Every finding on record at Orange Park Rehabilitation and Nursing Center

Based on a staff interview, record review, and a review of the facility's policies and procedures, the facility failed to update a resident's Pre-Admission Screening and Resident Review (PASRR) to include the resident's mental illness diagnosis for one (Resident #11) of two residents reviewed for PASRR completion from a total survey sample of 31 residents. The findings include: A review of the medical record revealed that Resident #11 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder - bipolar type and unspecified mood [affective] disorder. On 5/13/2025 at 11:09 AM, further review of the record revealed a PASRR completed on 7/11/2020 that did not document the resident's mental illness diagnoses of schizoaffective disorder - bipolar type, or unspecified mood [affective] disorder. A review of the resident's Annual minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/4/2024, revealed that the resident was diagnosed with epilepsy or seizure disorder, schizophrenia, multiple sclerosis, and unspecified mood [affective] disorder. Section N of the MDS indicated that the resident received antipsychotic and anticonvulsant medications during the 7-day assessment period. Further review of the record revealed that Resident #11 had active physician's orders for the following: Divalproex Sodium Oral Tablet Delayed Release 500 mg (milligrams), Give 1 tablet by mouth every morning and at bedtime for mood disorder (4/28/2023) Divalproex Sodium Oral Tablet Delayed Release 250 mg, Give 1 tablet by mouth at bedtime for mood disorder. Give with 500 mg dose for total dose of 750 mg (10/4/24) Risperdal Oral Tablet 2 mg, Give 2 mg by mouth one time a day for schizoaffective disorder, and give 4 mg by mouth at bedtime for schizoaffective disorder (2/25/25). Observe closely for side effects of antipsychotic medication including dry mouth, constipation, blurred vision, disorientation or confusion, difficulty urinating, hypotension, dark urine, yellow skin, nausea or vomiting, lethargy, drooling, extrapyramidal symptoms (tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or tongue) every shift (9/6/23) Observe closely for significant side effects of sedative/hypnotic medication including burning or tingling in hands or feet, changes in appetite, constipation, diarrhea, dizziness, drowsiness, dry mouth or throat, headache, stomach complaints, tremors, weakness every shift (9/6/2023) Psychiatric consult as needed (10/16/23) Observe closely for significant side effects of anti-depressant medication including drowsiness, blurred vision, dizziness, nausea, fatigue, trouble sleeping, dry mouth, hallucinations, other unusual changes in mood or behavior every shift (2/27/2025) Monitor for the following behaviors: yelling, mood changes, sleeplessness, hallucinations, delirium every shift (3/6/2025) A review of the resident's active care plan revealed the following focus area: [Resident #11] receives antipsychotic medication related to diagnosis of schizoaffective disorder - bipolar type and psychosis (created 4/19/23, revised 5/13/24). Goals/Interventions in place. A review of the Psychiatric Evaluation progress note with date of service 10/6/23 revealed that the diagnoses of bipolar disorder, current episode mixed, severe, with psychotic features; generalized anxiety and insomnia. The note also documented instructions to Please update diagnoses accordingly. On 5/15/2025 at 12:38 PM, an interview was conducted with the Business Office Manager (BOM) who stated she had been in her current position for 6 to 7 months. Further, she had been employed by the facility for seven years. She stated she was responsible for ensuring PASRRs were current and in each resident's EMR. When asked how she would determine whether or not a PASRR was accurate, she replied, I would look at the diagnoses and make sure it (the PASRR) is filled out properly. If it was not filled out properly, she stated she would correct it. If a PASRR indicated that a level II screening was needed, she would verify the information was correct, gather any further information needed, and submit that to the State Mental Health/Intellectual Disability Authority's website. A review of the facility's policy titled Coordination-Pre-Admission Screening and Resident Review (PASRR) Program (effective date: 1/14/2025), revealed: It is the policy of the facility to assure that all residents admitted to the facility receive a Pre-Admission Screening and Resident Review, in accordance with State and Federal Regulations. Procedure: 3. Coordination includes a preadmission screening for individuals with a mental disorder and individuals with an intellectual disability. 5. A nursing facility must notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in mental or physical condition of a resident who has mental illness or intellectual disability for resident review.

Based on staff interviews, record review, and a review of the facility's policies and procedures, the facility failed to provide one (Resident #25) of two residents reviewed for Preadmission Screening and Resident Review (PASRR) who had diagnoses indicating a serious mental illness (SMI) on admission, with a Level II PASRR screening. The findings include: A review of Resident #25's electronic medical record (EMR) revealed that the resident was admitted to the facility on [DATE] with a completed PASRR Level I dated 10/18/2024, which was located in the miscellaneous section of the EMR. The 10/18/2024 Level I PASRR indicated the need for a Level II screening to be conducted. No Level II screening was found in the record. The 3008 Hospital Transfer Form dated 10/31/2024 noted a primary diagnosis of schizoaffective disorder. Other diagnoses found in the resident's record included cerebral palsy, schizoaffective disorder - depressive type; major depressive disorder - recurrent/severe with psychotic symptoms; post-traumatic stress disorder (PTSD), and persistent mood disorder. (Photographic evidence obtained) On 5/14/2025 at 3:40 PM, evidence of a completed level II PASRR for Resident #25 was requested of both the Administrator and the Director of Nursing (DON). They stated they would look for it. On 5/15/2025 at 8:50 AM, the Administrator was asked whether she had found the Level II PASRR screening for Resident #25. She stated it had not been found. She further stated a Level II screening was being conducted this morning. On 5/15/2025 at 12:38 PM, an interview was conducted with the Business Office Manager (BOM) who stated she had been in her current position for 6 to 7 months. Further, she had been employed by the facility for seven years. She stated she was responsible for ensuring PASRRs were current and in each resident's EMR. When asked how she would determine whether or not a PASRR was accurate, she replied, I would look at the diagnoses and make sure it (the PASRR) is filled out properly. If it was not filled out properly, she stated she would correct it. If a PASRR indicated that a level II screening was needed, she would verify the information was correct, gather any further information needed, and submit that to the State Mental Health/Intellectual Disability Authority's website. When asked about the PASRR that was included in Resident #25's records sent from the hospital and dated 10/18/2024, she stated she did not look at the admission paperwork since the resident had been in this facility before. She further stated she did not know there was a new PASRR and that a Level II needed to be completed.

Based on record review, a staff interview, and a review of the facility's policies and procedures, the facility failed to develop a comprehensive care plan to address anticoagulant therapy for one (Resident #65) of 25 residents whose care plans were reviewed, from total survey sample of 31 residents. The findings include: A review of the medical record revealed that Resident #65 was admitted to the facility on [DATE] with diagnoses including COPD (chronic obstructive pulmonary disease), traumatic amputation of the left great toe, PVD (peripheral vascular disease), bipolar disorder, major depressive disorder, partial traumatic amputation of the left 5th toe, chronic pain syndrome, and unspecified heart failure. A review of the Admission MDS (minimum date set) assessment with an ARD (assessment reference date) of 4/18/25 revealed that the resident had a BIMS (brief interview for mental status) score of 15 out of 15 possible points, indicating intact cognition. Section N of the assessment indicated the resident received anticoagulant medication during the 7-day assessment period. On 5/12/25, a review of Resident #65's active Care Plan revealed there was no care plan/focus area for his current anticoagulant therapy. A review of the resident's active physician's orders revealed he was receiving Apixaban 5 mg (milligrams) by mouth BID (twice daily) for Atrial fibrillation with an order date of 4/12/25. A review of the May 2025 MAR/TAR (medication administration record/treatment administration record) revealed no monitoring was documented for anticoagulant therapy side effects or adverse reactions. On 5/15/25 at 4:30 PM, an interview was conducted with LPN (Licensed Practical Nurse/MDS (minimum data set) Coordinator A. When she was asked who was responsible for updating resident care plans, she replied, We both are, me and the other coordinator. The nurses also update them sometimes, but we'd rather do it ourselves. When she was asked about the process for updating care plans, she replied, I do all the Medicare Part A resident care plans and all long-term residents. The other coordinator does the managed care residents and she assists me as needed. LPN A was asked to explain the facility's process for updating the care plans. She stated, We run the orders in the morning and go through and update the care plans with the new orders. I also do updates quarterly when I complete the MDS that's due, and whatever information is shared by the clinical team, we also update that into the care plans. We attend the behavior meetings that are held once a week and we get updates, and we update new information during the actual care plan meetings. That's another opportunity to update the care plan. LPN A was asked to access the resident's care plan in the electronic medical record and provide evidence of the care plan for anticoagulant use. She confirmed that the care plan was updated to reflect anticoagulant therapy indicated for PVD on 5/12/25, and that prior to this date there had been no care plan for anticoagulant therapy. A review of the facility's policy and procedure titled Coumadin-Warfarin-Other Anticoagulant Management (dated April 2022), revealed: 3. Nursing will observe residents receiving Coumadin/Warfarin/Other Anticoagulants Therapy for adverse affects, signs and symptoms of bruising or bleeding throughout the course of the therapy. 4. Per observation, the resident's individualized care plan will be modified/adjusted as needed. 5. Nursing will report symptoms or changes of condition to the prescribing physician. 7. Nursing will consult with the pharmacist with questions and for clinical guidance related to drug interactions with current or new medications as indicated. A review of the facility's policy and procedure titled Care Plan-Comprehensive (dated January 2023), revealed: A Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs shall be developed for each resident. 2. The Comprehensive Care Plan has been designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems; d. Reflect treatment goals and objectives in measurable outcomes; h. Ensure the care plan is individualized and person-centered and reflects the resident's goals for admission and desired outcomes. .

Based on observations, interviews, record review, and facility policy and procedure review, the facility failed to provide a consistent, viable means of communicating in a language that the resident understood for one (Resident #42) of 31 sampled residents. Failure to provide interpretation during care may result in the resident's needs not being recognized or met. The findings include: During a tour of the facility on 5/13/2025 at 11:48 AM, Certified Nursing Assistant (CNA) L stated Resident #42 did not speak English. He spoke an African language. She was not sure which one; she had never heard of the language before. She did not know what country he was from. CNA L stated the resident had learned to say yes and no or shake/nod his head when asked questions. When he spoke, she did not understand him because he spoke in his native language. During an observation of Resident #42's room on 5/13/2025 at 11:49 AM , no communication board was observed. No interpreter services contact information was posted in the room. No information about an interpreter was posted. The room was dark, the resident was lying in bed and his head was covered with a blanket. During an interview with Licensed Practical Nurse (LPN) M on 5/13/2025 at 11:52 AM, she stated she was the assigned nurse for Resident #42 today. She stated she used simple gestures and words to speak and communicate with him. He understood a few English words. During an interview with Unit Manager J on 5/13/2025 at 12:00 PM, she stated the resident had a friend that spoke his language. They called his friend when they needed an interpreter. She was not sure which language the resident spoke. An interview with Resident #42 was attempted on 5/14/2025 at 10:12 AM. There was no communication board in his room. No interpreter services contact information was posted in the room. He did not appear to understand the questions asked of him in English. His friend's number was posted on the wall today; it was not posted there yesterday at 11:49 AM when the resident was visited. Resident #42 pointed at the piece of paper and spoke in his native language, Amharic (official language of Ethiopia). During an interview with LPN H on 5/14/2025 at 10:15 AM, she stated she was the assigned nurse for Resident #42 today. She stated she used simple gestures and words to speak and communicate with Resident #42. She did not think he understood English except for a few words. She was asked if the facility had an interpreter phone line they could use for an interpreter during an emergency with Resident #42. She looked through a large binder on her nursing cart twice and stated, Yes, we have one. I don't see it in here. I thought we had one. She left the cart and went to the Unit Manager to ask her. The Unit Manager was overheard telling LPN H that she thought the number was in the binder. LPN H told the Unit Manager she could not find it. The Unit Manager looked in the nurses' station. During an interview with Unit Manager J, LPN on 5/14/2025 at 10:15 AM, she was asked if there was a contracted interpreter for the facility in case of emergencies and in case Resident #42's friend could not be reached. She stated she believed there was a contracted interpreter service the facility used, but she could not remember where the information was located. She stated she would find out and she left the interview. She was observed walking to the other nursing unit. At 10:35 AM, LPN J returned and provided a sign on facility letter head that read: Securing Use of Language Line Services. The form had a phone number to use to access an interpreter. (Copy obtained) LPN J stated she was going to hang one of these signs in the resident's room and she went to his room. During an interview with Resident #42 on 5/14/2025 at 1:40 PM via the interpreter line, he stated the facility staff did not understand him when he talked to them. They did not use an interpreter. They sometimes called his friend. He stated he understood some of what the staff said to him, but not much. During a telephone interview with the Psychiatric Advanced Practice Registered Nurse (APRN) for Resident #42 on 5/14/2025 at 2:11 PM, she stated she used the interpreter line when she saw him because she did not understand his language. She had the phone number in her cell phone. She stated she thought Amharic was a fairly rare language here in the U.S. She usually took a long time to assess him. She stated she thought the information she got was reliable, however, Some of the information gets lost in translation. On 5/14/2025 at 2:12 PM, an observation of Activities of Daily Living (ADL) care for Resident #42 was made. CNA I and LPN H proceeded to change his brief, clean him and change his sheets. They did not attempt to speak to the resident. Resident #42 did not attempt to speak with the staff. When they were finished, LPN H asked Resident #42 to drink a liquid supplement that was on the nightstand in a cup with a straw. The resident spoke in his native language and LPN H did not appear to understand him; she did not respond to him. She kept putting the cup in front of him telling him to drink it. He kept responding in his native language. After some time, he took the cup and drank the supplement. He spilled it on his gown. After he finished drinking it, he spoke again in his native language. LPN H and CNA I proceeded to change his gown and bed linens. The resident spoke in his native language during this process. Neither LPN H nor CNA I responded to him. When asked if they understood what the resident was saying to them, they both stated they did not understand what he is saying. LPN H stated, We just have to guess. CNA I stated he could say some words in English so she could understand him at times. LPN H stated Resident #42 could tell her if he had a headache or if his stomach hurt. He points to his head or stomach. She did not conduct pain assessments with him because he did not appear to be in pain. LPN H and CNA I made no further attempts to communicate with the resident and left the room. During an interview with Resident #42's emergency contact and friend on 5/15/2025 at 3:55 PM, he stated he did not think Resident #42 understood the staff and the staff did not understand him. That's why they called him to interpret. He stated he had some health problems himself, and had not been able to come to visit Resident #42 in person for approximately eight months now, but Resident #42 called him on the phone often. Resident #42's friend stated the reason Resident #42 refused to take his medication was because he did not trust the staff. He was paranoid and thought they wanted to harm him. He stated he thought Resident #42 had some cognitive issues, but for the most part, he could make his needs known in his language and his memory was intact. He did not know if Resident #42 participated in any activities at the facility. During an interview with the Activities Director on 5/15/2025 at 3:37 PM, he stated the facility provided in-room activities for Resident #42. They provided him with games and an I-Pad device that he could use for games. The games were in English. Nothing was offered to Resident #42 in his native language. He liked to listen to music on his cell phone and preferred to stay in his room. A review of the resident's medical record revealed on the face sheet that he was admitted on [DATE]. His diagnoses included dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, type 2 diabetes mellitus with diabetic polyneuropathy, peripheral vascular disease, dysphagia, major depressive disorder, chronic heart failure, atherosclerotic heart disease, absence of left leg below knee, adult failure to thrive, and hypertension. (Copy obtained) A review of the Significant Change Minimum Data Set (MDS) assessment, dated 4/1/2025, revealed that the resident's primary language was Amharic. The question Do you need or want an interpreter to communicate with a doctor or health care staff? was answered yes. The resident's hearing was documented as adequate, speech was clear, he understood and was understood by others, and his vision was adequate. His Brief Interview for Mental Status (BIMS) score was 10 out of a possible 15 points, indicating moderate cognitive impairment. He had no behaviors toward himself or others. (Copy obtained) A review of Resident #42's active Care Plan, dated 4/11/2025, revealed a focus area that read: Spends most of time alone/Potential for altered activity pattern, likes staying to himself due to language barrier. Another focus area read: At risk for impaired communication/memory deficit as evidenced by Speech problem - speaks little English, speaks Oroma/Amharic; Language line [phone number]. Contact on face sheet is an interpreter. Another focus area read: [Resident #42] has impaired cognitive function/dementia or impaired thought processes related to dementia. Interventions: Ask yes/no questions in order to determine the resident's needs. Interventions included: Communcation: Use the resident's preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions - turn off TV, radio, close door etc. The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues - stop and return if agitated. (Copy obtained) A review of the nursing progress note dated 3/30/2024 read: Refused to eat, stated he was not hungry, was upset when encouraged to eat, food left at bedside with resident not touching his food. He was talking in his own dialect and upset at this writer when told he needed to speak English. He denies that he was hurting. He was covering his head. LPN H signed this nursing progress note. (Copy obtained) A review of the nursing progress note dated 4/29/2025 read: Call placed to resident's friend in attempt to have friend talk to resident about his diet intake and to inquire about any particular food preferences, friend able to communicate in resident's language. No answer to multiple calls and friend's mailbox full. LPN M signed this nursing progress note. (Copy obtained) Nursing notes reviewed from 3/4/2024 through 5/15/2025 revealed no indication that the nursing staff was using an interpreter to assess/communicate with the resident. (Copies obtained) A review of the facility's policy and procedure titled Communication Training revealed: Intent: It is the policy of the facility to provide a Staff Education Plan in accordance with State and Federal regulations. Procedure: The facility will include effective communications as mandatory training for direct care staff. (Copy obtained) A review of the facility's staff training documents used for Cultural Diversity Training revealed: Culturally competent care improves communication, increases trust, improves treatment efficacy, expands understanding of behaviors, decreases stress, facilitates clinical encounters for more favorable outcomes, increases interpersonal experiences, increases resident satisfaction, and improves health outcomes and quality of care. (Copy obtained). A review of the facility's policy and procedure titled Translation Services (dated 12/2024) read: When needed, the facility can utilize various translation services in order to communicate with a resident who is unable to understand English. 1. Staff may utilize Google Translation by going into Google and type in Google Translate and select the resident's native language. Staff or the resident can speak into the application and it will talk back. 2. Staff may utilize translation applications on their phone. 3. A representative of the resident, family member or employee may translate as needed. 4. Speech Therapy can work with the resident and create a communication board when needed. (Copy obtained) A review of the facility's form titled Securing Use of Language Line Services (dated 10/2016) revealed instructions, a telephone number, and an access code for accessing an interpreter 24 hours a day, 7 days a week.

Based on kitchen food service observations, staff interviews, facility record review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, by failing to record dish machine temperatures, and by failing to seal and date mark open bundles of bread on the bread rack. Food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: A tour of the kitchen was conducted on 5/12/25 at 11:00 AM. During the tour, the dish machine temperature log for April 2025 was reviewed and was incomplete. Temperatures were not recorded for breakfast or lunch on 4/25/25 or 4/26/25. Temperatures were not recorded for breakfast, lunch or dinner from 4/27/25 through 4/30/25. (Photographic evidence obtained) No date markings were observed on one open package of noodles or five open bundles of bread located on the bread rack in the dry storage room. Another observation of the kitchen was made on 5/14/25 at 10:55 AM. During this time, new observations were made of eight open bundles of bread on the bread rack in the dry storage room with no date markings. (Photographic evidence obtained) During an interview with Dietary Aide B on 5/15/25 at 1:30 PM, Dietary Aide B reported they were responsible for recording the dish machine temperatures, and temperatures were documented after each meal. Dietary Aide B stated a new dish machine was installed about three months ago, but there was never a period when the facility was without a dish machine. When asked what happened when bread was opened, used, and placed back on the bread rack, Dietary Aide B replied that the bread was sealed and dated. During an interview with [NAME] C on 5/15/25 at 1:37 PM, she reported that the Dietary Aides were responsible for recording the dish machine temperatures after every use. [NAME] C stated the dish machine had been down in the last month due to switching from a high-temperature machine to a low-temperature machine, and during that time, the three-compartment sink was utilized for dish washing. [NAME] C further reported that when bread was opened, used, and placed back on the bread rack, it was wrapped, labeled, and dated. During an interview with the Certified Dietary Manager (CDM) on 5/15/25 at 1:50 PM, he confirmed that the Dietary Aides were responsible for recording the dish machine temperatures. The CDM stated he reviewed the temperature log daily to ensure it was completed. He also confirmed that there was no time during the last month when the dish machine was down. Last month the facility switched from a high-temperature machine to a low-temperature machine, but the dish machine was not down. The CDM was asked to retrieve the temperature logbook. On 5/15/25 at 2:05 PM, the CDM provided the temperature logbook. A second observation of the dish temperature log for April 2025 revealed temperatures for breakfast and lunch on 4/25/25 and 4/26/25, and temperatures for breakfast, lunch and dinner from 4/27/25 through 4/30/25 were now complete. When asked to explain the facility policy related to date marking food. The CDM confirmed that everything coming in needed to be dated and rotated using the First In First Out (FIFO) method. He also confirmed that when bread was opened, used, and placed back on the bread rack, the bread was dated. (Photographic evidence of the April 2025 dish machine temerpature logs was obtained again on this date.) A review of the R&K Services, LLC, Hospitality Alliance document (undated), revealed: 2. Marking dates after opening or preparation: after opening or preparing food, mark the date or day on which the food needs to be served, sold, or discarded. If you plan to hold the food for longer than 24 hours, it's essential to keep track of when it was opened or prepared. (Copy obtained) A review of the R&K Services, LLC, Dish Machine Temperature Log policy (undated), revealed: Dishwashing staff will monitor and record dish machine temperatures to assure proper sanitizing of dishes. Procedure: 1. The food service manager will provide the dishwashing staff with a log to be posted near the dish machine. 2. The food service manager will train dishwashing staff to monitor dish machine temperatures throughout the dishwashing process. 3. Staff will be trained to record dish machine temperatures for the wash and rinse cycles at each meal. 4. The food service manager will spot check this log to assure temperatures are appropriate and staff is actually monitoring dish machine temperatures.

Based on observation, record review, and staff interview, the facility failed to provide respiratory care consistent with professional standards of practice for one (Resident #2) of 11 sampled residents who were receiving oxygen therapy, from a total sample of 28 residents. Resident #2's oxygen flow rate was set higher than the physician ordered. The findings include: On 06/26/2023 at 12:02 PM, Resident #2 was observed lying in bed at an elevated position wearing a nasal cannula (device used to provide supplemental oxygen). Resident #2 reported her oxygen should have been set to run at 2 liters per minute (L/min). Resident #2's oxygen concentrator was observed to be set on 3 L/min. (Photographic evidence obtained) A review of Resident #2's physician's order dated 05/20/2023, revealed that she should have been receiving oxygen at 2 L/min via nasal cannula as needed. (Photographic evidence obtained) On 06/27/2023 at 11:12 AM, another observation was made of Resident #2, who was sleeping in bed with her nasal cannula on and her oxygen concentrator set at 2.5 L/min. (Photographic evidence obtained) A medical record review for Resident #2 revealed that she was admitted to the facility from an acute care hospital on 5/19/2023. Her admitting diagnoses included Chronic Obstructive Pulmonary Disease (COPD), unspecified dementia, liver transplant, paraplegia, and major depressive disorder. The Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 05/25/2023, revealed that the resident scored 09 out of 15 possible points on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. She required extensive staff assistance to complete Activities of Daily Living (ADL) and she was receiving oxygen therapy. A review of the resident's comprehensive care plan, dated 06/01/2023, revealed she had a focus area for Emphysema/COPD with the goal to display optimal breathing patterns daily through the next review date. Interventions included oxygen settings per the physician's orders. (Photographic evidence obtained) During a 06/28/2023 interview with Registered Nurse (RN) A (assigned to Resident #2) at 12:20 PM, she confirmed the correct oxygen settings through the physician's orders. She stated the resident's oxygen flow rate setting should be 2 L/min as needed. RN A went to the resident's room and was asked to read the resident's current oxygen flow rate setting. RN A confirmed that the current setting was 2.5 - 3 L/min. She further stated the nursing staff checked oxygen settings every shift, and if the oxygen wasn't running at the accurate flow rate per the physician's order, they would make the adjustment accordingly. (Photographic evidence obtained) A review of the facility's policy and procedure for Administration of Drugs (dated April 2022), revealed under policy implementation: Drugs must be administered in accordance with the written orders of the attending physician. (Photographic evidence obtained) . 48201

Based on observations, interviews and record review, the facility failed to ensure one of three sampled resident rooms (Room 125), was maintained in a safe, sanitary, and comfortable environment, as evidenced by a water leak from the ceiling and blackened ceiling tiles. The findings include: On 9/8/2022 at 9:55 AM, an observation of room 125, occupied by Resident #1 was conducted. The overhead florescent light fixture had water inside the lense, and water was dripping from ceiling onto the floor and into waste basket next to Resident #1's bed. Water stains were visible on mattress cover of unoccupied bed. Three (3) ceiling tiles were observed with black substance present. (Photographic evidence obtained) On 9/8/2022 at 10:00 AM, an interview was conducted with Resident #1 in room 125. She stated, she reported the ceiling issues a couple of months ago and was told they would look for another room for her. She could not recall when the maintenance guy came in and looked at the room but confirmed nothing had been done to fix the issue. A record review of the facility's maintenance logs for June, July, August, and September 2022 revealed four maintenance requests related to Room 125. 1. June 13, 2022, overhead light leaking water onto resident's bed. Moved patient into 119A temporarily 2. July 3, 2022, light over bed leaking water onto bed - Documented in mold report we know 3. July 3, 2022, water leaking from ceiling 4. July 5, 2022, roof leaking - John knows (Photographic evidence obtained) An interview was conducted with the Maintenance Director on 9/8/2022 at 12:45 PM. He stated maintenance requests are currently reported on paper logs at nurse's station. He explained, they try to resolve work orders within 48 hours. He was asked if there were any leaks in the building. He stated, No, but we do have a moisture issue. When asked about room 125, he stated that there had been a moisture issue and that the light had been cleaned out and condensation was removed a couple weeks ago and that he was not aware that there were still moisture issues in that room. On 9/8/2022 at 12:50 PM, a second observation of Room 125 was conducted with the maintenance director present. Upon observing the room, he acknowledged the active leak, water in the light, and appearance of back substance on ceiling tiles. He stated that the room should be closed for repairs. During an interview with Administrator on 9/8/2022 on 1:50 PM, she stated, she was not aware Room 125 had any leaks or drips from the ceiling. An interview was conducted with Licensed Practical Nurse (LPN) A on 9/8/2022 at 2:00 PM. She reported that Resident #1 told her about a month ago the roof was leaking in her room. The resident was then moved to the other bed in same room. LPN A confirmed that she recorded the issue in maintenance book. When asked if she knew if issue had been resolved, she stated I don't know.

Based on observation, interviews, record review and policy and procedure review, the facility failed to ensure that two (Resident #228 and #229) of three residents on oxygen therapy, received the correct number of liters of oxygen ordered by the physician and failed to ensure one (Resident #17) of one resident reviewed for tracheostomies, received [CONDITION(S)] care as ordered by the physician, from a total sample of 34 residents. This could result in the resident not receiving appropriate care and/or clinical complications. The findings include: 1. A review of Resident #228's medical record revealed an admitted [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician's orders revealed, oxygen at 2-3L/min continuous via nasal cannula. The baseline care plan did not indicate oxygen therapy. On 10/05/21 at 11:40 AM, Resident #228 was observed lying in bed in supine position with oxygen via nasal cannula. An observation of her oxygen concentrator revealed an oxygen rate of 5 Liters/minutes (L/min). (Photographic evidence obtained) On 10/06/21 at 12:06 PM, Resident #228's oxygen concentrator was observed at 3.5 L/min. On 10/06/21 at 1:45 PM, Resident #228's oxygen concentrator was observed at 5 L/min. (Photographic evidence obtained) An interview was conducted with Employee A, Licensed Practical Nurse (LPN) on 10/06/21 at 1:46 PM. She stated that she had adjusted Resident #228's oxygen to 5 L/min since her oxygen saturation had dropped to 88%. When asked about the oxygen orders, she stated the resident had orders for 2-3 L/min, but also had orders to administered oxygen at 5 L/min if saturation was below 90%. When she was asked to provide a copy of the orders for 5 L/min of oxygen, she rechecked the orders and confirmed the resident did not have orders for 5 L/min. During an interview with the Director of Nursing (DON) on 10/06/21 at 2:00 PM, she confirmed that the nurse should not increase the dosage of oxygen without orders and said she instructed Employee A, LPN to contact the physician regarding Resident #228. 2. A review of Resident #229's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician's orders revealed, oxygen at 3L/min continuous via nasal cannula, oxygen saturation every shift, change tubing every week on Sundays, [MEDICATION(S)] 2 puffs once a day, [CONDITION(S)] - [CONDITION(S)] at 3L/min, head of bed elevated to alleviate shortness of breath. (Copy obtained) A review of Resident #229's 5-day minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status score of 14, indicating cognitively intact. The resident required extensive assistant with bed mobility, toileting, and transfer. The resident's care plan indicated she was at risk for cardiovascular complication, respiratory and diabetes. Interventions included to observe for shortness of breath, changes in sputum and report to physician and administer medication as ordered. (Copy obtained) On 10/05/21 at 11:47 AM, Resident #229 was observed in her room receiving oxygen via nasal cannula at 4 L/min. A Continuous Positive Air Pressure ([CONDITION(S)]) machine was located sitting on the resident's bedside table. (Photographic evidence obtained) An interview was conducted with Resident #229 on 10/05/21 at 11:48 AM concerning how much oxygen she was supposed to receive. She stated, My oxygen should be on 3 L/min. The resident added that she used the [CONDITION(S)] machine at night and the nurses help with the set up. When asked about the care of the [CONDITION(S)], she stated she was not sure who was supposed to do it. A review the October 2021 treatment administration record (TAR) for Resident #229 revealed the oxygen cannula was not changed on 10/03/21, and there was no documentation for [CONDITION(S)] care. During an interview with Employee A, LPN on 10/06/21 at 1:48 PM, she confirmed that Resident 229 oxygen was supposed to be on 3L/min and added that the resident used the [CONDITION(S)] at night. She was not sure who was supposed to take care of the [CONDITION(S)]. When asked about the oxygen cannula being changed. She stated it should be changed on Sunday, but she was not sure if it was changed as she does not work on the weekends. 3. A review of Resident #17's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician's orders revealed, [MEDICATION(S)] 0.125mg three times a day for secretion, oxygen via [CONDITION(S)] at 2 L/min, [CONDITION(S)] suctioning every shift and [CONDITION(S)] care every shift. A review of Resident #17's annual MDS assessment dated [DATE] revealed the resident required two-person total dependence for bed mobility, transfer, eating and toilet use. The resident required oxygen, suctioning and [CONDITION(S)] care. The resident care plan revealed the resident had potential for complication related to [CONDITION(S)]. Interventions included change [CONDITION(S)] as ordered, O2 as ordered, and [CONDITION(S)] care every shift and as needed (PRN). A review of the October 2021 TAR for Resident #17 revealed, [CONDITION(S)] care every shift was not documented. (Copy obtained) During an interview with Employee B, LPN on 10/07/21 at 3:07 PM, she confirmed that Resident #17 required [CONDITION(S)] care every shift and it should be documented on the TAR. After reviewing Resident #17's, October 2021 TAR, she acknowledged the [CONDITION(S)] care was not documented on the form. (Copy obtained) An interview was conducted with the Director of Nursing (DON) on 10/07/21 at 3:16 PM. She confirmed that Resident #17's [CONDITION(S)] care was not documented on the TAR or anywhere else. A review of the facility policy and procedure entitled Medication Administration dated 09/18 read: Page 3 Medication administration: 1. Medications are administered in accordance with the written orders of the prescriber. If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . If necessary, the nurse contacts the prescriber for clarification. This interaction with the pharmacy and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate. (Copy obtained)

Based on observations, interviews, record review and facility policy and procedure review, the facility failed to ensure appropriate administration of medication for one (Resident #33) resident, failed to ensure accurate records of receipt and disposition of all controlled drugs for one (Resident #2) resident, and failed to assure accurate storage of eyedrops during medication storage review for two of two carts reviewed, from a total of four carts in the facility. The findings include: On 10/05/21 at 12:00 PM, medication for Resident #33 was observed at her bedside. (Photographic evidence obtained) A record review for Resident #33 revealed an admitted [DATE]. A review of her quarterly minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 14, indicating cognitively intact. The resident required glasses for impaired vision. On 10/05/21 at 12:33 PM, Resident #33 stated that the nurse left the medication at her bedside after she asked the nurse what the medication was. During a medication storage inspection on 10/06/21 at 9:45 AM, the 100-hall front medication cart was observed to contain an unopened box of [MEDICATION(S)] eye drops in the cart. The box revealed instructions to refrigerate until open. On 10/06/21 at 10:15 AM, an inspection of the 100-hall back medication cart was conducted. During a random narcotic count, Resident #2's [MEDICATION(S)] acetaminophen10-325 milligrams (mg) revealed one tablet while the narcotic reconciliation sheet showed a balance of 3 tablets. (Photographic evidence obtained) During an interview with Employee D, Licensed Practical Nurse (LPN) on 10/6/21 at 10:16 AM, she confirmed that Resident #2's narcotic reconciliation sheet indicated 3 tablets and that only one tablet was available in the cart. Employee C, LPN then signed off one tablet from the narcotic sheet and stated that she had given the medication to the resident earlier and forgot to sign off. She then stated there should be two tablets. When she was asked about the process for narcotic reconciliation, she stated that two nurses count the medication at the beginning of the shift and that nurses are required to sign off the medication after administration. When asked about the reconciliation at the beginning of the shift, she stated that she counted the narcotic with the off going nurse and the count was accurate. She said, It's my fault and I will notify the DON right away. During an interview with Employee C, LPN on 10/06/21 at 10:47 AM, she stated that the eye drops box was unopened and in the medication cart because the resident had been refusing to take them. The nurse confirmed that the eye drops needed to be refrigerated per the instructions. Employee C, LPN was asked to conduct a random narcotic count. She obtained the narcotic book and started signing off the narcotic that she had already administered. When asked about the process of narcotic reconciliation, she stated that it should be documented after administration. On 10/06/21 at 1:45 PM, an interview was conducted with Employee A, LPN. She confirmed that she had left medication for Resident #33 at the bedside. She stated that she thought the resident would take the medication. She sometimes refuses medication and takes them later. After she realized the resident had not taken the medication she went back to the room and took them. When she was asked what the policy was if a resident refuses medications, she stated, she would try to give the medication at a different time, and after three tries, she would document the medication as refused and notify the physician. Employee A, LPN confirmed she did not follow the facility policy. On 10/06/21 at 2:06 PM, an interview was conducted with the Director of Nursing (DON) concerning the process of narcotic reconciliation. She stated that the nurses are supposed to sign off each medication after administration and two nurses should witness the destruction of medication if is refused or accidentally dropped. During the change of shift, two nurses should count narcotics and report any discrepancies. The DON confirmed that she was informed by Employee D, LPN that the narcotic count was off, and she is conducting an investigation. The DON was informed of Resident 33's medication left at the bedside and the eyedrops observed in the medication cart with directions to refrigerate. The DON confirmed that the staff members involved did not follow the facility policy and procedures. A review of the facility policy and procedure entitled, Medication Storage: Storage of Medication with effective date of 09/18, read: 4.1 Storage of Medication Policy Medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. Procedure: 11. Medications requiring refrigeration or temperatures between 2 degrees Celsius (36 degrees Fahrenheit) and 8 degrees Celsius (46 degrees Fahrenheit) are kept in the refrigerator with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place may be refrigerated unless otherwise directed as the cool temperatures are those between 8 degrees Celsius (46 degrees Fahrenheit) and 15 degrees Celsius (59 degrees Fahrenheit). Review of the facility's Controlled substance accountability form revealed the following: Guideline Use this form to verify that the controlled Drugs on hand have been counted and that each medication count agrees with the quantity stated on the residents individual controlled Drug record (s) and anytime when receiving or removing a scheduled II, III, IV, or V medication. 1. At each shift change or when keys are rendered a physical inventory of all controlled medication will be conducted by two stakeholders per state regulation: licensed nurse and/or Certified Medication Technician (CMT). This is completed as follows: a. The off going licensed nurse and/or CMT surrendering the keys will read from the Controlled Substance Accountability book each resident's-controlled Drug Record and the medication to be counted. The oncoming nurse and/or CMT will validate each resident's-controlled Drug Record and the medication to be counted. b. Once the count is complete, both licensed nurse and/or CMT will also count the individual controlled drug record (s). Both licensed nurse and/or CMT will sign the Controlled Substance Accountability Count Sheet. c. At any time during the shift a new Scheduled II, III, IV or V medication is added, discontinued, or removed, the controlled Substance accountability form will reflect the name of the resident, medication and strength, number of cards added or removed, number of sheets added or removed, and verified by two licensed nurses and/or CMT. d. If at any time the narcotic count is incorrect or individual narcotic sheets are not accounted for the count will stop in which a member of the administration will be notified. No one leaves the cart or the facility until authorized by a member of the nursing administration. Review of Medication administration policy and procedure effective 09/18 Page 3 Medication administration: 4. Medication are to be administered at the time they are prepared. 20. The resident is always observed after administration to ensure that the dose was completely ingested. If only a partial dose is ingested, this is noted on the MAR and action taken as appropriate. Page 6 Documentation: 1.The individual who administers the medication dose, records the administration on the Resident's MAR immediately following the medication being given. In no case should the individual who administered the medication report off- duty without first recording the administration of any medication. 2.If a dose of regularly scheduled medications is withheld, refused, or given at other than the scheduled time (for example, the resident is not in the nursing care center at the scheduled dose time, or a starter dose of antibiotic is needed,) the space provided on the front of the MAR for the dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation. If two consecutive doses of a vital medication are withheld or refused, the physician is notified. (Copy obtained)

Based on interview and record reviews, the facility failed to provide a discharge summary for one (Residents #75) of three residents sampled, which included a recapitulation of each resident's stay, inclusive of diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results, and a final summary of the residents' status at the time of the discharge that was available for release to authorized persons and agencies, with the consent of the resident or resident's representative. The facility also failed to include in the discharge summary, a reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter), as well as a post-discharge plan of care that was developed with the participation of the resident and, with the resident's consent, the resident representative(s), which would assist each resident to adjust to his or her new living environment. The findings include: A record review for Resident #79 revealed an admitted [DATE] and discharge date of [DATE]. There was no discharge summary documentation or information regarding the resident's reason or place of discharge in the resident's file. During an interview with the Administrator on 10/07/21 at 2:15 PM, she confirmed that Resident #79 did not have a completed discharge summary. There was no documented evidence of signed discharge summary having been provided to Resident #79, her representatives or the receiving facilities upon discharge. During an interview with the Social Services Director on 10/07/21 at 3:30 PM, she acknowledged she was responsible for the resident's discharge and confirmed that Resident #79 was not provided a discharge summary. A review of the facility policy and procedure titled Discharge Planning Process revised on 7/29/21, read: Guideline: The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition then to post- discharge care, and reduction of the factors leading to preventable readmission. Residents discharged to another Health care setting 2. The resident and or representative will be provided publicly available standardized quality information such as CMS Nursing Home Compare, HH Compare, and LTCH compare websites and other resource use data such as readmission rates. (Copy obtained)

Based on observations, interviews and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one (Resident #188) of three residents reviewed for accidents, from a total sample of 34 residents. The findings include: A record review for Resident #188 revealed an admitted [DATE]. Her primary medical diagnosis was dementia with behavioral disturbance. Secondary diagnoses included [CONDITION(S)] and need for assistance with personal care. A review of Resident #188's annual minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status score of 4, indicating severe cognitive impairment. The resident required extensive assistance with activities of daily living. On 10/04/2021 at 11:20 AM, Resident #188 was observed lying in bed. She was positioned diagonally in the bed with her feet hanging off the left side of the bed. Two floor mats were stacked against the wall. An event history note, dated 12/21/2020 at 10:13 AM, revealed the resident was found on the floor next to her bed and sustained a laceration to her forehead. She was transferred to the hospital for evaluation and treatment. A review of Resident #188's comprehensive care plan revealed a focus area for falls. The resident's goal was to remain free from serious injury. An intervention, dated 12/20/2020 directed staff to place the bed in low position and to place floor mats to both sides of the bed. An intervention dated 3/12/2020 directed staff to assist resident to her wheelchair for meals. An intervention dated 7/29/2019 directed staff to observe the resident frequently and place in a supervised area when out of bed. On 10/04/2021 at 12:15 PM, Resident #188 was observed lying in bed. Two floor mats were stacked against the wall. On 10/04/2021 at 2:45 PM, Resident #188 was observed lying in bed. Two floor mats were stacked against the wall. On 10/06/2021 at 10:55 AM, Resident # 188 was observed in her bed rocking back and forth. Two floor mats were stacked against the wall. On 10/06/2021 at 12:15 PM, Resident # 188 was observed lying in her bed with the head of the bed elevated. Her over-bed table was positioned in front of her, and her meal tray was on the table. The floor mats were stacked against the wall. On 10/06/2021 at 1:30 PM, an interview was conducted with Employee J, Certified Nursing Assistant (CNA) who was assigned to care for Resident #188. The CNA stated, she was familiar with the resident's care and explained that the resident was not a fall risk, and she wasn't sure why fall mats were in the resident's room. On 10/06/2021 at 1:33 PM, Employee J, CNA stated she wished to correct her previous statement. She explained that the Resident #188 was a fall risk and confirmed the floor mats were to be placed on both sides of the bed when the resident was in bed.

Based on interviews and record reviews, the facility failed to obtain routine dental care for one (Resident #47) of one resident sampled for dental services from a total sample of 34 residents. The findings include: On 10/4/2021 during a tour of the facility at 11:13 AM, Resident #47 stated she was awaiting a dental consult to have two of her teeth removed before she could have knee surgery. A review of the clinical record for Resident #47 revealed a 7/9/2021 order for dental consult - Necrotic teeth extraction prior to knee surgery. On 9/30/2021 a second order for dental consult revealed - Extraction of decayed teeth. There was no documentation in the residents' record showing the dental consult order for 7/9/21 was completed. Further review of the clinical record for Resident #47 revealed an admitted [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the annual minimum data set (MDS) assessment dated [DATE], revealed a brief interview for mental status (BIMS) score of 15 out of a possible 15 points, indicating no cognitive impairment. A review of the resident's comprehensive care plan revealed no care plan for dental care prior to surgery. A progress note, dated 7/8/2021, revealed the resident returned from orthopedic with orders for labs in 5 weeks, for f/u appts, for dental to extract necrotic teeth prior to knee surgery and for dietary to see to increase protein, 100 gm supplements to improve [MEDICATION(S)], prealbumin levels prior to surgery (knee surgery) copies of orders to social service and dietary, labs scheduled, transport notified of f/u appt dates. During an interview with the Social Services Director (SSD) on 10/7/2021 at 10:18 AM, she stated, she was unsure if Resident #47 had a dental consult appointment. If it was scheduled, it was not scheduled through her. When asked about the communication of appointments, the SSD stated, if the appointment was scheduled, it normally would not be communicated to her. The SSD stated that the driver also schedules appointments. During an interview with the driver on 10/7/2021 at 2:20 PM, he was asked about his scheduling process. He stated that he receives the appointment requests from the nurses in his box. If a resident doesn't need to be scheduled, the form will have the resident's name, appointment location and appointment time. If the resident needs to be scheduled, the form will have the resident's name and appointment location. He was asked if a dental appointment was set for Resident #47 after the first recommendation from her physician on 7/9/2021. The driver stated that he was not aware of any dental appointment for the resident and confirmed, he had no record of her going out for a dental consult. When asked if there was a policy in place for scheduling appointments, he stated that he did not know of a policy. An orthopedic consultation report for Resident #47 dated 9/30/2021 revealed the following: Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] Findings: Severe [CONDITION(S)] impacting ambulation Recommendations/new orders: dental extraction of necrotic teeth, lab draw of CBC w/diff, [MEDICATION(S)], prealbumin, transferrin, hemoglobin A/C, review in 2 weeks with PA. An interview with the Director of Nursing (DON) was conducted at 2:56 PM on 10/07/2021. The DON was asked about a policy for scheduling appointments. The DON searched the online system but was unable to locate a policy. During an interview with the Administrator on 10/07/2021 at 3:01 PM, she confirmed there is no policy for setting medical appointments. If a patient receives an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . If the person has their own provider, then they call that office and let transportation know about the appointment. Transportation usually makes the appointment because they know when the van is available. If the van is not available, then we will notify outside transportation.

Based on observations, interviews and record review, the facility failed to ensure a refrigerator in the nourishment room was maintained at acceptable temperatures and failed to store and label items appropriately in 1 of 1 nourishment rooms. The findings include: On [DATE] at 12:00 PM, the facility's nourishment room was observed and revealed the following: - Refrigerator temperature log was missing dates for ,d+[DATE], ,d+[DATE], and ,d+[DATE]. (Copy obtained) - The freezer had ice cream in it but did not have a thermometer in it. - Freezer temperature logs for September and [DATE] were blank. (Copy obtained) - Refrigerator had a blue spill on bottom of unit. (Photo obtained) - Pizza box with 1 slice of pizza in the refrigerator with no name or date on the box. (Photo taken) - One container of cheese and ham in the refrigerator with no name and a date of [DATE] on it. (Photo taken) - One small container of sauce in the refrigerator with no lid, date, or name on it. (Photo obtained) - Pepsi bottle in the refrigerator with no date or name. - A sub in the refrigerator with no name or date on it. (Photo obtained) On [DATE] at 12:15 PM, an interview was conducted with Employee C, Licensed Practical Nurse (LPN). She stated, she usually throws away expired food but forgot to do it yesterday. She confirmed that food should be labeled and thrown away after 3 days. She stated that nurses are responsible for keeping nourishment room clean and recording the refrigerator temperatures daily. During an interview with the Administrator on [DATE] at 1:39 PM, she stated that the nourishment room was the responsibility of the nurses. She confirmed that the refrigerator temperatures should be taken daily and that food should be properly dated and labeled in the refrigerator. On [DATE] at 5:50 PM, the administrator and DON confirmed there was no facility policy for nourishment room items, maintenance, or sanitation.

Based on observations, interviews, record reviews, and policy and procedure review, the facility failed to provide treatment and care in accordance with professional standards of practice, by failing to notify the physician of excessively high blood glucose levels for one (Resident #1) of three residents reviewed. This failure potentially contributed to protracted non-healing of the resident's pressure ulcer, and systemic damage based on excessively high and ongoing blood glucose levels. The findings include: A review of the medical record revealed that Resident #1 was a [AGE] year-old female with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/6/2021 at 11:30 a.m., Resident #1 was observed in bed on her left side facing the door. She rang her call bell and Employee B, Licensed Practical Nurse (LPN), entered the room. She wiped the resident's right upper arm with an alcohol wipe, and administered an injection. Employee B was asked what Resident #1 had been given, and she replied she'd administered the resident's scheduled insulin. During an interview with Employee B, LPN, on 4/6/2021 at 11:45 a.m., she was asked whether Resident #1 ever refused her insulin. The nurse replied, No, not from me, and in general I don't think so. She usually refuses her oral medication. At 4:58 p.m., when asked about management of Resident #1's blood glucose levels, she stated, I think she has a sliding scale. When she was asked to locate the resident's sliding scale in the electronic medical record, she stated, I thought she had a sliding scale. She had been on one before. She further stated the resident was not currently on a sliding scale and her blood glucose levels were not well controlled. A review of Resident #1's Vital Signs Report documentation of blood glucose levels revealed that on 3/25/2021, Resident #1's blood glucose levels ranged between 480 and 488 mg/dl (milligrams per deciliter). On 3/26/2021, they ranged between 240 and 450 mg/dl. On 3/27/2021, they ranged between 450 and 600 mg/dl. On 4/1/2021, her blood glucose level reached 400 mg/dl. On 4/2/2021, they ranged between 418 and 600 mg/dl. On 4/3/2021, they ranged between 210 and 496 mg/dl. On 4/4/2021, they ranged between 298 and 347 mg/dl. On 4/5/2021, they ranged between 267 and 430 mg/dl, and on 4/6/2021, her blood glucose reached 284 mg/dl. An order dated 3/31/2021 read, Endocrinology follow up with [physician's name]. Special instructions: Set up an appointment next week. As of 4/6/2021, there was no documentation to verify that a follow-up appointment had been made. A review of the nursing notes from 3/1/2021 through 4/6/2021, revealed no documentation indicating that communication was made with the physician related to the resident's continued high blood glucose levels. A review of the March and April 2021 Medication Administration Records (MARs), revealed a request by the physician to schedule a follow-up appointment with the Endocrinology physician, but there was no documentation in the resident's medical record verifying that had been done. A review of the Wound Evaluation and Management Summary by the wound physician on 1/15/2021, revealed a HBAIC (Hemoglobin A1C - test revealing average blood glucose level) was recommended on 1/8/2021. Recorded factors complicating wound healing included the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the medical record revealed no documentation indicating adherence to these recommendations. The pressure ulcer at the sacrum measured 7.5 cm (centimeters) x 7 cm x 2 cm with 20% slough (yellow/white dead tissue). A review of the Wound Evaluation by the wound physician on 4/2/2021, revealed a goal of treatment would be healing, evidenced by a 6.7 % decrease in surface area, and that DM was still a factor complicating wound healing. The pressure ulcer measured 7 cm x 7 cm x 2 cm with 20% slough. A review of the facility's policy titled Signature Health Care Resident with Diabetes (reviewed last on 9/17/2015) revealed, Administer medication and lab work as ordered. Report abnormal results promptly. Monitor for thirst, excessive appetite, or voiding, change in level of consciousness or mood, perspiring, and report to physician promptly. Monitor and ensure position changes. A review of the facility's policy titled Pressure Ulcer (Injury) Treatment (reviewed last on 7/24/2018), revealed, Pressure ulcer treatment requires a comprehensive approach, including: managing systemic (affecting the entire body) issues and maximizing the potential for healing.

Based on observations, interviews, record reviews, and policy and procedure review, the facility failed to provide services to maintain acceptable nutritional status, including offering sufficient fluid intake and ensuring the resident's ability to perform the task of eating and drinking adequately for one (Resident #1) of three residents reviewed, by failing to provide a beverage of choice or a beverage at all for Resident #1 from 10:05 a.m. until 3:40 p.m. on 4/6/2021. The findings include: A review of the medical record revealed that Resident #1 was a [AGE] year-old female with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/6/2021 at 10:05 a.m., Resident #1 was observed lying in her bed, positioned on her left side, facing the doorway. There were two empty drink cups on her bedside table with remnants of a colored liquid in them. Resident #1 stated she wanted a drink, and she was encouraged to pull her call light for assistance. While the call light was flashing/ringing, Employee A, Certified Nursing Assistant (CNA), was observed using her cell phone while sitting in the corner of the hallway, one door away from Resident #1's room. Employee A did not respond to the call light until five minutes had passed. In the meantime, the resident stated, They never come. They won't come I tell you. in a defeated tone of voice. Upon Employee A's entrance to the room at 10:10 a.m., Resident #1 requested first a drink, then added that she wanted a soda from her wardrobe closet. Inside of her closet were sugar-free sodas and juices. On the floor, adjacent to her bed, was a case of bottled water, which had been provided by her family. Resident #1 was unable to access any of these beverages independently. Upon Resident #1's request for a soda from her closet, Employee A stated, The nurse said you didn't take your insulin, so you can't have a pop. Resident #1 replied, I never refused my insulin. She (the nurse) just didn't give it to me. Employee A stated, I'm going to go check with the nurse. Employee A left the resident's room. After five minutes, no one returned to the resident's room. A search through two hallways was conducted, but Employee A could not be located. On 4/6/2021 at 11:30 a.m., Resident #1 was observed in bed, still on her left side facing the door. The two empty drink cups with remnants of a colored liquid were still on the bedside table. An observation of the resident's closet revealed it contained several small bottles of Sprite Zero, several small bottles of diet cranberry juice, and several small bottles of regular Mott's apple juice. Resident #1 stated she had not had a drink yet and still wanted a drink. She also requested a ham sandwich. She rang her call bell and Employee B, Licensed Practical Nurse (LPN), entered the room. Resident #1 asked Employee B if she could have a sandwich, and Employee B replied yes as she started for the door. Employee B did not ask the resident's sandwich preference until prompted. At that time, Resident #1 stated she'd like a ham sandwich. On 4/6/2021 at 12:21 p.m., Employee A was observed exiting Resident #1's room. Resident#1 was still positioned on her left side facing the door. On her bedside table, lying on top of a plastic sandwich bag, was a ham sandwich with one unopened packet of mayonnaise and one unopened packet of mustard lying on the table beside it. The same two empty drink cups with remnants of a colored liquid were observed on the table. No plate or napkins were provided. Resident#1 was attempting to open the mayonnaise packet using her one good hand by hitting the packet at the edge of the table repeatedly and unsuccessfully. She put the packet down, placed her hand to her head, closed her eyes and shook her head. No drink had been provided to the resident, and nothing was delivered during the time it took her to eat the sandwich. Resident #1 stated she had still not received a drink. She was tearful and said she was thirsty. On 4/6/2021 at 1:59 p.m., Resident #1 was observed positioned on her right side facing the window and away from her bedside table. The table was observed with the same two empty drink cups with remnants of a colored liquid, along with the empty, plastic sandwich bag and the mayonnaise and mustard packets. On 4/6/2021 at 3:30 p.m., a new shift had just started and Employee C, CNA, was observed in the hallway with a hydration cart, filling drinks. This was the first time during the survey that a hydration cart was seen on that nursing unit. Employee C was observed providing drinks to the residents at the top of the hallway. He had not yet reached Resident #1's room. At this time, the resident was observed on her right side, unable to see who entered the room. She asked, Excuse me, excuse me, can you turn me please? She was encouraged to use her call light. Resident#1 started feeling around the bed and stated, I cannot find it. The call light was not on the bed. Employee C was called to the room and found the call light closed inside of the resident's bedside table, which was on the opposite side of the bed, behind her. She could not reach it. Employee C stated he had not come to the resident's room yet, because he was passing drinks first. Observed on the resident's bedside table were the same two empty drink cups with remnants of a colored liquid inside. On 4/6/2021 at 3:40 p.m., the resident was observed still lying on her right side. The bedside table had been moved to the right side, the two empty drink cups had been moved, and a full cup of ice water was on the bedside table. During an interview with the Director of Nursing (DON) on 4/6/2021 at 5:08 p.m., she was asked to describe expected practice related to provision of hydration, repositioning, answering/positioning of call lights, and basic resident care. She stated, Residents are supposed to be turned every two hours, although some people may require or request it less often. Fluids are passed twice per shift. Some residents may ask for water, juice or soda, and if residents do not want water, they can have other drinks as long as their diets permit. Staff should record the amount of fluid residents accept. Call lights should be positioned where residents can reach them, and staff, when providing care, should introduce themselves and indicate what they came in the room to do. A review of the observations made during the course of the day was shared with the DON. She shook her head and asked, Was it the agency nurse? A review of Resident #1's care plans revealed a care plan for dehydration that included interventions including: Assist with fluids as needed. Keep fluids accessible. Offer a variety of fluids. A review of Resident #1's Vital Signs Report with Documentation of Fluids Received, showed that on 3/27/2021, she received a total of 1200 ml (milliliters) of fluids. From 3/28/2021 through 3/30/2021, there was no documentation verifying Resident #1 had received any fluids. On 3/31/2021, documentation showed she received a total of 1440 ml of fluids. On 4/1/2021, documentation showed she received a total of 1320 ml of fluids. On 4/3/2021, no provision of fluids was documented to verify that the resident had received any. On 4/4/2021, a total of 250 ml of fluids was documented as having been provided. On 4/5/2021, a total of 1080 ml of fluids was documented as having been provided. On 4/6/2021, there was no documentation of fluids provided during the day shift. A review of the facility's policy titled Hydration (reviewed last on 6/27/2018), revealed, Facility staff/volunteers shall offer fluids to residents between meals, during activities and before bedtime (unless contraindicated). Water is made available at mealtime, at bedside, on hydration cart (unless contraindicated). Residents will receive sufficient amounts of fluid to maintain proper hydration. A review of the facility's policy titled Signature Health Care Resident with Diabetes (reviewed last on 9/17/2015) revealed, Administer medication and lab work as ordered. Report abnormal results promptly. Monitor for thirst, excessive appetite, or voiding, change in level of consciousness or mood, perspiring, and report to physician promptly. Monitor and ensure position changes.

Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program by not conducting appropriate visitor screenings to prevent the transmission of COVID-19 during 4 of 6 opportunities observed. This has the potential to affect the staff and 65 residents of the facility. The findings include: Upon entrance into the facility on [DATE] at 9:00 AM, Employee A, screener, failed to screen Surveyor #1 for symptoms consistent with COVID-19, history of travel to high risk locations, and contact/exposure to individuals with symptoms. Only a temperature was taken. On 7/28/20 at 9:00 AM, Employee B failed to screen Surveyors #1, #2 and #3 for symptoms consistent with COVID-19, history of travel to high-risk locations, and contact/exposure to individuals with symptoms. Only a temperature was taken. An interview was conducted with Employee B on 7/28/20 at 10:30 AM where the employee confirmed that she was responsible for conducting the visitor screenings on 7/28/20. She was asked to describe what she does during her shift due to COVID. She stated she comes to work, puts on her mask, washes her hands and wipes down the entire front desk. When asked what she does if someone comes in the front door, she stated she makes sure they have a mask on and if they are dropping off something for a resident, she wipes down the item and keeps it at the front desk for 24 hours. When asked what she does specifically for employees, she stated when they leave, she gives them a paper bag to put their N95 mask in it and it is labeled with their name and she keeps it at the front desk. When an employee comes in for their shift, she takes their temperature, writes their name down and she gives them the sticker that says they have been screened. Review of the Policy and Procedure Coronavirus (COVID-19)-Restriction of Visitors effective 3/9/2020, and revised 6/29/2020 revealed that the facility will implement restricted visitation to strive to prevent the spread of COVID-19. It also indicated if visitation is necessary, visitors are screened upon entry into the facility using the questions on the Visitor Log for symptoms of COVID-19 as identified/defined by the Centers for Disease Control (CDC) and any visitor with any of the symptoms identified by the CDC should not be permitted to enter the facility at any time (even in end-of-life situations). The policy further states if a visit is allowed, a trained stakeholder can review the visitor's screen and determine if the visitor can enter the facility. A trained stakeholder is identified as the following: Having received education on COVID-19 symptoms and risk factors, the screening process and screening questions, regulations and guidance related to limiting a resident's right to visitors, how to manage situations where visitors or vendors may not want to leave the premises. If the is approved for entry, the visitor is given a sticker with the date and signature of the stakeholder approving the visitor for entry. On 7/28/20 at 11:15 AM, record review with the Interim Director of Nurses (DON) of in-services and sign-in sheets for the required staff training prior to allowing them to screen visitors and employees did not find Employee B attended any required training or in-service prior to conducting COVID-19 screenings. The interim DON confirmed she had no documentation that Employee B received the required training regarding screening for COVID-19. On 7/28/2020 at 11:30 AM, the Interim DON, she was asked about the facility's screening processes for visitors. She confirmed that upon entry into the facility, visitors were to be screened for fever, respiratory symptoms, and recent travel. She explained that the findings from the screening were to then be documented on the screening form and the person conducting the screening then signs the form and gives a sticker to the visitor stating the visitor has been screened.

Based on record reviews and interviews, the facility failed to develop a comprehensive care plan that met the resident's medical and nursing needs for one (Resident #1) of one sampled residents with a [MEDICAL CONDITION], from a total of five residents in the sample. The findings include: A review of the clinical record for Resident #1 revealed a medical [DIAGNOSES REDACTED]. She also underwent placement of a gastrostomy tube for nutrition and could take nothing by mouth. The resident was totally dependent on staff for activities of daily living. During a review of the resident's comprehensive care plan it was noted the plan did not include care of the resident's [MEDICAL CONDITION]. On 2/3/2020 at 4:33 PM an interview was conducted with the minimum data set (MDS) coordinator. She acknloweged that the resident's care plans did not include a plan for care of the resident's [MEDICAL CONDITION] and stated that one would be created.

Based on staff interviews and resident record reviews, the facility failed to ensure residents received treatment and care in accordance with the comprehensive care plan for one (Resident #1) of one sampled residents with a [MEDICAL CONDITION], from a total of five residents in the sample. The findings include: A review of the clinical record for Resident #1 revealed a medical [DIAGNOSES REDACTED]. She also underwent placement of a gastrostomy tube for nutrition and could take nothing by mouth. The resident was totally dependent on staff for activities of daily living. On 12/18/2019, medications were inadvertently given to the resident by mouth and she was subsequently sent to the hospital after developing a fever. The resident started antibiotic treatment in the hospital for aspiration pneumonitis and returned to the facility on [DATE]. A review of the resident's physician's orders [REDACTED]. (Photographic evidence obtained) The x-ray report was not available for review on the record and the assistant director of nursing was asked to locate a copy. On 2/3/2020 at 4:22 PM, an interview was conducted with the nursing home administrator and assistant director of nursing. Both parties explained that the x-ray had not been performed as ordered by the physician, that the physician would be notified and an x-ray would be obtained.

Based on observation, resident and facility record review and staff interviews, the facility failed to ensure infection prevention practices were implemented to keep urinary catheter collection bags off of the bare floor for one (Resident #2) of two sampled residents with catheters, from a total of five residents in the sample. The findings include: An interview was conducted with Resident #2 in his room at 10:15 am on 2/3/20. He was seated on the side of his bed. His partially full and uncovered urine collection bag was observed lying directly on the floor under his bed. Resident #2 was asked it he realized his catheter's collection bag was on the floor. He responded by stating yes, that was where the staff put it. (Photographic evidence obtained) Resident #2 was observed at 1:35 pm on 2/3/20 in his room. He was lying in his bed with his eyes closed. His uncovered urine collection bag was still on the floor underneath the bed. In a third observation at 3:55 pm on 2/3/20, Resident #2 was still in bed with his eyes closed, the bag still on the floor underneath him. (Photographic evidence obtained) A record review for Resident #2 found he was readmitted to the facility on [DATE]. A 5-day Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/13/20, found Resident #2 had a brief interview for mental status score of 9, reflecting moderate independence with daily decision making. He had a [DIAGNOSES REDACTED]. He was not assessed with [REDACTED]. The discharge return anticipated MDS with an ARD of 1/24/20 revealed he now had a urinary catheter. Resident #2 was care planned 1/23/20 for his indwelling urinary catheter related to [MEDICAL CONDITION] and urine retention, with approaches to position the bag below the level of his bladder. A review of facility and personnel records found a Catheterization Competency checklist was used for testing the competency of the facility's nursing staff. Step 35 of the checklist noted: Hang (urine) collection bag on bed frame. Do not hang it from the side rails and avoid letting it touch the floor. An interview was conducted with Certified Nursing Assistant (CNA) A at 12:18 pm on 2/3/20. She stated some of the residents she provides care for had urinary catheters. She reported the urine retention bags should be stored in a blue dignity cover and hung on the bedside. She stated the bags should never rest or be placed on the floor as this promoted cross contamination. CNA B was interviewed at 1:40 pm on 2/3/20. She said she was trained that urinary catheter bags should be in a cover and attached to the side of the bed or the resident's chair. They should never be on the floor. The Assistant Director of Nursing (ADON) was interviewed at 3:55 pm on 2/3/20. She stated her expectation for urine retention bags was that they were covered and hung on the far side of the bed. She stated they should not be on the floor. She was escorted to Resident #2's room and was shown the bag on the floor. She said, Oh, no. When told the observation occurred over both shifts during the day, she had no response or explanation.

Based on observations, interviews and record reviews, the facility failed to provide nursing staff with the appropriate competencies and skill sets necessary to care for residents' needs, evidenced by one nurse (Employee A, LPN) who failed to appropriately disinfect a blood glucose meter before or after its use for one resident (#65) out of a total of 24 residents who required blood glucose monitoring. Observations of the glucometers on all four of the facility's medication carts revealed that three of four carts contained a soiled glucometer. These included both carts on the 100 hall and one of the two carts on the 200 hall. Resident #31, who was diagnosed with [REDACTED]. These failures placed Resident #65 and all diabetic residents requiring blood glucose monitoring at risk for transmission of infectious blood-borne pathogens including Human Immunodeficiency Virus ,[MEDICAL CONDITION]., and [MEDICAL CONDITION] virus. A review of the facility's education records revealed that 15 of 33 nurses employed by the facility had never received any competency training related to cleaning/disinfection of blood glucometers, and 16 received incorrect training, prior to the facility changing the competency instructions. These failures placed Resident #65 and all diabetic residents requiring blood glucose monitoring at risk for transmission of infectious blood-borne pathogens including [MEDICAL CONDITION] and Human Immunodeficiency Virus. On 10/23/19 at 11:02 a.m., the Immediate Jeopardy (IJ) started. On 10/24/19 at 1:00 p.m., the Administrator was notified of the IJ determination. On 10/25/19 at 2:17 p.m., the facility provided an acceptable IJ removal plan for the appropriate cleansing and disinfection of glucometers. On 10/25/19 at 5:30 p.m., Immediate Jeopardy was removed after validation of the implementation of the IJ removal plan. Cross reference to F880. The findings include: On 10/23/19 at 11:02 AM Employee A, Licensed Practical Nurse (LPN) was observed removing her glucometer from the medication cart. The glucometer was wrapped in a dry bleach wipe. The LPN unwrapped the glucometer and placed it on top of her cart. Upon picking it up to enter Resident #65's room, the glucometer was observed to be soiled on the top next to the strip insertion site. Employee entered the room, obtained two brown paper towels from the dispenser and laid them on the bedside table. Next, she donned gloves. The surveyor excused herself to find another surveyor as a witness. Two additional surveyors entered the room with the surveyor who made the initial observation. The glucometer was lying on the paper towels. Employee A, LPN stated, Okay, we will do the blood sugar now. The she inserted the test strip, wiped the resident's right hand pointer finger, and picked up the lancet. The surveyors intervened before the nurse performed the fingerstick, and asked her to step into the hallway. Resident #65 stated that we needed to hurry, so she did not miss the smoke break. The resident told Employee A that she could do her blood sugar after she smoked. Employee A was asked about the glucometers and she stated, Yes, they are clean. She stated that she had just unwrapped it from the bleach wipe. The surveyor asked who cleaned it, and she stated, It was cleaned on the 11-7 shift. She was asked about the red-like spot (resembling blood) noted on the glucometer and Employee A stated, Oh, that little brown spot there. Then she took a bleach wipe and wiped the spot and it came off. When she opened the bleach wipe and it had a soiled spot on it from cleaning the glucometer. On 10/23/19 at 11:18 AM, the surveyor observed the medication cart A Front hall with Employee C, Registered Nurse (RN). She had three (3) glucometers on top of her cart, and one was noted to be soiled. She was asked if the glucometers were clean and she stated, I will clean it again. (Photographic evidence was obtained). She was asked how they clean them, and she stated that they wrap them in a bleach wipe and leave them in the cup for three minutes. On 10/23/19 at 11:22 AM, the surveyor observed Cart B on the Front hall with Employee B, Licensed Practical Nurse (LPN), and she had two glucometers on her cart. One was labeled #1 and the second one was labeled #3. She opened her cart and both glucometers were laying in her basket in the top drawer. She was asked if the glucometers were clean and she indicated that they were. Upon examining the glucometers, the surveyor noted that both were soiled with a red-like substance (resembling blood). Photographic evidence was obtained. She was asked about the spots on the glucometer, and the LPN responded that they were soiled. The nurse stated, We clean them, but I guess we don't always get them good enough. The surveyor asked her how they clean the glucometers and she stated, We wipe them down, wrap them in the bleach wipe, and place them in the cup for three minutes. Then we can use them. On 10/23/19 review of the facility's education records revealed that 15 (Employees M, Q, R, S, U, W, X, Y, Z, AA, BB, CC, DD, EE and FF) of 33 nurses employed by the facility had never received any competency training related to cleaning/disinfection of blood glucometers. Further review revealed that 16 (Employees A, B, C, D, E, G, K, L, O, T, V, GG, II, JJ, Director of Nursing, and Staff Development Coordinator) received incorrect training, prior to the facility changing the competency instructions. A facility policy and procedure for cleaning/disinfecting of the glucometers was requested; however, the facility did not have a current policy and procedure. A review of the Microdot Bleach Disposable Wipes label instructions revealed: Directions for Use: It is a violation of Federal Law to use this product in a manner inconsistent with its labeling. Disinfection: 1. Always use personal protective equipment. 2. Open Microdot Bleach Wipe canister. 3. Remove pre-saturated 6x 6 wipe. 4. Apply towelette and wipe desired surface to be disinfected. 5. A 30 second contact time is required to kill all the bacteria [MEDICAL CONDITION]** on the label except a one minute contact time is required to kill [MEDICATION NAME] mentagrophytes and a three minute contact time is required to kill [MEDICAL CONDITION] spores ([MEDICAL CONDITION]). Reapply as necessary to ensure that the surface remains wet for the entire contact time. 6. Allow surface to air dry and discard used wipe. A review of the Assure Platinum Cleaning and Disinfection Guidelines revealed: Page 47 Cleaning & Disinfecting Guidelines Healthcare professionals should wear gloves when cleaning the Assure Platinum meter. Wash hands after taking off gloves. Contact with blood presents a potential infection risk. We suggest cleaning and disinfecting the meter between patient use. Option 1: Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicide wipe. To use a wipe, remove from container and follow product label instructions to disinfect the meter. Take extreme care not to get liquid in the test strip and key code ports of the meter. many wipes act as both a cleaner and disinfectant, though if blood is visibly present on the meter, two wipes must be used; use one wipe to clean and a second wipe to disinfect. Option 2: To clean the outside of the blood glucose meter, use a lint-free cloth dampened with soapy water or [MEDICATION NAME] alcohol (70-80%). To disinfect the meter, dilute 1 mL of household bleach (5-6% sodium hypochlorite solution) in 9 mL of water to achieve 1:10 dilution (final concentration of 0.5-0.6% sodium hypochlorite). The solution can then be used to dampen a paper towel (do not saturate the towel). Then use the dampened paper towel to thoroughly wipe down the meter. Please note that there are commercially available 1:10 bleach wipes from a variety of manufactures. Take extreme care not to get liquid in the test strip and key code ports of the meter. With all the recommended meter cleaning and disinfecting methods, it is critical that the meter be completely dry before testing a resident's glucose level. Please follow the disinfectant product label instructions to ensure proper drying time. A review of the Centers for Disease Control and Prevention (CDC) guidelines for infection Prevention during Blood Glucose Monitoring and Insulin Administration (6/8/17) revealed the following, The Centers for Disease Control and Prevention (CDC) has become increasingly concerned about the risks for transmitting [MEDICAL CONDITION] virus (HBV) and other infectious diseases during assisted blood glucose (blood sugar) monitoring and insulin administration. Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected, then it should not be shared. Outbreaks of [MEDICAL CONDITION] virus (HBV) infection associated with blood glucose monitoring have been identified with increasing regularity, particularly in long-term settings, such as nursing homes and assisted living facilities, where residents often require assistance with monitoring of blood glucose levels and/or insulin administration. On 10/25/19 at 2:17 p.m., the facility provided an acceptable Immediate Jeopardy removal plan for the appropriate cleansing and disinfection of glucometers, which included the following: - The facility completed an ad hoc (as needed) QAPI (Quality Assurance Performance Improvement) meeting including the medical director on 10/24/19. Training and education plan for the IJ status was approved by committee. - On 10/25/19 the Director of Nursing provided one to one education with Nurse A on the proper procedure for cleaning/disinfecting glucometers. Education included steps for cleaning and/or disinfecting glucometers and competencies with return demonstration on how to properly clean the glucometer. - System: On 10/24/19 the Regional Nurse Consultant conducted education, training and competencies with the SDC (Staff Development Coordinator) and DON (Director of Nursing) on verifying competency for training of staff. Glucometers were checked for cleanliness on 10/24/19 and then again on 10/25/19. New glucometers were ordered on [DATE] and arrived in the building on 10/25/19 and were in the medication rooms on A and B units if in the event one needs to be replaced. - As of 10/25/19 at 11:45 a.m., 47% of nurses were re-educated by the DON and/or SDC on procedure for Education included steps for cleaning and/or disinfecting glucometers and competencies with return demonstration on how to properly clean the glucometer. - On 10/25/19, certified letters will be sent out to PRN (as needed) and Part Time licensed nursing staff with education on policy and procedure for properly cleaning and disinfecting glucometers. Prior to working next scheduled shift, the Director of Nursing or SDC will complete competency through return demonstration. New orientees receive education on glucometer cleaning/disinfecting and blood-borne pathogens during orientation. On 10/24/19 at 6:11 PM, the Administrator and Regional Nurse Consultant (RNC) stated that all the nurses have already had competencies, including return demonstration. When the surveyor reviewed the competency form, it documented that the staff were to clean the glucometer with a cloth dampened with soap and water. The RNC stated that this part was incorrect and it should not be on there. She then asked for the blank copy back and stated that she will have to revamp it. A review was completed for the written competencies and they had the same content about cleaning the glucometer with soap and water. The RNC stated that all staff in-serviced would have to be in-serviced again, after they corrected the competency form. No employee would be allowed to provide blood glucose monitoring before receiving the new training. On 10/25/19 review of the facility's education records confirmed that 18 had been retrained with the revised competency (Nurse employees A, B, C, D, E, G, K, N, P, V, GG, HH, II, JJ, KK, LL, Director of Nursing (DON) and Staff Development Coordinator). Employees M, Q, R, S, U, W, X, Y, Z, AA, BB, CC, DD, EE and FF still needed the training. As of 10/25/19 at 4:45 p.m., observation of the medication carts revealed the glucometers had been cleaned. Three of four carts had no identified concerns; however, one glucometer on medication Cart B in the Front hall, was observed with a small red dot (resembling blood). The DON was notified of the concern and intervened immediately. The facility will continue to conduct on-going audits. Tthey completed an ad hoc (as needed) QAPI (Quality Assurance Performance Improvement) meeting including the medical director on 10/24/19. The QAPI committee approved the training and education plan to address the IJ noncompliance.

Based on observations, interviews, record reviews, a review of the Assure Platinum Blood Glucose Monitoring System QA/QC (quality assurance/quality control) reference guidelines, a review of the Microdot Bleach Disposable Wipes product description and efficacy information, and a review of the Centers for Disease Control and Prevention guidelines, the facility failed to ensure blood glucose meters were cleaned and disinfected during resident use to prevent the spread of blood-borne pathogens. During an observation of Blood Glucose Monitoring (BGM) via finger stick testing, Employee A, a licensed practical nurse (LPN) failed to clean and disinfect the glucometer (a device used to measure blood glucose levels) before or after its use for one (Resident #65) of 24 residents requiring blood glucose monitoring. Observations of the blood glucometers on all four of the facility's medication carts revealed that three of four carts contained a soiled glucometer. These included both carts on the 100 hall and one of the two carts on the 200 hall. Resident #31, who was diagnosed with [REDACTED]. These failures placed Resident #65 and all diabetic residents requiring blood glucose monitoring at risk for transmission of infectious blood-borne pathogens including Human Immunodeficiency Virus ,[MEDICAL CONDITION]., and [MEDICAL CONDITION] virus. On 10/23/19 at 11:02 a.m., the Immediate Jeopardy (IJ) started. On 10/24/19 at 1:00 p.m., the Administrator was notified of the IJ determination. On 10/25/19 at 2:17 p.m., the facility provided an acceptable IJ removal plan for the appropriate cleansing and disinfection of glucometers. On 10/25/19 at 5:30 p.m., Immediate Jeopardy was removed after validation of the implementation of the IJ removal plan. Cross reference to F726. The findings include: On 10/23/19 at 11:02 AM Employee A, Licensed Practical Nurse (LPN) was observed removing her glucometer from the medication cart. The glucometer was wrapped in a dry bleach wipe. The LPN unwrapped the glucometer and placed it on top of her cart. Upon picking it up to enter Resident #65's room, the glucometer was observed to be soiled on the top next to the strip insertion site. Employee entered the room, obtained two brown paper towels from the dispenser and laid them on the bedside table. Next, she donned gloves. The surveyor excused herself to find another surveyor as a witness. Two additional surveyors entered the room with the surveyor who made the initial observation. The glucometer was lying on the paper towels. Employee A, LPN stated, Okay, we will do the blood sugar now. The she inserted the test strip, wiped the resident's right hand pointer finger, and picked up the lancet. The surveyors intervened before the nurse performed the fingerstick, and asked her to step into the hallway. Resident #65 stated that we needed to hurry, so she did not miss the smoke break. The resident told Employee A that she could do her blood sugar after she smoked. Employee A was asked about the glucometers and she stated, Yes, they are clean. She stated that she had just unwrapped it from the bleach wipe. The surveyor asked who cleaned it, and she stated, It was cleaned on the 11-7 shift. She was asked about the red-like spot (resembling blood) noted on the glucometer and Employee A stated, Oh, that little brown spot there. Then she took a bleach wipe and wiped the spot and it came off. When she opened the bleach wipe and it had a soiled spot on it from cleaning the glucometer. On 10/23/19 at 11:18 AM, the surveyor observed the medication cart A Front hall with Employee C, Registered Nurse (RN). She had three (3) glucometers on top of her cart, and one was noted to be soiled. She was asked if the glucometers were clean and she stated, I will clean it again. (Photographic evidence was obtained). She was asked how they clean them, and she stated that they wrap them in a bleach wipe and leave them in the cup for three minutes. On 10/23/19 at 11:22 AM, the surveyor observed Cart B on the Front hall with Employee B, Licensed Practical Nurse (LPN), and she had two glucometers on her cart. One was labeled #1 and the second one was labeled #3. She opened her cart and both glucometers were laying in her basket in the top drawer. She was asked if the glucometers were clean and she indicated that they were. Upon examining the glucometers, the surveyor noted that both were soiled with a red-like substance (resembling blood). Photographic evidence was obtained. She was asked about the spots on the glucometer, and the LPN responded that they were soiled. The nurse stated, We clean them, but I guess we don't always get them good enough. The surveyor asked her how they clean the glucometers and she stated, We wipe them down, wrap them in the bleach wipe, and place them in the cup for three minutes. Then we can use them. A facility policy and procedure for cleaning/disinfecting of the glucometers was requested; however, the facility did not have a current policy and procedure. A review of the Microdot Bleach Disposable Wipes label instructions revealed: Directions for Use: It is a violation of Federal Law to use this product in a manner inconsistent with its labeling. Disinfection: 1. Always use personal protective equipment. 2. Open Microdot Bleach Wipe canister. 3. Remove pre-saturated 6x 6 wipe. 4. Apply towelette and wipe desired surface to be disinfected. 5. A 30 second contact time is required to kill all the bacteria [MEDICAL CONDITION]** on the label except a one minute contact time is required to kill [MEDICATION NAME] mentagrophytes and a three minute contact time is required to kill [MEDICAL CONDITION] spores ([MEDICAL CONDITION]). Reapply as necessary to ensure that the surface remains wet for the entire contact time. 6. Allow surface to air dry and discard used wipe. A review of the Assure Platinum Cleaning and Disinfection Guidelines revealed: Page 47 Cleaning & Disinfecting Guidelines Healthcare professionals should wear gloves when cleaning the Assure Platinum meter. Wash hands after taking off gloves. Contact with blood presents a potential infection risk. We suggest cleaning and disinfecting the meter between patient use. Option 1: Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicide wipe. To use a wipe, remove from container and follow product label instructions to disinfect the meter. Take extreme care not to get liquid in the test strip and key code ports of the meter. many wipes act as both a cleaner and disinfectant, though if blood is visibly present on the meter, two wipes must be used; use one wipe to clean and a second wipe to disinfect. Option 2: To clean the outside of the blood glucose meter, use a lint-free cloth dampened with soapy water or [MEDICATION NAME] alcohol (70-80%). To disinfect the meter, dilute 1 mL of household bleach (5-6% sodium hypochlorite solution) in 9 mL of water to achieve 1:10 dilution (final concentration of 0.5-0.6% sodium hypochlorite). The solution can then be used to dampen a paper towel (do not saturate the towel). Then use the dampened paper towel to thoroughly wipe down the meter. Please note that there are commercially available 1:10 bleach wipes from a variety of manufactures. Take extreme care not to get liquid in the test strip and key code ports of the meter. With all the recommended meter cleaning and disinfecting methods, it is critical that the meter be completely dry before testing a resident's glucose level. Please follow the disinfectant product label instructions to ensure proper drying time. A review of the Centers for Disease Control and Prevention (CDC) guidelines for infection Prevention during Blood Glucose Monitoring and Insulin Administration (6/8/17) revealed the following, The Centers for Disease Control and Prevention (CDC) has become increasingly concerned about the risks for transmitting [MEDICAL CONDITION] virus (HBV) and other infectious diseases during assisted blood glucose (blood sugar) monitoring and insulin administration. Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected, then it should not be shared. Outbreaks of [MEDICAL CONDITION] virus (HBV) infection associated with blood glucose monitoring have been identified with increasing regularity, particularly in long-term settings, such as nursing homes and assisted living facilities, where residents often require assistance with monitoring of blood glucose levels and/or insulin administration. On 10/25/19 at 2:17 p.m., the facility provided an acceptable Immediate Jeopardy IJ removal plan for the appropriate cleansing and disinfection of glucometers, which included the following: - The facility completed an ad hoc (as needed) QAPI (Quality Assurance Performance Improvement) meeting including the medical director on 10/24/19. Training and education plan for the IJ status was approved by committee. On 10/25/19 at 1:17 p.m., an interview was conducted with the Medical Director regarding the concerns with the facility failing to clean and/or disinfect the glucometers correctly, before and after using on the residents. He stated that the facility should provide a glucometer for each resident individually, and will tell the facility that as well. He stated that it was very concerning that there were residents with the [DIAGNOSES REDACTED]. On 10/25/19 at 2:41 p.m., an interview was conducted with the Administrator and she stated that the Medical Director had recommended each resident requiring blood glucose monitoring having their own glucometer. She stated, We are tabling that for now, because it is not the facility policy to provide glucometers to the residents, plus it would become a storage concern. ------------------------------- On 10/25/19 at 10:58 a.m., a follow up blood glucometer observation was conducted with Employee B, Licensed Practical Nurse (LPN) with Resident #81. The following was observed: LPN removed three gloves and placed them on top of her medication cart. Then she donned gloves from the box on the cart (2 pairs). After, she removed the glucometer and placed it in the white basket that she removed from the top drawer of the medication cart. The LPN placed the test strip, alcohol wipes, and lancet in the basket. Then she went to the room and placed the white basket on the sink in the resident's room; no barrier was provided under the basket (Photographic evidence was obtained). Next, she washed her hands, donned gloves and inserted the test strip. She opened an alcohol wipe and cleansed Resident #81's left hand pointer finger. The LPN obtained the blood sample and ejected the test strip from the glucometer into the trash can. Next, she removed her gloves, did not wash her hands and returned to the medication cart. Then she donned gloves, and placed the lancet in the sharps container. After, she removed a bleach wipe and cleansed the glucometer for 30 seconds. Next, she placed the glucometer in a plastic cup on top of her medication cart. She removed two more bleach wipes and wrapped the glucometer and placed it back in the plastic cup to sit for three minutes. On 10/25/19 at 11:02 a.m. an interview was conducted with Employee B, Licensed Practical Nurse (LPN) regarding the glucometer observation and if she had followed recommended infection control practices. She stated, No, I did not. She was asked about taking the white basket in the room as her barrier and placing it on the sink, then brining it back to the cart after. Tee LPN responded, Yes, you're right. She was asked about the test strip being placed in the garbage and not washing her hands after, and she stated, Yes, you're right. She was asked if she had received education prior to working her shift and she stated yes from (staff development coordinator). The surveyor asked asked if the LPN had to perform return demonstration and she stated, Yes, I did. On 10/25/19 at 11:10 a.m. a follow up blood glucometer observation was conducted with Employee G, Licensed Practical Nurse (LPN), with Resident #67, and the following was observed: The LPN removed her glucometer, one test strip, two alcohol wipes and one lancet from the top drawer of her medication cart. Next, she entered the resident's room and obtained a brown paper towel from the dispenser on the wall. She placed the towel on the table and placed her supplies on the paper towel. After, she donned gloves and cleansed Resident #67's left fourth finger. Next, she obtained her blood sugar reading. Then she removed the test strip, wrapped it up in her glove and threw it in the trash can in the resident's room. She gathered her supplies and left the room, and she failed to wash her hands. Next, she threw the lancet in the sharps container (attached to the cart). Then she opened the cart and obtained bleach wipes, donned gloves, removed one wipe and cleansed the glucometer. Next she removed two more wipes and wrapped the glucometer and placed it in the plastic cup for three minutes. Finally, she removed her gloves and threw them away. On 10/25/19 at 11:16 AM an interview was conducted with Employee G, Licensed Practical Nurse (LPN), and she stated that she failed to wash her hands after she completed the blood sugar check. She was asked about training and she stated that the Staff Development Coordinator had provided her training. When asked about the barriers, she stated that she should use a non-permeable barrier. She then confirmed that she failed to do so, and used a paper towel. She was asked about disposing of the test strip and she replied that she was told that if it was in her glove, she could throw it away in the regular trash. On 10/25/2019 at 10:54 am, the Assistant Director of Nursing (ADON) was observed in an isolation room of a resident with an infection without the required personal protection equipment (PPE). During an interview with the ADON and the Administrator on 10/25/2019 at 11:07 am, the ADON stated that she removed the PPE after completing the resident's care, but did not exit. She stated that she remained in the resident's room without PPE. The Administrator confirmed that the ADON should have remained in PPE while in the resident's room. During an interview on 10/25/2019 at 12:34pm, the Administrator stated that all staff are to remain in PPE while inside isolation rooms, even if they are no longer providing resident care.