamine] .tablet; 10mg; amt: 1 oral Once A Day. Review of the Physician's Order dated 5/1/2026, revealed .alprazolam [an antianxiety medication] .0.5 mg: amt:1 tab twice a day . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #60 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment, which revealed he was cognitively intact. The facility was unable to provide a self-administration of medication assessment for Resident #60. Observation in the resident's room during medication administration on 5/18/2026 at 8:37 AM, revealed LPN A entered Resident #60's room to administer medications, called the resident by name, provided privacy, and told him what medications were to be administered. LPN A administered Aspirin 81mg, Bupropion HCI 150mg, carbidopa-levodopa tablet; 25-100 mg, Furosemide 20 mg, guaifenesin ER 600mg, loratadine 10mg, Clear lax 17gm, Xanax, 0.5mg, orally Pataday 0.2% eye drops, and ipratropium-albuterol solution for nebulization; 0.5 mg-3 mg via (by means of) nebulizer. LPN A started the nebulizer treatment, told resident she would be back in 15 minutes to turn it off, and exited the room. Staff failed to remain present during the administration of Resident #60's nebulizer treatment. 3. Review of medical records revealed Resident #61 was admitted to the facility on [DATE], with diagnoses including Urinary Tract Infection and Chronic Kidney Disease. Review of the Physician Orders dated 5/1/2026, revealed .Estradiol [treatment for vaginal changes] cream .vaginal .Special Instructions: PATIENT MAY SELF ADMINISTER. Medication to keep in Nurse's medication cart . Review of the Care Plan dated 5/1/2026, revealed . Patient is approved for self-application of Estradiol; medication to be stored in the nurse's medication cart . Review of the quarterly MDS assessment dated [DATE], revealed Resident #61 scored a 15 on the BIMS assessment, which indicated she was cognitively intact. Observation in the resident's room on 5/17/2026 at 11:15 AM and 4:04 PM, and on 5/18/2026 at 11:00 AM, revealed a jar of prescription medicated vaginal cream unsecured and unattended on Resident #61's bathroom counter. During an observation and interview on 5/18/2026 at 2:58 PM, the Assistant Director of Nursing (ADON) was asked if prescription medication should be left in the resident's bathroom. The ADON stated, .No ma'am . The ADON was asked if prescription medications should be kept in the medication cart. The ADON stated, .Absolutely .

Based on policy review, facility documentation review, job descriptions, observation, and interview, the facility failed to ensure food was stored and served under sanitary conditions when floors were soiled throughout the kitchen, cookware and equipment were soiled, when the dishwasher was not maintained at an appropriate temperature for sanitation, and when 1 of 1 staff (Cook N) failed to perform hand hygiene during tray line service. The facility had a census of 82 with 82 of those residents receiving a tray from the kitchen. The findings include: 1. Review of the facility policy titled, Cleaning Equipment, dated ,d+[DATE], revealed .Equipment must be cleaned and/or sanitized after every use .Department inspections should be conducted to review sanitation, and immediate action should be taken to correct any problems that interfere with meeting sanitary standards . Review of the facility policy titled, Griddles/Grills, dated ,d+[DATE], revealed .After each use .For char-grills, use stiff brush to remove food particles from grate . Review of the facility policy titled, Refrigerator and Freezer Storage, dated ,d+[DATE], revealed .Refrigerator and frozen foods will be stored properly for optimal product safety .Foods will be stored in their original container or a NSF [National Sanitation Foundation] approved container or wrapped tightly in moisture-proof film, foil .clearly labeled with the contents and use by date . Review of the facility policy titled, Machine Warewashing, dated ,d+[DATE], revealed .Most tableware, utensils, adaptive equipment, pots and pans .can be effectively cleaned and sanitized in warewashing machines. Most warewashing machines sanitize by using either hot water or a chemical-sanitizing solution .High-Temperature Machines .rely on hot water to clean and sanitize. The temperature of the wash solution in dish machine that use hot water to sanitize may not be less than 165 [degree] F [Fahrenheit] .The temperature of the final sanitizing rinse must be at least 180 [degree] F .The temperature is measured using a built-in thermometer to check the temperature of the water at the manifold, where the water sprays into the tank .Check each rack for soiled items as it comes out of the machine. Run dirty items through again until they are clean. Most items will only need to pass if proper equipment and procedures are used .Keep the warewashing machine in good repair .If the temperature are not in the proper range, immediately call the appropriate service company and stop the operation of the machine . Manually finish the dishes if necessary, following manual warewashing guidelines .Use disposal (plates/utensils, etc.) for the next meal if necessary. Do not utilize the dish machine again until it is in good repair. 2. Review of the Registered Dietitian Nutritionist job description dated [DATE], revealed .Reviews sanitation and safety of the FNS [Food and Nutrition Services] department routinely and provides guidance in finding solutions to any problems noted .Has a thorough understanding and practice of all regulations (local, state, and federal) which affect FNS including department. Must be able to work with and train staff to improve patient care and FNS services . Review of the Director of Food and Nutrition Services job description dated [DATE], revealed .To ensure all functions of the FNS [Food and Nutrition Services] Department, both Administrative and Clinical duties are carried out accurately and appropriately .Responsible for development/adherence to policies and procedures .cleaning schedules, and other food services management tools .Has a thorough understanding and practice of all regulations .which affect Evaluates trends and developments food safety and service practices and techniques and investigates their adaptability to the FNS program .Inspects FNS department regularly to ensure that it is safe, secure, and sanitary . 3. Observation and interview in the Kitchen during the initial tour on [DATE] at 10:26 AM, revealed the following: a. 2 cooking pots hanging above the 3 compartment sink with black build up on the bottom of the pots. b. a perforated pan with dried food particles on the side. The CDM (Certified Dietary Manager) confirm that the perforated pan should be clean and free of food particles. c. 2 small clear dessert bowls stacked inside each other with cantaloupe stuck between the 2 bowls in a storage bin. The CDM confirmed that the bowls should be clean and food should not be on the bowls. d. a metal mixing kettle and a metal stand up mixer with build up of spillage and dried food particles. e. plastic rolling containers with breadcrumbs, rice, and fish batter, soiled with dried food splatters on the exterior of the containers. f. the bottom shelf of a metal prep table with dried spillage and dried food particles. g. a metal drying rack with a build up of dried food and tan spillage on the sides and on the bottom of the rack. h. the char-grill with thick carbon build up. The CDM confirmed that it was black build up. i. the floor throughout the kitchen was soiled and with thick black build under the deep fryer. j. 2 opened and undated loaves of wheat bread on a ledge above the serving line. k. half loaf of white bread opened and undated on a ledge above the serving line. l. 2 expired 4-ounce (oz) cups of grape juice dated [DATE] stored in the reach in refrigerator. m. 20 expired 4 oz cups of grape juice dated [DATE] stored in the walk-in refrigerator. 4. Observation and interview in the kitchen on [DATE] at 3:53 PM, the CDM confirmed that the dishwasher temperatures (temp) are supposed to be 160 degrees F at wash and 180 degrees F at rinse. The CDM stated, Staff are supposed to inform me or maintenance when the temp is too low, the water temp will come down ,d+[DATE] degrees and are instructed to wait ,d+[DATE] minutes then restart (dishwasher) . Observation and interview in the Kitchen on [DATE] at 10:02 AM, revealed [NAME] O was in the dish room running the dish washer and the dishwasher final rinse temp was not maintained and dropped to 151 degrees F. [NAME] R was asked, what's the process for reporting the dishwasher temperatures when they are not maintained. [NAME] R stated, I don't know the answer . [NAME] R returned with the CDM. The CDM was asked how he ensures that dishes are being sanitized properly if temperatures are not being maintained. The CDM confirmed that there was not any sanitation on the dishwasher since it is a high temp dishwasher and stated, Staff know to stop and let the water reheat after ,d+[DATE] minutes. Review of the Kitchen's Dishroom Record, dated ,d+[DATE], revealed the rinse temperature was below 180 degrees on the following dates: a. [DATE] AM 169 degrees, evening 178 degrees b. [DATE] AM 175 degrees, noon 176 degrees c. [DATE] AM 171 degrees, d. [DATE] AM 174 degrees, noon 174 degrees, evening 177 degrees e. [DATE] AM 179 degrees, noon 177 degrees, evening 169 degrees f. [DATE] AM 175 degrees, noon 173 degrees, evening 175 degrees g. [DATE] noon 177 degrees, evening 179 degrees h. [DATE] noon 179 degrees, evening 178 degrees i. [DATE] AM 179 degrees Observation and interview on [DATE] at 10:16 AM, revealed the Regional Registered Dietitian (RD) had a test tray placed in the dishwasher with the final rinse temperature dropping to 160 degrees. The RD confirmed that there was an issue with the dishwasher and that someone would be contacted to assess the dishwasher. The RD confirmed that the facility would implement the use of disposable dining ware for serving meals. 5. Observation in the Kitchen on [DATE] from 3:55 PM to 4:26 PM, revealed [NAME] N walking away from the serving line multiple times, touching multiple items (including the warming oven handle) in the kitchen, without changing gloves or performing hand hygiene prior to returning to serving line. [NAME] N was observed obtaining 2 sweet potatoes from the warming oven with gloved hand and smashing 1 of the potatoes with gloved hand. 6. Review of the Named company invoice for the dishwasher dated [DATE], revealed .a leak at the vacuum breaker was repaired .a temp probe was repaired for the energy recover system. The incoming power for the booster is missing .They need to get a[an] electrician to fix the incoming power for the booster . Review of the service report dated [DATE], revealed .Back of House issue found .Machine [dishwasher] rinse temp not meeting 180 degrees .Rinse Temperature: 144 [degrees] Fahrenheit .Monitoring rinse temp for compliance to protect guests, reputations, machine efficiency .Chemical Sanitation 50PPM [Parts Per Minute] .Monitoring chemical sanitation level for compliance to protect guests and reputation .Installed stacking pump to allow dishes to be sanitized while rinse temp is low . 7. Observation and interview in the kitchen on [DATE] at 9:08 AM, revealed the stove eyes with thick carbon build up and a tan thick build up on the right front eye. The CDM stated that Ecolab came out last night and added a sanitizing line to the dishwasher. The CDM was asked regarding the testing of the sanitation of the dishwasher. The CDM stated that the facility does not have the sanitation test strips needed to test the dishwasher sanitation. The CDM confirmed that Ecolab performed a sanitation test prior to leaving. The CDM stated, I was perched the entire time that they were using the dishwasher to ensure the temps [temperatures] were not dropping. Observation and interview in the kitchen on [DATE] at 9:46 AM, revealed [NAME] M washing dishes in the dish room with a wash temp of 142 degrees. [NAME] M turned the dishwasher off and did not report low temperatures to anyone. The CDM was asked how he was ensuring the sanitation of trays and dishes with having 2 Covid residents in the facility. The CDM confirmed Ecolab ran sanitation to the dishwasher. The CDM was asked how he was ensuring the proper sanitation level without being able to test. The CDM stated, I see where you are coming from. During an interview on [DATE] at 12:08 PM, the Regional RD confirmed that she was first made aware of the issues with the dishwasher on [DATE] and contacted the dishwasher manufacturer and Ecolab. The Regional RD was asked who made the decision to go back to using regular dishes and utensils. The Regional RD confirmed that she was not included in that decision. During an interview on [DATE] at 2:49 PM, revealed the RD confirmed that he has not been included in any conversations related to any issues with the dishwasher or any concerns related to the sanitation of the dishwasher this week or prior. The RD confirmed that was a concern related to covid residents and the issue with the dishwasher sanitation. During an interview on [DATE] at 3:38 PM, revealed the CDM, Regional RD, RD, and the Administrator were present. The CDM confirmed that opened food items should be labeled and dated. The CDM confirmed that expired food items should be discarded by the use by date. The CDM was asked if cookware or equipment should have thick carbon build up. The CDM stated, No. The CDM confirmed that there should not be dried food particles on clean dishes or cookware. The CDM confirmed that there should not be dried food particles, spillage, or dried substance build up on the sides or base of the rack, and mixing kettle and stand. The CDM confirmed that the dishwasher temperature logs should reflect appropriate temperatures in range and confirmed that staff should not leave the serving line and return without performing hand hygiene.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure 1 of 4 (Registered Nurse (RN) L) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 2 errors were observed out of 33 opportunities, resulting in a medication error rate of 6.06%. The findings include: 1. Review of the undated facility policy titled, Med Pass Education Tool, revealed .Anything that indicates slow-release or enteric coating .should NOT be crushed .Other common medications that should not be crushed .EC [Enteric Coated] aspirin [used to thin the blood] .Potassium tablets [a dietary supplement] . Review of the undated facility policy titled, Med Pass Education Tool, revealed .Anything that indicates slow-release or enteric coating .should NOT be crushed .Other common medications that should not be crushed .EC [Enteric Coated] aspirin .Potassium tablets . 2. Review of the medical record revealed the Resident #77 was admitted to the facility on [DATE], with diagnoses including Age-related Osteoporosis, Fibromyalgia, Chronic Kidney Disease, Pleural Effusion, Chronic Atrial fibrillation, Hyperlipidemia, Hypothyroidism, Long Term (current) Use of Aspirin, and Anemia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #77 had a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #77 had intact cognition. Review of the Physicians Orders dated 1/24/2025-2/12/2025, revealed .calcium carbonate - vitamin D3 [used for low bone density] tablet .600mg [milligram] -10 mcg [microgram] (400 unit) .1 tab [tablet] .oral Twice a day .carvedilol [used for high blood pressure] tablet . 6.25 mg .1 tab . oral Twice a day .hydrochlorothiazide [used for high blood pressure] tablet .12.5 mg .1 tab .oral Once A Day . magnesium oxide [OTC] (over the counter) [used for constipation] tablet .400 mg (241.3 mg magnesium) .1 tab .oral Twice A Day .methocarbamol [used for muscle spasm] tablet .500 mg .1 tab .oral Three times a day .potassium chloride tablet extended release .10 mEq [milliequivalent] .1 tab .oral once a day .Eliquis (apixaban) [used to thin blood] tablet .5 mg .1 tab .oral Twice A Day .cholecalciferol (vitamin D3) [used for low bone density] tablet .125 mcg (5,000 unit) .1 tab .oral Once A Day .losartan [used for high blood pressure] tablet .100 mg .1 tab .oral Once a day .allopurinol [used for gout] tablet .100 mg .1 tab .oral Once A Day .aspirin [OTC] tablet .delayed release (DR/EC) .81 mg .1 tab .oral Once a day .cyanocobalamin (vitamin B 12) [used to treat anemia] tablet .1,000 mcg .1 tab . oral Once A Day .ezetimibe [used to treat high cholesterol] tablet .10 mg .1 tab .oral Once A Day .Eye Health Plus Lutein (vit a, c and e-lutein-minerals) [used for age-related eye disease] tablet .300 mcg-200mg-27mg-2mg 1 oral Once A Day .Ferrous Sulfate [used for anemia] tablet 325 mg .1 tablet .oral Once A Day . Observation during medication administration on 2/12/2025 at 8:27 AM, revealed RN L removed the following medications from the cart to administer to Resident #77. a. calcium carbonate - vitamin D3 tablet; 600mg -10 mcg 1 tablet b. carvedilol 6.25 mg 1 tab c. hydrochlorothiazide 12.5 mg 1 tab d. magnesium oxide tablet 400 mg 1 tab e. methocarbamol tablet 500 mg 1 tab f. potassium chloride tablet extended release 10 mEq 1 tab g. Eliquis 5 mg 1 tab h. cholecalciferol 125 mcg 1 tab j. losartan tablet 100 mg 1 tab k. allopurinol tablet 100 mg 1 tab l. aspirin delayed release (DR/EC) 81 mg 1 tab m. cyanocobalamin 1,000 mcg 1 tab n. ezetimibe tablet 10 mg 1 tab o. Eye Health Plus 1 tab p. Ferrous Sulfate tablet 325 mg 1 tab RN L crushed the medications including the extended-release potassium and delayed release enteric coated aspirin, placed the medication in a cup with applesauce, entered the room and administered the medications to Resident #77, resulting in 2 medication errors for crushing the extended release and enteric coated medications. During an interview on 2/12/2025 at 10:50 AM, RN L was asked if the potassium chloride extended release and aspirin delayed release should have been crushed. RN L stated, I think some dissolve, I think it's up to the provider and the pharmacy. During an interview on 2/12/2025 at 4:08 PM, the Director of Nursing confirmed slow-release and enteric coated medications should not be crushed.

Based on the medical record review, observation, and interview, the facility failed to ensure the environment was free of accident hazards when unsecured sharps were observed in 1 of 80 (Resident #47) occupied resident rooms. The findings include: Review of the medical record revealed Resident #47 was admitted to the facility on [DATE], with diagnoses including Supraventricular Tachycardia, Atrial Fibrillation, Hemiplegia and Hemiparesis and Cerebral Infarction. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #47 was cognitively intact, was dependent with toileting, required partial/ moderate assistance with transfers and bed mobility, setup or clean-up assistance with personal hygiene, used a wheelchair and walker for mobility and received anticoagulants. Review of the Care Plan dated 11/29/2024, revealed .Anticoagulant . At Risk for Bleeding . Approach .Use electric razor . Review of Physician's Order dated 11/27/2024, revealed Eliquis [a medication to prevent blood clotting] .tablet .5 mg [milligram] .1 tab [tablet] .oral Every 12 Hours. Observation in the Resident's room on 2/10/2025 at 11:27 AM, revealed Resident #47 was up in the wheelchair watching television (tv) with 2 blue disposable razors noted in a wash basin on the counter in the bathroom. Observation in the Resident's room on 2/10/2025 at 4:48 PM, revealed 2 blue disposable razors noted in a wash basin on the counter in the bathroom. During an observation and interview on 2/10/2025 at 5:58 PM, the Director of Nursing (DON) was shown the razors in Resident #47's bathroom and was asked should these razors be out on the counter in resident's bathroom. The DON stated, No, they should be in the drawer. During an interview on 2/11/2025 at 7:47 AM, the DON confirmed Resident #47 should not have had razors in his room. During an interview with Certified Nursing Assistant (CNA) I on 2/12/2025 at 12:35 PM, CNA I was asked if Resident #47 uses a bladed razor or an electric razor. CNA I confirmed Resident #47 uses an electric razor and stated, I've never seen him with a bladed razor.

Based on policy review, observation, and interview, the facility failed to ensure to maintain or enhance residents' dignity and respect during dining when 6 of 9 (Unit Manager (UM) A, Certified Nursing Assistant (CNA) B, Licensed Practical Nurse (LPN) J, CNA F, Staffing Coordinator E, and CNA G) failed to knock and/or announce themselves before entering a resident's room and failed to use courtesy titles when addressing residents and when referring to residents. The findings include: 1.Review of the facility's undated sheet titled, Partner Education-Dignity Training, revealed .We all must show respect toward each patient and preserve the rights and needs of our patients at all times. We expect that you will provide patients with a comfortable and pleasant environment .Respect your privacy, dignity, and confidentiality . 2. Review of the facility's policy titled, USE OF COURTESY TITLES, dated 6/2006, revealed .It is the policy of this center to use courtesy titles .when addressing patients in all written records and communication . 3. Observation during dining on the 500 Hall on 2/10/2025 at 11:30 AM, revealed UM A entered Resident #31's room and stated, Hey sweetheart are you ready to eat ., entered the bathroom for a washcloth, washed the resident's hands, exited the resident's room and returned to the meal cart. UM A failed to knock and/or announce herself prior to entering the resident's room and failed to use courtesy titles when addressing the resident. 4. Observation during dining on the 500 Hall on 2/10/2025 at 11:45 AM, revealed CNA B and LPN J entered Resident #25's room, failed to knock and/or announce themselves prior to entering the resident's room, placed the meal tray on the over the bed table, CNA B stated, You want me to make you a milkshake girlie ., exited the room and looked back and stated, I'll be right back my friend . and returned to the meal cart. 5. Observation during dining in the 500 Hall Common Dining Room on 2/10/2025 at 11:50 AM, revealed UM A approached the table with a bottle of hand sanitizer and stated, The man with the plan, you know the deal seal . referring to Resident #27 while applying hand sanitizer to the resident's hands. UM A then walked to the right side of the table to Resident #1 and stated, Let me get your hands sweet heart while applying hand sanitizer to Resident #1's hands, and then UM A looked over to the left side of the same table and stated to Resident #24, Are you ok dear . UM A failed to use courtesy titles when addressing or referring to Resident #1, #24, and #27. 6. Observation during dining in the 500 Hall Common Dining Room on 2/10/2025 at 11:52 AM, revealed UM A applied hand sanitizer to Resident #34's hands, Resident #34 stated, Why are you doing this. UM A stated, Boo Boo you know that we do this . UM A failed to use a courtesy title when addressing or referring to Resident #34, 7. Observation during dining on the 500 Hall on 2/12/2025 at 7:30 AM, revealed CNA F and Staffing Coordinator E entered Resident #42's room, CNA F placed the meal tray on the over the bed table, both CNA F and Staffing Coordinator E repositioned the resident in the bed, sanitized their hands, and exited the room. Neither CNA F or Staffing Coordinator E knocked and/or announced themselves prior to entering Resident #42's room. 8. Observation during dining on the 500 Hall on 2/12/2025 at 7:35 AM, revealed Staffing Coordinator E removed a tray from the meal cart, entered Resident #48's room, and placed the meal tray on the over the bed table, exited the room and returned to the meal cart. Staffing Coordinator E failed to knock and/or announce herself prior to entering Resident #48's room. 9. Observation during dining on the 500 Hall on 2/12/25 at 7:45 AM, revealed CNA G removed a tray from the meal cart, knocked and entered Resident #27's room, placed the tray on the over the bed table, Resident #27 stated, May I ask a question. CNA G stated, What's that hun [honey], adjusted the resident in bed, sanitized her hands and exited the resident's room, and returned to the meal cart. 10. During an interview on 2/12/2025 at 4:08 PM, the Director of Nursing (DON) confirmed staff should knock and announce themselves prior to entering a resident's room. The DON confirmed that residents should be addressed with courtesy titles and should not be referred to with pet names. 49269

Based on review of rosemontpharma.com, policy review, medical record review, interview, and observation, the facility failed to ensure residents were free from significant medication errors for 1 of 4 sampled residents (Resident #77) reviewed. The findings include: 1. Review of the rosemontpharma.com article titled, Information For Patients On The Dangers Of Tablet Crushing, dated 9/2023, revealed . The clinical consequences for the patient of crushing tablets or opening capsules can mean that the drug is less effective or more likely to cause side effects. When crushing disrupts a drug's sustained-release properties, the active ingredient is no longer released and absorbed gradually, resulting in overdose. When a gastro-resistant layer is destroyed by crushing, underdosing is likely . Enteric coatings .These stop the drug breaking down in the stomach, to protect either the stomach or the drug, or to enable it to be released further along the digestive process . Modified or prolonged release .These drugs - also known as extended release, slow release or controlled release - are steadily released, which means they don't have to be taken so frequently . Review of the undated facility policy titled, Med Pass Education Tool, revealed .Anything that indicates slow-release or enteric coating .should NOT be crushed .Other common medications that should not be crushed .EC [Enteric Coated] aspirin .Potassium tablets . 2. Review of the medical record revealed the Resident #77 was admitted to the facility on [DATE], with diagnoses including Age-related Osteoporosis, Fibromyalgia, Chronic Kidney Disease, Pleural Effusion, Chronic Atrial fibrillation, Hyperlipidemia, Hypothyroidism, Long Term (current) Use of Aspirin, and Anemia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #77 had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Review of the Physician's Orders for Resident #77 dated 1/24/2025-2/12/2025, revealed .aspirin [OTC] [over the counter] tablet, delayed release .81 mg [milligram] 1 tab [tablet] Once a day .potassium chloride extended release 10 mEq [milliequivalent] .once a day . Observation during medication administration on 2/12/2025 at 8:27 AM, revealed RN (Registered Nurse) L removed medications from the medication cart including potassium chloride extended release 10 mEq and aspirin 81mg tablet delayed release, placed in medicine cup, meds crushed the medications, mixed with applesauce, and administered the medications to Resident #77. During an interview on 2/12/2025 at 10:50 AM, RN L was asked if the potassium chloride extended release or aspirin delayed release should have been crushed. RN L stated, I think some dissolve, I think it's up to the provider and the pharmacy. During an interview on 2/12/2025 at 4:08 PM, the Director of Nursing confirmed slow-release or enteric coated medications should not be crushed. Refer to F759

Based on policy review, medical record review, observation, and interview, the facility failed to prevent the spread of infections when 1 of 4 (Registered Nurse (RN) K) nurses failed to properly perform hand hygiene during blood glucose monitoring and cleaned an injection site with a used alcohol pad during medication administration. The findings include: 1. Review of the undated facility policy titled, Med Pass Education Tool, revealed, .Use proper hand hygiene prior to donning and after doffing gloves .Use proper hand washing technique .Use a clean towel to turn off water . Review of the facility policy titled, 709 Hand Hygiene, dated April 2024 revealed, .To decrease the number of microorganisms, preventing cross contamination between staff and patients .Rinse your hands with water and use disposable towels to dry. Use towel to turn off the faucet . 2. Review of the medical record revealed Resident #278 was admitted to the facility on [DATE], with diagnoses including Hypertensive Heart Disease, Congestive Heart Failure, Diabetes, and Cellulitis. Review of the Social Services Noted dated 2/5/2025, revealed a Brief Interview for Mental Status assessment was performed on 2/5/2025, revealing a score of 11, indicating Resident #278 was moderately cognitively impaired. Review of the Care Plan dated 2/4/2024, revealed .Diabetes .Monitor blood glucose levels as ordered and administer meds [medications]/insulin as directed . Review of the Physician's Orders dated 2/3/2025 revealed insulin aspart U-100 insulin pen [a medication to lower blood glucose] .100 unit/mL [milliliter] .7 UNITS . subcutaneous .Take before lunch and dinner .[blood glucose monitoring] .Before Meals and At Bedtime . Observation in Resident #278's room on 2/11/2025 at 11:41 AM, revealed RN K prepared to perform blood glucose monitoring, entered the bathroom, washed her hands, turned off water with her bare hand, and dried her hands with paper towel. Observation in Resident #278's room on 2/11/2025 at 12:10 PM, revealed RN K prepared to administer an insulin injection, cleaned an area to the left lower abdomen with an alcohol pad, and placed the alcohol pad on the over the bed table without a barrier. RN K picked the alcohol pad up off the overbed table and used the same alcohol pad to wipe Resident #278's left lower abdomen, removed the needle cap, and administered the insulin into the abdomen. During an interview on 2/12/2025 at 3:03 PM, RN K confirmed when performing handwashing the water should be turned off with a paper towel, not with her bare hand, and when cleaning an injection site an alcohol wipe should not be reused once placed on an over the bed table without a barrier. During an interview on 2/12/2025 at 4:08 PM, the Director of Nursing confirmed an alcohol wipe should not be reused to clean an injection site if it has been laid on an over the bed table without a barrier and a paper towel should be used to turn off the water when performing hand washing.

Based on facility policy review, observations, and interviews, the facility failed to ensure proper food handling for 1 of 7 random residents observed during lunch meal. The findings include: Review of the facility's undated policy titled, Assistance with Meals, revealed, .employees who provide resident assistance with meals will be trained and shall demonstrate competency in the prevention of foodborne illness, including personal hygiene practices and safe food handling . Observation and interview in the second floor dining area on 7/5/2022 at 11:55 AM, revealed the Social Services Director (SSD) provided set up assistance with lunch meal tray. Continued observation revealed the SSD touched the dinner roll without gloves on while applying butter. Interview revealed the SSD confirmed she did touch the dinner roll without gloves on while applying butter. She confirmed she should not have touched the resident's food without gloves. During an interview on 7/5/2022 at 1:09 PM, the DON stated she expected staff to wear gloves when touching a resident's food. She confirmed staff was required to wear gloves when handling food to prevent the spread of foodborne illnessess.

Based on medical record review and interview, the facility failed to complete a timely Minimum Data Set (MDS) Assessment for 4 (#9, #19, #45, #53) of 7 residents reviewed. The findings include: Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #9's Physicians Orders dated 3/22/19 revealed, .(named) Hospice start of service 3/22/19 .Patient Terminal [DIAGNOSES REDACTED]. Medical record review of Resident #9's Admission MDS dated [DATE] revealed the resident was not receiving hospice care. Medical record review of Resident #9's Significant Change in status MDS revealed the Accelerated Rehabilitative Disposition (ARD) date was 3/27/19 and was captured for Hospice care. Further review revealed the MDS Assessment was electronically signed and completed on 4/16/19, not completed within 14 days of the ARD date (determination period). Medical record review revealed Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #19's Significant Change MDS dated [DATE] revealed the resident had a change in status for mobility and depression from the 5 day MDS dated [DATE] and the 14 day MDS dated [DATE]. Further review revealed the MDS was not completed within 14 days of the determination date. Medical record review revealed Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #45's Physician order [REDACTED].Admit to (named hospice) . Medical record review of Resident #45's Significant Change in status MDS Assessment revealed the ARD date was 7/15/19, seventeen days after Resident #45 was admitted to Hospice care, resulting in a late Assessment. Medical record review revealed Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #53's Significant Change in Status Minimum (MDS) data set [DATE] revealed the resident had a change in status for BIMS and Mood from the Admission MDS dated [DATE]. Further review revealed the MDS Assessment was not completed within 14 days of the determination date. Interview with the MDS Coordinator on 9/17/19 at 6:20 PM in the conference room when asked to look at Resident #45's Physician orders [REDACTED]. I wasn't informed by nursing when the resident went to Hospice care so the Assessment was done late. Interview with the MDS Coordinator on 9/18/19 at 3:20 PM in the conference room confirmed the significant change MDS for Resident's (#9, #19, and #53) were not completed within 14 days of the determination date (ARD).

Based on facility policy review, medical record review and interview, the facility failed to update a care plan for 1 (#53) of 41 residents reviewed. The findings include: Facility policy review, Updating and Revising Care Plans, updated 10/1/16, revealed .Care plans are updated as needed .New problems are handled as they arise, and are to be added to the current care plan even if the change in condition is not considered significant enough for a complete revision . Medical record review revealed Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #53's Fall Care Plan revised on 2/6/19 revealed no bedside commode intervention in place. Continued review revealed the care plan was revised on 2/10/19 to remove bedside toilet from room. Interview with Director of Nursing on 9/18/19 at 8:46 AM in the conference room confirmed Resident # 53's Fall Care Plan dated 2/6/19 was not updated to reflect the intervention for the bedside commode. Further interview confirmed .the bedside commode was not on the care plan but the bed side commode was removed on 2/10/19 .

Based on facility policy review, medical record review, observation and interview, the facility failed to properly store a nebulizer mask to prevent the spread of infection for 1 (#340) of 7 residents who received respiratory services. The findings include: Facility policy review, Specific Medication Administration Procedures, dated 6/2016 revealed, .store in a plastic bag with the resident's name and date on it . Medical record review revealed Resident #340's was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #340's Physician order [REDACTED].[MEDICATION NAME] solution (bronchiodialtor) for nebulization, 2.5 mg (milligram)/3 ml (milliliters) (0.83%) .1 inhalation Every 4 Hours-PRN (as needed). Medical record review of Resident #340's Physician order [REDACTED]. [MEDICATION NAME]-[MEDICATION NAME] solution (bronchiodialtor) for nebulization, 0.5 mg-3 mg (2.5 mg base) 3mL .1 inhalation Every 4 Hours. Observation on 9/16/19 9:35 AM in Resident #340's room revealed the nebulizer mask laying on the bedside table not stored in a bag. Observation and Interview on 9/18/19 at 7:30 AM in Resident #340's room with RN #4 confirmed the nebulizer mask was not stored in a bag. Interview with the Director of Nursing and the Registered Respiratory Therapist on 9/18/19 at 800 AM in the first floor hallway confirmed the nebulizer equipment was to be placed in a bag when not in use.

Based on facility policy review, observation and interview the facility staff failed to use hand sanitizer while delivering lunch trays to 2 rooms (434 and 435) of 10 rooms observed. The findings include: Review of the facility policy, Handwashing dated 6/03, revealed .When to wash hands: i. before passing out trays or handling food . Observation on 9/16/19 at 12:03 PM on the 1st floor revealed Certified Nurse Aide (CNA) #7 left room [ROOM NUMBER] without using hand sanitizer or washing hands after delivering a lunch tray. Continued observation revealed CNA #7 retrieved a tray from the tray cart and went into room [ROOM NUMBER] to deliver a lunch tray without sanitizing or washing her hands. Interview with CNA #7 on 9/16/19 at 12:07 PM on the 1st floor when asked what was the facility policy for handwashing stated .I would wash my hands but I just went in there to set a tray down . Continued interview with CNA #7 stated .you are suppose to wash or use hand sanitizer when coming in and out of the room . Interview with the Director of Nursing on 9/18/19 at 5:16 PM in the conference room stated .if a tray is put in the room by the CNA, they should sanitize before and after. If the patient is touched you do hand washing .

Based on facility policy review, resource article for cleaning agent, observation and interviews, the facility failed to use proper floor cleaning disinfectant solution to destroy [MEDICAL CONDITION] (C Diff) bacterial spores to prevent the spread of infection. The findings include: Facility policy review, Proper Cleaning Procedures, undated, revealed it was not specific to[DIAGNOSES REDACTED] spores. Review of article, Efficacy of cleaning products for[DIAGNOSES REDACTED]icile associated diarrhea in geriatric rehabilitation, Canadian Family Physician, dated (MONTH) 2010, revealed, .Of the agents tested , those containing high levels of chlorine (5000 milligrams/Liter free chlorine) showed consistent efficacy against[DIAGNOSES REDACTED]icile spores . Observation on 9/18/19 at 8:11 AM in room [ROOM NUMBER] revealed Housekeeper #1 cleaning isolation room using disinfectant germicidal spray to clean the floor and shower stall. Observation on 9/18/19 at 8:20 AM in room [ROOM NUMBER] revealed the disinfectant cleaning agent label listed no bleach ingredients. Interview with Housekeeper #1 on 9/18/19 at 8:40 AM in the hallway outside of room [ROOM NUMBER] when asked what solution does she use to clean the floors in[DIAGNOSES REDACTED] isolation rooms, she confirmed she used the disinfectant germicidal spray in all the rooms on the floor. Continued interview when asked specifically if she used a bleach solution for the floors in[DIAGNOSES REDACTED] isolation rooms, she confirmed the disinfectant germicidal spray was used on all rooms and it was her understanding the solution was effective on all bacteria. Interview with Director of Plant Operations (DPO) on 9/18/19 at 9:00 AM in the hallway outside of the laundry room, when asked if he was aware the disinfectant germicidal spray was used on the floor in room [ROOM NUMBER] isolation room for[DIAGNOSES REDACTED], instead of a bleach solution to clean the floors, he confirmed he was not aware the disinfectant germicidal spray used is not effective on[DIAGNOSES REDACTED] spores. Continued interview when questioned about the lack of bleach ingredients, the DPO states he would like to call the supplier of the cleaning solution to find out if this solution is effective on the[DIAGNOSES REDACTED] spores. Interview with the DPO on 9/18/19 at 10:05 AM in the hallway outside of the conference room confirmed the facility was using the wrong disinfectant solution for[DIAGNOSES REDACTED] rooms. Interview with the Administrator on 9/18/19 at 10:55 AM in the conference room confirmed the cleaning solution used on the floor in the[DIAGNOSES REDACTED] isolation room [ROOM NUMBER] was not effective on the[DIAGNOSES REDACTED] spores.

Based on facility policy review, medical record review, observation and interview the facility failed to implement a base line care plan to include respiratory services for 1(#340) of 7 residents reviewed. The findings include: Review of facility policy, Care Plans - Baseline, dated (MONTH) (YEAR) revealed .A baseline plan of care to meet the resident's immediate needs shall be developed with forty-eight (48) hours of admission .The Interdisciplinary Team will review the healthcare practitioner's orders .and implement a baseline care plan .including but not limited to: Initial goals based on admission orders [REDACTED].The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan . Medical record review revealed Resident #340 was admitted to the facility with [DIAGNOSES REDACTED]. Medical record review of Resident #340's Physician order [REDACTED].Oxygen at 3 (liters) L/ (minute) min via nc (nasal cannula) Every shift . Observation on 9/16/19 at 9:35 AM in Resident #340's room revealed he received oxygen at 3 L/min per nc. Observation on 9/18/19 at 7:30 AM in Resident #340's room revealed he received oxygen at 3 L/min per nc. Interview with the Director of Nursing (DON) on 9/17/19 at 4:39 PM in the conference room when asked to look at the base line care plan for Resident #340, the DON confirmed there were no respiratory interventions on the baseline care plan.

Based on facility policy review, observation, interview and medical record review, the facility failed to maintain infection control protocols while passing meal trays by failing to use Personal Protective Equipment (PPE) while entering 1 of 4 rooms with transmission based precautions in effect; and failed to ensure respiratory equipment tubing was changed weekly and dated for 4 of 15 residents (#6, #39, #66, and #76) receiving respiratory treatment. The findings include: Review of facility policy, Infection Control revised 10/1/13 revealed, .The Infection Control Program is an organization-wide program including policies and procedures for the surveillance, prevention and control of infection .The policies and procedures are designed to prevent and contain infections preventing spread from patient-to-patient and from patient-to-employee . Review of the facility policy, Oxygen revised 7/2014 revealed, .Change oxygen tubing every 7 days. Label the tubing with date, nurse's initials .Change humidifier when empty or at least every 7 days with the tubing change .Change nebulizer and tubing every 7 days . Observation on 9/17/18 at 12:02 PM on the 400 hall of the mid day meal pass revealed room [ROOM NUMBER] had a sign outside the room on the door frame indicating to check with the nurse before entering the room. Further observation revealed a 3 drawer table outside the room by the door containing PPE. Continued observation revealed Certified Nurse Aide (CNA) #3 entered room [ROOM NUMBER] with a meal tray, placed it on the over bed table and moved the table closer to the resident. The CNA was not using any PPE. Interview with CNA #3 on 9/17/18 at 12:03 PM in the hall by room [ROOM NUMBER] was asked what type of isolation the resident was on and stated, I'm not sure, but I can find out. CNA #3 asked another staff member who was passing meal trays what type of isolation the resident was on and informed the surveyor it [MEDICAL CONDITIONS] (a very difficult bacteria to cure) in her hip, and then stated, I should have at least put on gloves. Interview with Registered Nurse (RN) #2 on 9/17/18 at 2:25 PM in the conference room was asked what the CNA's were expected to do before entering an isolation room if the cause for transmission based precautions was unknown. RN #2 stated, They should ask the nurse the cause for the isolation, or use full PPE prior to entry into the room. The RN confirmed the facility failed to prevent infection control protocols by failing to use PPE prior to entering an isolation room. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a 14 day Admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 7 indicating severe cognitive impairment. The resident required extensive assistance of 1 person for bed mobility, transfers, and toileting. He received oxygen while a resident in the facility. Medical record review of Physician's Orders dated 8/31/18 for nebulizer treatments every 4 hours as needed for wheezing; 9/10/18 for oxygen at 3 liters per minute by nasal cannula; 9/17/18 oxygen tubing to be changed every week on day shift. Continued review revealed the order was discontinued on 9/18/18. Observation on 9/17/18 at 4:02 PM in Resident #6's room revealed the resident was using oxygen by a nasal cannula. Further observation revealed the tubing was not attached to the oxygen concentrator but was lying on the floor under the bed by the trash can. Further observation revealed the oxygen tubing was dated 9/5/18. CNA #1 entered the resident's room at 4:04 PM, picked the tubing off the floor and attached it to the concentrator which was running at 3 liters per minute. Continued observation with the CNA present confirmed there was a nebulizer on the bedside table with the tubing dated 9/10/18, and another nasal cannula tubing attached to a portable oxygen tank behind the resident's wheelchair that was dated 8/22/18 and was not in a bag. CNA #1 asked the surveyor if the unused tubing was to be stored in a bag and the surveyor asked the CNA what the facility policy stated. The CNA stated, I'll go get a bag. CNA #1 returned at 4:11 PM and placed the tubing dated 8/22/18 attached to the portable oxygen tank in a clear plastic bag. The CNA left the room and returned at 4:15 PM and discarded the bag of tubing dated 8/22/18 and told the resident he was to use the oxygen tubing he was using on the concentrator on the portable tank when he was up in his wheelchair. The resident nodded his head yes in understanding. Interview with the Respiratory Therapist (RT) on 9/18/18 at 9:35 AM in the conference room stated she was in the facility every 2 weeks and changed the nebulizer, [MEDICAL CONDITION] (continuous positive airway pressure machine generally used for sleep apnea) and oxygen tubing at that time and dated it. The RT confirmed tubing used on portable oxygen tank was to be the same tubing used in the room on the concentrator and all tubing and nebulizer equipment should be stored in a bag for sanitary reasons. Further interview with the RT confirmed the oxygen tubing dated 8/22/18 should have been discarded and not used. Further interview confirmed oxygen tubing lying on the floor was to be discarded and not used on the resident. The RT stated the nurses were to date tubing upon admission or when the tubing was changed out for some reason. RT #1 reiterated all oxygen tubing was to be changed every 2 weeks. Interview with Licensed Practical Nurse (LPN) #1 on 9/19/18 at 3:30 PM in the conference room confirmed the order to change oxygen tubing every 7 days was part of an order set that was ordered when a resident had oxygen or nebulizer treatment. When asked why the tubing change order was ordered on [DATE] then discontinued on 9/18/18 she stated, There was some confusion on Monday about having the tubing change order every 7 days, then we were told it was every 2 weeks so I dc'd (discontinued) it the next day. Interview with RN #2 on 9/19/18 at 3:41 PM in the conference room when asked how often oxygen tubing was changed stated, the policy we gave you said every 7 days. When asked about oxygen, nebulizer tubing and mask equipment storage, the RN stated it should be in a bag for and dated. Continued interview when asked who was responsible to change and date oxygen tubing he stated RT. Further interview confirmed he was not aware of the disconnect between RT and nursing staff regarding oxygen and nebulizer tubing changes until brought to his attention by the state surveyors. The RN was asked why the facility wasn't following their policy or protocol for tubing changes every 7 days he stated, We had a failure to communicate our procedures to all parties involved. Medical record review revealed Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician's Telephone Order dated 8/23/18 revealed .Oxygen tubing change .every 7 days . Further review revealed .Oxygen 4 liter per minute inhalation every shift .[MEDICATION NAME] sulfate 2.5 mg (milligram)/3ml (milliliter) Neb solution 1 ampul nebulization every 4 hours as Needed Wheezing Nebulization. Dx: Respiratory Symptoms . Observation on 9/17/18 at 10:20 AM and 3:27 PM in Resident #39's room revealed the humidifier water and nasal cannula were undated. Further observation revealed the nebulizer tubing was not dated and was uncovered on top of the bedside table. Interview with RN #1 on 9/17/18 at 3:27 PM in Resident #39's room stated We put them in bags, and date the tubing. Further interview confirmed This is not dated. Interview with the RT on 9/18/18 at 9:33 AM in the conference room revealed, the equipment was changed out every 2 weeks. Further interview the nebulizer equipment was changed out every 2 weeks. Further interview revealed the nebulizer kit equipment was dated and was in a plastic bag when not in use. Further interview confirmed Everyone should know to date and change tubing. Medical record review revealed Resident #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician's Telephone Orders dated 9/12/18 revealed .Oxygen 2 L (liter) PNC (pre nasal cannula) PRN (as needed) .[MEDICATION NAME] 0.5 mg -3mg (2.5mg base)/3ml Neb Solution ([MEDICATION NAME]/[MEDICATION NAME]) 1 ampul inhalation every 6 hours as needed Wheezing Nebulization. Dx: shortness of breath .Oxygen tubing change .every week on Wednesday Day shift . Observation on 09/17/18 at 10:00 AM and 4:05 PM in Resident 66's room revealed nasal cannula, humidifier water, and nebulizer kit were not dated. Further observation revealed nebulizer equipment on the floor against the wall on the right side of the resident's bed. Interview with RN #1 on 9/17/18 at 4:14 PM in Resident #66's room confirmed the respiratory equipment was not dated, and the nebulizer machine was on the floor. Interview with the RT 9/18/18 at 9:33 AM in the conference room revealed the respiratory equipment was changed out every 2 weeks. Further interview confirmed Everyone should know to date and change tubing. Interview with RN #2 on 9/19/18 at 3:41 PM in the conference when asked if staff was familiar with the facilities policy confirmed the policy says changing the tubing out weekly. Further interview revealed the nebulizer on the floor should not be there. The mask should be in a bag at bedside and dated. RN #2 stated the Respiratory Therapist is responsible, she is here weekly. I don't know why we were not following the policy. Our wires were crossed, she says 14 days and the policy says 7 days. Medical record review revealed Resident #76 was admitted to the facility on [DATE] [DIAGNOSES REDACTED]. Medical record review revealed the Physician Order dated 8/30/18 for .Oxygen at 2L per NC (nasal cannula) every shift .Oxygen tubing change every 7 days . Medical record review of the 5 day Admission MDS dated [DATE] revealed Resident #76 was receiving oxygen while a resident at the facility. Observation on 9/18/18 at 9:11 AM in Resident #76's room, with CNA #2 present, revealed the resident in a wheelchair with a nasal cannula in place and the oxygen concentrator in operation. Further observation revealed the oxygen tubing was dated 9/5/18. Interview with CNA #2 on 9/18/18 at 9:11 AM in Resident #76's room confirmed the oxygen tubing was dated 9/5/18. Interview with the RT on 9/18/18 at 9:15 AM in the hallway outside Resident #76's room revealed the RT checked and changed all residents with facility owned respiratory equipment tubing and water every 2 weeks and facility nursing staff changed the tubing as needed. Interview with RN #2 on 9/19/18 at 3:41 PM in the conference room confirmed the facility policy for changing respiratory equipment tubing and dating the tubing was scheduled weekly. Further interview revealed the RT came to the facility weekly and was to change the respiratory equipment tubing and date the tubing during the weekly visit. Further interview confirmed, after reviewing physician orders, the facility failed to change the tubing weekly as ordered.

Based on the review of the facility policy, medical record review, observation, and interview, the facility failed to follow the care plan interventions for oxygen protocol for 2 of 39 (#39 and #76) resident care plans reviewed. The findings include: Record review of the facility policy, Infection Control Issues revised 7/2014 revealed .1. Change oxygen tubing every 7 days. Label the tubing with date, nurse's initials. 2. Change humidifier when empty or at least every 7 days with tubing change . Medical record review revealed Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician's Telephone Order dated 8/23/18 revealed .Oxygen tubing change . every 7 days . Further review revealed .Oxygen tubing change . every week on Wednesday DAY Shift . Medical record review of the Care Plan dated 9/13/18 revealed . Interventions: Oxygen tubing change per protocol . Observation on 9/17/18 at 10:20 AM and at 3:37 PM in Resident #39's room revealed the humidifier water, and nasal cannula were undated. Further observation revealed the nebulizer tubing was not dated and was uncovered on top of the bedside table. Interview with Registered Nurse (RN) #1 on 9/17/18 at 3:27 PM in Resident #39's room revealed We put them in bags, and date the tubing. Further interview confirmed This is not dated. Interview with RN #2 on 9/19/18 at 3:41 PM in the conference room revealed the facility failed to follow the care plan interventions for oxygen protocol. Further interview confirmed the oxygen protocol should have been followed. Medical record review revealed Resident #76 was admitted to the facility on [DATE] [DIAGNOSES REDACTED]. Medical record review revealed the Physician Order dated 8/30/18 for .Oxygen at 2L (liters) per NC (nasal cannula) every shift .Oxygen tubing change every 7 days . Medical record review of the Care Plan with the onset date 9/1/18 revealed .Respiratory Complications: At risk for related to [MEDICAL CONDITION], Dependence on supplemental oxygen . Further review revealed the approaches included .Oxygen tubing change .every 7 days . Observation on 9/18/18 at 9:11 AM in Resident #76's room, with Certified Nurse Aide (CNA) #2 present, revealed the resident in a wheelchair with a nasal cannula in place and the oxygen concentrator in operation. Further observation revealed the oxygen tubing was dated 9/5/18. Interview with CNA #2 on 9/18/18 at 9:11 AM in Resident #76's room confirmed the oxygen tubing was dated 9/5/18. Interview with RN #2 on 9/19/18 at 3:41 PM in the conference room confirmed the facility policy for changing respiratory equipment tubing and dating the tubing was scheduled on a weekly basis. Further interview revealed the Respiratory Therapist came to the facility weekly and was to change the respiratory equipment tubing and date the tubing during the weekly visit. Further interview, after the care plan was reviewed for Resident #76, confirmed the facility failed to follow the care plan to change and date the oxygen tubing weekly.

Based on review of the Centers for Disease Control (CDC) How to Safely Remove Personal Protective Equipment (PPE) guidelines, review of the facility's CDC HAND HYGIENE WHEN & (and) HOW TO WASH YOUR HANDS employee training tool, policy review, observation and interview, the facility failed to ensure measures to prevent the potential spread of infection were followed when 2 of 2 (400 hall and 500 hall biohazard room) biohazard storage rooms observed had soiled gloves lying on the floor and 1 of 4 (Registered Nurse (RN) #2) nurses observed during medication administration failed to properly perform hand hygiene. The findings included: 1. Review of the CDC's How to Safely Remove Personal Protective Equipment (PPE) guidelines documented, .Discard gloves in a waste container . a. Observations in the 500 Hall biohazard room on 8/1/17 at 8:08 AM, revealed 7 pairs of blue soiled gloves lying on the floor. b. Observations in the 400 Hall biohazard room on 8/1/17 at 8:45 AM and at 1:21 PM, revealed 1 pair of blue soiled gloves lying in the middle of the floor. c. Observations in the 500 Hall biohazard room on 8/1/17 at 1:16 PM, revealed 1 pair of blue soiled gloves lying in the middle of the floor. Interview with RN #3 on 8/1/17 at 8:10 AM, in the 500 Hall biohazard room, RN #3 was asked if soiled gloves should be lying on the floor in the biohazard room. RN #3 stated, No. Interview with the Director of Plant Operations on 8/1/17 at 8:26 AM, in the sitting room on the 500 hall, the Director of Plant Operations was asked if soiled gloves should be lying on the floor in the biohazard room. The Director of Plant Operations stated, Absolutely not .I actually went in that room and picked up a couple of gloves off of the floor myself this morning. Interview with the Director of Nursing (DON) on 8/1/17 at 1:36 PM, in the Administrator's Office, the DON was asked how the staff should dispose of soiled gloves. The DON stated, They should take them off and put them in the trash can . The DON was asked if she would expect to find soiled gloves lying in the floor of the biohazard room. The DON stated, No if they miss the trash can I expect them to pick them up and throw them away. 2. The facility's CDC HAND HYGIENE WHEN & (and) HOW TO WASH YOUR HANDS employee training tool documented, .WET your hands with clean, running water (warm or cold), and apply soap .RINSE your hands well under clean, running water .DRY your hands using a clean towel .Turn off water faucet using clean towel . The facility's INFECTION CONTROL MANUAL .HANDWASHING policy documented, PROCEDURE Wash hands before and after contact with each patient, after toileting, smoking or eating, and before and after removal of gloves. Essential steps in effective handwashing: .Rinse soap off hands with running water .Dry hands with a paper towel .Turn water off with paper towel . Observations during medication administration in Resident #327's room on 8/1/17 at 9:20 AM, revealed RN #2 entered Resident #327's room and placed the ordered medications on the overbed table, stepped into the restroom, washed her hands and turned off the faucet with her wet hands, dried her hands, then returned to Resident #327's bedside, donned gloves, and handed the inhaler to Resident #327. RN #2 then removed her gloves, donned new gloves, asked the resident to blow her nose, then administered the nasal spray. RN #2 took the used tissue with her gloved hands and disposed of it, removed her gloves, donned new gloves, and administered the oral medications. RN #2 then went back into the restroom, washed her hands, and turned off the faucet with her wet hands, dried her hands, and left the room. RN #2 failed to use a clean, dry paper towel to turn the faucet off and failed to perform hand hygiene between glove use. Interview with the DON on 8/1/17 at 5:10 PM, in the Administrator's office, the DON was asked if it was acceptable for a nurse to turn off the water faucet with her wet hands after washing her hands and the DON stated, No.

Based on policy review, observation, and interview, the facility failed to ensure food was served under sanitary conditions by not washing hands in accordance with professional standards by 4 of 6 (Dietary Aide #1, 2, 3, and 4) Dietary Aides observed during three dining observations in the main dining room. The findings included: Review of the facility Safety and Sanitation Best Practices Guidelines policy dated 6/2016 documented correct sanitation procedures would be used in the dining room. Observation on 7/31/17 at 11:00 AM in the main dining room Dietary Aide #1 and #2 provided menus to residents upon arrival to the main dining room, plated the food from the steam table, served the food, handled monetary transactions with visitors and staff, cleared the tables of soiled dishes, utensils, and glasses and returned them to the service area without performing hand hygiene . Observation on 07/31/17 at 11:30 AM in the main dining room , Dietary Aide #1 cut a resident's meat, served food to a staff member, handled monetary transactions and did not perform hand hygiene between tasks. Observation on 7/31/17 at 11:42 AM in the main dining room, Dietary Aide #2 cleared soiled dishes and utensils from the tables, proceeded to the service area, placed the soiled items in a bin, went directly to the kitchen, returned with a to go plate for a visitor, and handled monetary transactions without performing hand hygiene. Observation on 7/31/17 at 11:50 AM in the main dining room, Dietary Aide #2 assisted a resident to attach a sack to her wheelchair, then proceeded to plate and serve food for 1 visitor and 3 staff members and handle monetary transactions without performing hand hygiene. Observation on 7/31/17 at 11:58 AM in the main dining room, Dietary Aide #2 cleared a table of 2 used plates and 2 used glasses, carried the plates in one hand and placed her fingers inside the rim of the soiled drinking glasses and placed them in a bin. Dietary Aide #2 then proceeded to plate and serve food to arriving staff and visitors and handled the monetary transactions without performing hand hygiene. Observation on 8/1/17 at 12:00 PM in the main dining room, Dietary Aide #3 cleared a table, carried the soiled dishes to the service area with bare hands and went directly to the kitchen without performing hand hygiene. Observation on 8/2/17 at 7:39 AM in the main dining room Dietary Aide #4 removed soiled dishes with bare hands, took the dishes back to the service area , placed them in the bin on the floor, and went directly to the kitchen without performing hand hygiene. Observation on 8/2/17 at 7:44 AM, Dietary Aide #4 took the residents' drink order, proceeded to the service area, poured a glass of milk, and delivered the milk to a resident. Observation at 7:49 AM of the service area revealed the tray that Dietary Aide #4 used to pour glass of milk had food debris and a white Styrofoam cup with small amounts of brown liquid inside the cup on the tray. There were also 3 clean glasses on the tray. The bin with soiled dishes, utensils, and glasses was on the floor. Interview with Dietary Aide #4 in the main dining room on 8/2/17 at 8:10 AM, Dietary Aide #4 Dietary Aide #4 stated she was not aware that she did not wash her hands after clearing the tables and then delivered food to residents. Dietary Aide #4 acknowledged that handwashing should be done after assisting a resident, clearing tables, and handling money and that the bin for the soiled dishes should not be on the floor. Dietary Aide #4 stated she was trained on food safety and sanitation procedures when she was hired. Interview with the Dietary Manager (DM) on 8/2/17 at 8:15 AM in the main dining room, the DM stated all dietary aides were expected to wash their hands before serving, handling money, assisting residents, clearing tables or when necessary. The DM acknowledged the dirty dishes were in a bin on the floor this morning. The DM acknowledged the tray used to hold clean glasses and pour milk had food debris and should not have dirty cups on it. The DM stated it was her expectation dietary aides maintain good sanitation practices by handwashing after tasks such as handling soiled dishes, between assisting a resident, and handling money. Interview with the Administrator on 8/2/17 at 10:00 AM in the dining room, the Administrator stated that the DM trains new dietary aides on all kitchen procedures including sanitation, handwashing, and serving food. The Administrator stated his expectation was hand hygiene be performed when necessary to assure good sanitation practices during the meal service.

Based on policy review, medical record review, observation and interview, the facility failed to implement interventions for falls for 1 of 3 (Resident #341) sampled residents reviewed for accident hazards during the stage 2 review. The findings included: Review of the facility's Incident and Accident Process policy documented, .Review the Care plan for any possible updates that might be required related to a change/update . Medical record review revealed Resident #341 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's Fall High Risk-Patient Selection form dated 7/22/17 documented .Falls History - fell in past 30 days . The facility's Post Fall Initial Note dated 7/23/17 documented, .Date and time of incident 07/23/2017, 07:00 AM .pt (patient) found in bed with wound to head stating he lost his balance and fell .received half a dollar size contusion on back of head with lacerations in center . The facility's Manager Post Fall Investigation dated 7/25/17 documented, .Needed Care Plan changes .fall mat at bedside . Review of the interim care plan dated 7/22/17 revealed Resident #341 was at risk for falls and had an intervention for the bed to be in the lowest position and locked. The care plan was updated on 7/23/17 with the additional intervention to place fall mats at bedside. Observations in Resident #341's room on 7/31/17 at 3:23 PM, and on 8/1/17 at 7:46 AM, revealed Resident #341 lying in his bed with no fall mats at the bedside. Observations in Resident #341's room on 8/1/17 at 3:17 PM, revealed Resident #341 lying in his bed, the bed was locked in the elevated position, and no fall mats were at the bedside. Interview with Registered Nurse (RN) #4 on 8/1/17 at 3:23 PM in Resident #341's room, RN #4 confirmed the bed was not in the lowest position and there were no fall mats in use. Interview with the Director of Nursing (DON) on 8/1/17 at 3:37 PM, in the front lobby, the DON was asked if she expected fall prevention interventions to be followed. The DON stated, Yes ma'am.

Based on policy review, observation, and interview, the facility failed to ensure accurate labeling of medication bottles and safe disposal of medications including expired medications and those of discharged residents in 2 of 6 ( E Medication Cart and 2nd Floor Medication Storage Room)medication storage areas and 1 of 4 (Registered Nurse (RN) #2) nurses observed during medication administration that left medications unattended . The findings included: 1. Review of the facility Medication Storage in the Facility policy dated 06/2016 documented, .Medications and biologicals are stored safely, securely, and properly .The medication supply is accessible only to licensed nursing personnel . The procedure for outdated medication or discontinued medication documented they should be removed immediately from inventory and disposed of according to the facility's policy for disposal. 2. Observation during medication administration in Resident #327's room on 8/1/17 at 9:20 AM, revealed RN #2 entered the room, placed the nasal spray, inhaler, and prepared oral medications on Resident #327's overbed table, then walked into the restroom, leaving the medications unattended, in reach of the resident, and out of her line of vision while she washed her hands. Interview with RN #2 on 8/1/17 at 9:35 AM, RN #2 was asked if it was appropriate to leave medications unattended and out of her line of vision at the patient's bedside while she washed her hands. RN #2 stated, No .I should have taken the meds with me . Interview with the Director of Nursing (DON) on 8/1/17 at 5:10 PM, in the Administrator's office, the DON was asked if it was acceptable for a nurse to leave medications unattended at the bedside. The DON stated, .we don't leave her meds (medications) at bedside . 3. Observation of the E Medication Cart on 8/1/17 at 4:00 PM, one bottle of Fluticasone nasal spray that had an open date of 1/14/17. The attached preprinted pharmacy label revealed the Fluticasone was to be used daily until the stop date of 1/25/17. The medication was ordered for a total of 14 days and remained on the E Hall medication cart. Interview with RN #2 on 8/1/17 at 4:07 PM in the hallway, RN #2 acknowledged the medication was expired, the resident was no longer on the medication, and it should have been removed from the medication cart and sent back to pharmacy. RN #2 further stated nurses are responsible to check the medication carts for discontinued and expired medications. Interview with the Assistant Director of Clinical Services (ADCS) on 8/2/17 at 11:15 AM in the ADCS office, the ADCS acknowledged the Fluticasone had been discontinued on 1/25/17 and it was her expectation the medication be removed from the medication cart at the time the medication was discontinued and returned to the pharmacy immediately by placing in the pharmacy return bin located in the medication storage room. Observations on 8/1/17 at 4:30 PM with RN #2 in the medication storage room on the second floor revealed one bottle of unopened Systane Ultra eye drops with a preprinted pharmacy label that indicated the medication expired on 05/2017. Interview with RN #2 at the time of the observation revealed the resident had been discharged from the facility. There was a bottle of a Pennsaid 2% that did not have a label on the bottle to indicate for whom the medication was prescribed. Interview at the time of the observations in the medication storage room, RN #2 acknowledged that the Systane Ultra eye drops was expired and the other medication was for a resident who had been discharged from the facility. She stated the medications should have been returned to the pharmacy immediately after the medication expired and immediately after a resident was discharged from the facility. Interview with the Assistant Director of Clinical Services in her office on 8/2/17 at 11:15 AM, she acknowledged the expired medication and the medications from discharged residents should not be placed on a shelf in the medication storage room. She indicated it was her expectation that discontinued or expired medications be placed in the pharmacy return bin in the medication storage room.