Every finding on record at Pavilion for Health Care, The

Based on observation, record review, staff interview, and policy and procedure review, the facility failed to maintain accurately documented medical records for one (Resident #13) of one resident reviewed for non-pressure related skin conditions. The findings include: An observation was made of Resident #13 on 6/18/24 at 10:00 AM. He had a large, tan colored, adhesive dressing on his left leg, dated 6/14/24. A review of the electronic medical record (EMR) revealed a physician's order dated 6/12/24, instructing nursing staff to cleanse the left leg below the knee skin tear with normal saline, apply antibiotic ointment, and cover with a Band-Aid once a day, every other day until healed. A review of the June 2024 treatment administration record (TAR) revealed that Registered Nurse (RN) A signed the treatment as having been completed per the physician's order on 6/16/24. An interview was conducted with RN A on 6/20/24 at 10:41 AM. She stated she worked on 6/16/24, and was assigned tasks including the completion of residents' ordered skin treatments. She reviewed the TAR and confirmed that her initials were signed for the 6/16/24 skin treatment for Resident #13. She stated placing her initials in the TAR meant the treatment was completed as ordered. She was not sure why the date on the dressing would have read 6/14/24 during the observation on 6/18/24. She stated she thought 6/16/24 was the day the resident's wife took him out, and he did not want the bandage changed before he left with his wife. RN A stated she was off duty by the time they returned. She further stated she should have gone back and documented that the treatment was not administered on 6/16/24. She stated the area was a scratch from a skin lesion. A review of the facility's policy for Charting and Documentation (revised 1/2018), revealed that all services provided to the resident, or any changes in the resident's medical or mental condition, would be documented in the resident's medical record. Documentation of procedures and treatments shall include care-specific details and shall include at a minimum: e. whether the resident refused the procedure/treatment.

Based on observations, interviews, and record review, the facility failed to adhere to the parameters ordered by the physician for the administration of blood pressure medication for one (Resident # 31) of five residents observed during medication administration, from a total of 18 residents in the sample. The findings include: During a medication administration observation for Resident #31 on 09/14/22 at 9:37 a.m., Licensed Practical Nurse (LPN) A obtained [MEDICATION(S)] 10 milligrams (mg) and Losartan 100 mg. Both medications had special instructions to hold the medications if the resident's blood pressure (BP) was less than 120/80. LPN A popped the medications into the medication cup, performed hand hygiene and went into Resident #31's room. Before administering the medication, the nurse was asked for the resident's blood pressure. She stated it was 125/62 millimeters of mercury (mmHg). She was asked to verify the resident's blood pressure again before administering the medication. She again stated, The blood pressure is 125/62 mmHg and proceeded to administer the medication. (Copy of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] In an interview on 09/14/22 at 9:49 a.m., LPN A was asked to review the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Both medications had special instructions to hold the medications if the if the resident's blood pressure (BP) was less then 120/80. When asked if the medication should have been administered, she stated she went by the top number (systolic - 120) and not the bottom number (diastolic - 62). She stated she was not sure what the facility's policy said about that. A review of Resident #31's medical record revealed that he was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of his Care Plan, initiated on 8/13/21 and revised on 9/09/22, revealed that he was at Risk for Falls due to recent hospitalization , adapting to new surroundings, right lower extremity weakness, polyneuropathy, [CONDITION(S)] and [CONDITION(S)]. The Care Plan further revealed that Resident #31 had falls on 8/23/21, 11/7/21, 12/16/21, 5/25/22, 6/11/22, and on 9/09/22. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] <) 120/80. Another order, dated 9/14/22, was written for Losartan tablet 100 mg, 1 tablet orally once a day: Hold if BP<120/80. (Copy obtained) A review of the August 2022 and September 2022 MARs revealed that Resident #31 received [MEDICATION(S)] and Losartan on 8/19/22 (BP 131/68), 8/25/22 (BP 139/79), 9/4/22 (BP 131/69), 9/13/22 (BP 166/77) and 9/14/22 (BP 125/62). (Copies of the MARs were obtained) In an interview on 09/15/22 at 11:45 a.m., the Director of Nursing (DON) and the Administrator were informed of the medication errors. They both verbalized understanding and stated education would be initiated. A review of the facility's policy and procedure titled Medication Administration (revised August 2014), revealed that medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration. The administration procedure revealed that medications are to be administered in accordance with the written orders from the prescriber and administered without unnecessary interruptions. According to the National Heart, Lung, and Blood Institute at https://www.nhlbi.nih.gov/health/low-blood-pressure#:~:text=If%20your%20blood%20pressure%20drops,a%20weak%20and%20rapid%20pulse (Accessed on 9/27/22 at 4:05 p.m.), If your blood pressure drops too low, your body ' s vital organs do not get enough oxygen and nutrients. When this happens, low blood pressure can lead to shock, which requires immediate medical attention. .

Based on observations, record reviews, and staff interviews, the facility failed to ensure a medication error rate of 5% or less, based on three errors out of 31 opportunities for error, resulting in an error rate of 9.68%. This involved three (Residents #31 and #6 & #13) of five residents observed during medication administration, from a total sample of 18 residents. The findings include: During a medication administration observation for Resident #31 on 09/14/22 at 9:37 a.m., Licensed Practical Nurse (LPN) A obtained [MEDICATION(S)] 10 milligrams (mg) and Losartan 100 mg. Both medications had special instructions to hold the medications if the resident's blood pressure (BP) was less than 120/80. LPN A popped the medications into the medication cup, performed hand hygiene and went into Resident #31's room. Before administering the medication, the nurse was asked for the resident's blood pressure. she stated it was 125/62 millimeters of mercury (mmHg). She was asked to verify the resident's blood pressure again before administering the medication. She again stated, The blood pressure is 125/62 mmHg and proceeded to administer the medication. (Copy of the medication administration record (MAR) obtained) During another observation on 09/14/22 at 9:48 a.m., LPN A was observed preparing medication for Resident #6. She obtained Aspirin 81 mg, [MEDICATION(S)] 1 mg, [MEDICATION(S)] 15 mg, [MEDICATION(S)] sulfate 325 mg, and [MEDICATION(S)] 40 mg. All of the medications were popped into a medication cup. LPN A also obtained four ounces of Ensure (nutritional supplement), then proceeded into Resident #6's room. After performing hand hygiene, LPN A assisted the resident in taking the medication by pouring all of the pills into the resident's mouth. She then gave the resident the Ensure. After Resident #6 was finished drinking the Ensure, LPN A performed hand hygiene before administering eye drops. While she was performing hand hygiene, Resident#6 was observed taking a pill out of her mouth and dropping it on the floor. LPN A was made aware of the resident's behavior, and she picked the pill up from the floor. She then asked Resident #6 if she had additional pills in her mouth, and the resident spit out two additional pills. LPN A stated the medications spit out were [MEDICATION(S)], Aspirin and [MEDICATION(S)] sulfate. (Photographic evidence obtained) LPN A discarded the medication and notified the Director of Nursing (DON). The DON arrived and could be heard explaining to LPN A her next steps to take. In an interview on 09/14/22 at 9:49 a.m., LPN A was asked to review the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Both medications had special instructions to hold the medications if the if the resident's blood pressure (BP) was less then 120/80. When asked if the medication should have been administered, she stated she went by the top number (systolic - 120) and not the bottom number (diastolic - 62). She stated she was not sure what the facility's policy said about that. When asked about Resident #6's behavior of pocketing her medication, LPN A confirmed that she should have checked the resident's mouth to ensure she had swallowed the medication. On 09/15/22 at 9:25 a.m., Registered Nurse (RN) B was observed preparing medications for Resident #13. After obtaining all the medication, she stated she needed to remove the [MEDICATION(S)] from Resident #13's right upper extremity. She performed hand hygiene, administered the medication to the resident, and walked out of the resident's room without removing the [MEDICATION(S)]. RN B proceeded to administer medication to the next resident. In an interview on 09/15/22 at 10:00 a.m., RN B was asked to review Resident #13's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Copy of the MAR obtained) RN B was reminded by the clinical educator who was accompanying her during medication pass that she forgot to remove the patch. RN B walked back to the resident's room and removed the patch. In an interview on 09/15/22 at 11:45 a.m., the Director of Nursing (DON) and the Administrator were informed of the medication errors. They both verbalized understanding and stated education would be initiated. A review of the facility's policy and procedure titled, Medication Administration (revised August 2014), revealed that medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration. The administration procedure revealed that medications are to be administered in accordance with the written orders from the prescriber and administered without unnecessary interruptions. 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 in the MAR and action is taken as appropriate. The individual who administers the medication dose should record the administration on the resident's MAR directly after the medication is given. .

Based on observations, staff interviews, and facility document review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The findings include: A tour of the kitchen began at 11:51am on 4/5/2021. A microwave and juice machine fountain, both located next to the entrance of the kitchen, were not clean. Dried food particles and miscellaneous stains were observed on the door, sides, base, and internal hood of the microwave, above the area where food is placed during heating. Thick, gel-like substances were splattered along the panel of the juice fountain above the spouts where the juice is dispensed. (Photographic evidence obtained). A tour of the nourishment room conducted on 4/5/2021 at 1:35pm, revealed that a microwave and a juice fountain used for residents were not clean. Dried food particles were on the base and internal hood of the microwave, above the area where food is placed during heating. Thick, gel-like substances were splattered along the panel of the juice fountain above the spouts where the juice is dispensed. (Photographic evidence obtained). During an interview with the Activities Director on 4/6/2021 at 10:07 am, she said that there is only one nourishment room in the facility for resident use. The juice fountain is used to provide residents with beverages, and that the microwave located in the nourishment room is also for resident use. The Certified Nurse Assistants (CNAs) and dietary staff work together to keep the nourishment room and equipment clean. During a second tour of the kitchen and the nourishment room conducted on 4/6/2021 at 2:21 pm, the microwaves and juice fountains in each area remained unclean. During an interview on 4/6/2021 at 2:23pm with Employee D, Licensed Practical Nurse (LPN), she confirmed that the residents receive their beverages from the juice fountain in the nourishment room. It is the responsibility of a CNA, who gets the assignment at the beginning of the shift, to ensure that the nourishment room is cleaned each shift. During a third tour of the kitchen and nourishment room conducted on 4/7/2021 at 12:38pm, the microwaves and juice fountains remained unclean in each area. Review of the CNA daily assignment sheet provided by Employee A, LPN, revealed that on 4/7/2021, two CNAs were assigned to clean the nourishment room on their allotted shift. During an interview conducted on 4/7/2021 at 12:55 pm with the Certified Dietary Manager (CDM), he stated that the kitchen staff are solely responsible for the daily cleaning of the microwave and juice fountain located in the kitchen, and that kitchen staff and dietary work together to ensure the nourishment room equipment is cleaned daily. He was directed to the microwaves and drink fountains in the kitchen and nourishment room. Upon observation, he confirmed that they were not clean and that they should have been.

Based on observation, record review and staff interviews, the facility failed to maintain an infection control program to ensure prevention of development and transmission of communicable disease and infections for 1 of 2 residents sampled for nebulizer use from total of 28 sampled residents. (Resident #2) The findings include: A record review for Resident #2 revealed an [AGE] year-old female admitted on [DATE]. Her [DIAGNOSES REDACTED]. She was alert, oriented and ambulated independently in her room. During an interview with Resident #2 in her room on 4/23/18 at 2:10 pm, a nebulizer machine was observed on the windowsill. The nebulizer tubing, medication cup and mouthpiece were also observed on the windowsill, and not placed in a plastic storage bag. The tubing was not labeled or dated. During the interview with Resident #2, she was asked how often she received nebulizer treatments, and she stated three times a day. She stated she was able to administer the nebulizer treatment herself after the nurse put the medication in the cup. When she finished the treatment, the nurse would return and clean the medication cup and mouthpiece and put them on the windowsill. When asked if the tubing, medication cup and mouthpiece were placed in a plastic bag in between use, she said not that she was aware. Observations were made on 4/24/18 at 10:30 am, on 4/25/18 at 1:30pm, and on 4/26/18 at 11:00 am. The tubing, medication cup and mouthpiece were found sitting on the windowsill, and were not placed in a plastic bag to keep them clean and sanitary. An interview was conducted with Registered Nurse A on 4/25/18 at 1:33 pm. When asked how often the nebulizer tubing and supplies were changed, she stated every Sunday night. She said the new supplies came with a hanging plastic bag to keep the supplies in when not in use. Also, the tubing and bag were labeled and dated when changed. When asked if there was a reason why Resident #2's nebulizer supplies and tubing were left on windowsill, she stated they should be put away after each use. A review of the facility's policy Respiratory Practices, Small volume nebulizer included : upon completion of the treatment, rinse the small volume nebulizer mouthpiece and the T piece with tap water and dry, place in treatment bag labeled with resident name and dated. An interview was conducted with Director of Nursing (DON) on 4/25/18 at 1:40 pm. He was asked what the infection control policy stated regarding storage of nebulizer tubing and supplies for residents receiving nebulizer treatments. He stated that the nebulizer tubing and supplies were changed every week on Sunday night. Also, the new supplies and tubing were labeled and dated and stored in a plastic hanging bag. He was asked whether he was aware that Resident #2's nebulizer tubing and supplies were being kept on the windowsill of her room and not in a plastic bag per the facility's policy. He stated no . .

Based on staff interviews and observations made in the kitchen during two of three survey days, the facility failed to prepare and serve food in accordance with professional standards for food service safety. This practice potentially impacted any resident who consumed food prepared in the kitchen. The findings include: During a tour of the facility's main kitchen on 5/1/2017 at 12:20:11 PM, observations revealed the entire kitchen floor was soiled. At that time, an interview with the Kitchen Manager revealed that the floor would be swept at the end of the day. The floor needed to be deep cleaned. There were a lot of leftover food items in the refrigerators which were labeled and dated, but the dates were written over as if the facility changed the dates in order to comply with the regulations. A large bowl of undated tuna salad was observed at 12:28 PM. An interview with the cook at 12:30 PM revealed that the tuna was made on 4/30/17 by another unknown cook. The Dietary Manager was unaware of the source of the food. On 05/01/2017 at 12:30:11 PM, observations in the kitchen revealed two bunches of celery soaked in a dirty 2-compartmental sink. The cook's sink had a layer of scum at the bottom of the water. The evening cook stated that she did not see the scum, but threw the celery bunches into this water to clean them. The walls behind the kitchen sink were observed with splashes of food debris. The stove top and the flat grill were observed with burnt-on food debris. On 5/1/2017 at 12:35 PM, the morning cook stated that she would clean the burnt range and flat grill. On 5/1/17 at 12:30 PM, the standing mixer's rotary engine top was observed with dried food debris. The equipment was covered with plastic, which meant clean and ready for use. The robot coupe container was stored inappropriately on top of rolls of wrapping foil and plastic wrap. The container was cracked lengthwise and discolored with age. The Dietary Manager promised to have the kitchen cleaned up by the evening.

Based on observations, interviews, and record reviews, the facility failed to ensure proper sanitation of cookware, dishes, and utensils, and failed to ensure that proper temperatures were obtained for all food item consistencies. The findings include: During the initial tour of the kitchen on 4/11/16 at 10:20 am with the FSD (Food Service Director) and the CDM (Certified Dietary Manager), the dish machine was checked by a staff member for sanitizer level. The reading for chlorine was 10 ppm (parts per million) and was verified by the CDM. The acceptable reading was 50-100 ppm. Paper products were used for the lunch meal. Chlorine levels were adjusted and re-tested at 12:03 pm on 4/11/16. The reading at that time was 100 ppm. On a return visit on 4/14/16 at 11:05 am, lunch had been prepared and taken to the Pavilion. A review of past temperature logs for foods leaving the kitchen revealed that out of 17 logs, 7 had at least one meal missing any pureed, ground, or chopped items. The CDM confirmed that there were residents that would need ground or pureed diets, but not always the need for chopped foods. Record review revealed on 3/23/16, there were no pureed or ground foods for breakfast or lunch with temperatures recorded. On 3/25/16, there were no pureed or ground foods for breakfast or lunch with temperatures recorded. On 3/27/16, there were no pureed or ground foods for dinner with temperatures recorded. On 3/29/16, there were no pureed or ground foods for breakfast or lunch with temperatures recorded. On 3/30/16, there were no pureed or ground foods for breakfast or lunch with temperatures recorded. On 4/3/16, there were no pureed or ground foods for lunch with temperatures recorded. On 4/4/16, there were no pureed or ground foods for breakfast or lunch with temperatures recorded.

Based on observations, record reviews, and staff interviews, the facility failed to ensure residents were free of accident hazards for 2 residents (Residents #25, and #46), out of 26 residents sampled. The findings include: 1. An interview with Employee D, Licensed Practical Nurse (LPN), on 4/12/2016 at 11:13 AM confirmed the Resident #25 had fallen 2 times on 3/12/2016, and on 1 fall occurred on 3/15/2016. A review of the facility's incident log revealed that on 3/12/2016 at 5:29 am, (Resident) had wiggled her legs over the side of the mattress and was half way between the floor and the bed and staff assisted her to the floor. On 3/12/2016 at 7:45 AM, the log revealed, (Resident) found sitting on floor next to bed, had wiggled out of bed. On 3/15/2016 at 12:20 AM, log revealed, (Resident) was found on her knees next to her bed, holding onto the side rail. On 04/13/2016 at 8:55 AM, and at 3:34 PM, an observation was conducted of Resident #25 lying in her bed and a floor mat was observed to the left side of her. An observation was conducted on 04/14/2016 at 8:13 AM of Resident #25 lying in her bed and a floor mat was located on the left side of the bed. An observation was conducted on 04/14/2016 at 8:30 AM of Resident #25 being assisted with her breakfast by Employee F, Certified Nursing Assistant. An interview was conducted at this time with the CNA and she confirmed the resident should have floor mats on both sides of her bed. The employee proceeded to look in the resident's room and closet and she did not locate the floor mat. She was asked who was responsible to make sure residents have their mats on the floor, and she replied, the Director of Nursing. A record review was conducted for Resident #25 and it revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS), dated [DATE], revealed resident was dependent of staff for all Activities of Daily Living. A review of the care plan, dated 1/15/2016, revealed Resident #25 remains at risk for falling related to impaired gait/balance cognitive impairments, 2 person extensive assistance with transfers/ ambulation, frequent incontinence, chronic pain, and use of narcotic and psychotropic medications. Interventions include, but not limited to bilateral floor mats. During an interview on 04/13/2016 at 3:38 PM with Employee E, CNA, she was asked what she does for Resident #25 to ensure she was safe and free from falls. She replied, I will check on her frequently, make sure her bed is in low position, alarms on her and floor mats are in place. The employee confirmed at this time there were no floor mats on the right side of the resident's bed. An interview on 04/14/2016 at 8:36 AM with the DON confirmed Resident #25 should have floor mats to both sides of her bed. An interview on 04/14/2016 at 8:47 AM with Employee A, LPN, confirmed the floor mat that should be on the right side of floor for Resident #25 could not be found in the room. 2) In an observation of Resident #46's room at 2:24 PM on 4/11/16, the resident was in bed sleeping. There was a fall mat on the floor on the left side of the bed. There was a fall mat on the right side of the bed up against the wall. A review of a Care Plan for Resident #46, dated 3/28/16, reported that the resident remained at risk for falls related to falls prior to admission, left hip fracture, dementia, cognitive impairments, impaired gait/balance. Interventions included floor mats ordered, will implement upon arrival 3/29/16.

Based on observations, record reviews, and staff interviews, the facility failed to provide the necessary care and treatment of [REDACTED].#16), as evidenced by wound care and assessments being conducted by a Licensed Practical Nurse and performing dressing changes to a wound in an unsafe and unsanitary manner out of 2 residents reviewed for pressure ulcers. The findings include: 1. An interview was conducted on 4/12/2016 at 11:16 AM with Employee D, Licensed Practical Nurse, confirmed Resident #16 had an unstageable (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcer to her coccyx. A review conducted of the wound progress notes by Employee A, Licensed Practical Nurse (LPN), dated 4/12/16 at 3:32 PM, read, Pressure area to right buttocks has shown no changes since implementation of new dressing orders. Measures 2.2 centimeters (cm), x 2.6 cm. X .02 cm wound edges are red, and edges are covered in yellow/green slough. A progress note by Employee A, dated 4/9/16 at 5:45 PM, read, Dressing change to coccyx changed d/t being soiled. Wound is white with black circle to center of wound. Odor present, pad 50% covered, with brown exudate. Resident tolerated the procedure well, but refused pain medication, scant bleeding around circumference, staff turning resident every 2 hours. A note dated 4/5/2015 at 9:49 AM read, Pressure to right buttocks shows no improvement from last review. Measures 2.5 x 3 cm, wound bed with green yellow slough, and center site 0.02 cm in depth, wound edges are red and macerated. A signed order for wound care, dated 4/7/16, read, Cleanse wound to right buttocks with cleanser, apply skin prep around site, apply Medi-honey alginate, cover with plain calcium alginate, and cover with Xtrasorb adhesive foam every 3 days and as needed. 2. An observation was conducted on 04/14/2016 from 10:18 AM - 10:29 AM of wound care being performed for Resident #16 for an unstageable pressure ulcer (exhibits a full-thickness tissue loss in which the base of ulcer is covered in slough in the wound bed) to her coccyx by Employee A, Licensed Practical Nurse (LPN). Employee A gathered her supplies and washed hands before starting the dressing change. Resident #16 was informed of the dressing change and was rolled to her right side by Employee B, Certified Nursing Assistant (CNA), who was assisting to turn/hold the resident during the dressing change. Employee A walked to the bedside of the resident and donned gloves and gathered her dressing items from a recliner that was located to the left side of the resident's bed. She placed a sheet of foil on the bed, and placed her 4X4 gauze and wound cleaner on the foil sheet. The nurse gathered the 4x4 gauze, applied a moderate amount of wound cleaner to the gauze, and placed the gauze back on the foil sheet. The nurse then proceeded to remove the old dressing from the resident's wound on her coccyx and placed the used dressing on the foil sheet next to her clean gauze and cleaner. Employee A wiped the wound and then folded the 4x4 gauze, cleaned the wound from the center out, and again the folded the gauze. The employee then picked up the bottle of wound cleaner and placed more solution on the used gauze and wound and placed it on the resident's bed, proceeded to wipe the wound again, then placed the dirty gauze on the foil sheet. The employee removed her gloves, gathered the items on the foil sheet, and then disposed of items in the garbage. Employee A then gathered the new dressing items from the recliner next to her (located beside the resident's bed), and without washing her hands, placed a new foil sheet next to the resident with her bare hands. Employee A then donned new gloves without washing her hands, opened a packet of skin prep and applied the prep to the outer edges of the resident's wounds, then placed the used skin prep pad back on the clean foil next to her supplies. The nurse then obtained a pair of scissors (which had previously been placed on the bed when gathering supplies) and a pre-opened package of Medi-Honey, and cut a small square. The nurse placed the scissors on the bed and held the medicated pad with her gloved hands and placed on the resident's wound. The nurse then took the scissors and picked up a package of calcium alginate and cut a square piece, picked the piece up with her hands, and placed on the resident's wound. The employee then opened a package with an Xtrasorb dressing, took a sharpie pen that was on the bed, dated and initialed the dressing, and placed the dressing on the wound. The sharpie pen was then placed on the resident's bed next to the scissors. The nurse then gathered all of her supplies, placed them in a large Ziploc baggie, and assisted the resident to be repositioned. An interview was conducted with Employee A, LPN, on 04/14/2016 at 10:30 AM. She was asked when and with what product does she clean the scissors that she used for the dressing change. The employee replied, I will clean them when I go out of the room and will clean them with alcohol. The employee was also asked if she washed her hands after removing the old dressing and applying the new one, and she confirmed she did not follow proper procedure for handwashing. An interview was conducted with the Director of Nursing on 04/14/2016 at 10:42 AM, and she confirmed Employee A did not perform proper hand washing and infection control practices, and should have washed her hands in between removing old gloves and donning new ones, and after removing the soiled dressing, cleaning the wound, and applying the new dressing. The DON was asked for the procedure on cleaning the scissors used for dressing changes and she stated, We use alcohol, we didn't know that we needed to use something else. A review was conducted of the facility's Policy & Procedure (P&P) for Infection Control Guidelines for All Nursing Procedures, dated August 2012, and it read, Employees must wash their hands for ten to fifteen seconds using anti-microbial soap and water under the following conditions: before and after direct contact with residents, any contact with other body fluids, after removing gloves, after handling items potentially contaminated items with blood, body fluids, and secretions. (Photographic evidence obtained) A review of the facility's P&P for Hand washing/Hand hygiene, dated 8/2015, read, Use anti-microbial or non-anti-microbial soap and water for: Before and after direct contact with residents, after handling clean or soiled dressings, contaminated equipment, and after removing gloves. The use of gloves does not replace hand washing/hand hygiene. (Photographic evidence obtained) A review was conducted of the facility's P&P for Cleaning and Disinfection of Resident Care Items and Equipment, dated 7/2014, which read, For Semi-Critical items which consist of items that may come in contact with mucous membranes or non-intact skin. Such devices should be free from all microorganisms, must be cleaned and disinfected before reuse by another resident. (Photographic evidence obtained) An interview was conducted with Employee A on 04/14/2016 at 11:30 AM, and she was asked for the facility's P&P for wound care. She replied, We don't have a specific P&P for wound care. Employee A confirmed she has been performing wound care on the residents since December and has never received formal wound care training. She stated, I'm not really a wound care nurse, but since I have come back, I have been doing it. The employee was questioned how was she trained and she stated, I have done training on my own. The LPN was asked if she was the staff member performing the wound care assessments and she replied, Yes, and confirmed she was not aware an LPN could not assess wounds. An interview was conducted on 04/14/2016 at 11:49 AM with the Administrator, Director of Nursing (DON), Employee A, and Employee C, LPN (infection control nurse), and all confirmed they were not aware that an LPN could not do measurements or assess a wound. The DON stated, I thought it was okay for an LPN to do it as long as she has RN supervision. An interview was conducted with Employee C, LPN, on 04/14/2016 at 12:28 PM, and was asked how often the facility trains employees on infection control and what program the facility uses. She replied, We don't really have an infection control program or training for the facility. The employees take that with their annual training on-line. When asked if the facility had conducted any in-services or had any skills check list to make sure staff were educated on infection control, she replied, Honestly, no. She was then asked how do new staff and nurses know what to clean re-usable equipment with and gather information on that? She replied, I'm not sure but I'm sure they get told that during orientation.

Based on observations, record reviews, and staff interviews, the facility failed to provide and arrange services that meets professional standards of quality for wound care and assessments as evidenced by a Licensed Practical Nurse performing assessments on pressure ulcers, and not performing wound care in a safe and sanitary manner for Resident #16, out of 2 residents sampled for pressure ulcers. The findings include: Professional Standard of Care is defined in Chapter 766.102 as the prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which in light of all relevant surrounding circumstances is recognized as acceptable and appropriate by reasonably prudent similar health care providers. The Florida Nurse Practice Act, Chapter 464.003 defines the practice of professional nursing as the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not limited to: the administration of medications and treatments as prescribed or authorized by a duly licensed practitioner, practice of practical nursing as the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured or informed and the promotion of wellness, maintenance or health, and the prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician or a licensed dentist. 1. An interview was conducted on 4/12/2016 at 11:16 AM with Employee D, Licensed Practical Nurse, confirmed Resident #16 had an unstageable (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcer to her coccyx. A review conducted of the wound progress notes by Employee A, Licensed Practical Nurse (LPN), dated 4/12/16 at 3:32 PM, read, Pressure area to right buttocks has shown no changes since implementation of new dressing orders. Measures 2.2 centimeters (cm), x 2.6 cm. X .02 cm wound edges are red, and edges are covered in yellow/green slough. A progress note by Employee A, dated 4/9/16 at 5:45 PM, read, Dressing change to coccyx changed d/t being soiled. Wound is white with black circle to center of wound. Odor present, pad 50% covered, with brown exudate. Resident tolerated the procedure well, but refused pain medication, scant bleeding around circumference, staff turning resident every 2 hours. A note dated 4/5/2015 at 9:49 AM read, Pressure to right buttocks shows no improvement from last review. Measures 2.5 x 3 cm, wound bed with green yellow slough, and center site 0.02 cm in depth, wound edges are red and macerated. A signed order for wound care, dated 4/7/16, read, Cleanse wound to right buttocks with cleanser, apply skin prep around site, apply Medi-honey alginate, cover with plain calcium alginate, and cover with Xtrasorb adhesive foam every 3 days and as needed. 2. An observation was conducted on 04/14/2016 from 10:18 AM - 10:29 AM of wound care being performed for Resident #16 for an unstageable pressure ulcer (exhibits a full-thickness tissue loss in which the base of ulcer is covered in slough in the wound bed) to her coccyx by Employee A, Licensed Practical Nurse (LPN). Employee A gathered her supplies and washed hands before starting the dressing change. Resident #16 was informed of the dressing change and was rolled to her right side by Employee B, Certified Nursing Assistant (CNA), who was assisting to turn/hold the resident during the dressing change. Employee A walked to the bedside of the resident and donned gloves and gathered her dressing items from a recliner that was located to the left side of the resident's bed. She placed a sheet of foil on the bed, and placed her 4X4 gauze and wound cleaner on the foil sheet. The nurse gathered the 4x4 gauze, applied a moderate amount of wound cleaner to the gauze, and placed the gauze back on the foil sheet. The nurse then proceeded to remove the old dressing from the resident's wound on her coccyx and placed the used dressing on the foil sheet next to her clean gauze and cleaner. Employee A wiped the wound and then folded the 4x4 gauze, cleaned the wound from the center out, and again the folded the gauze. The employee then picked up the bottle of wound cleaner and placed more solution on the used gauze and wound and placed it on the resident's bed, proceeded to wipe the wound again, then placed the dirty gauze on the foil sheet. The employee removed her gloves, gathered the items on the foil sheet, and then disposed of items in the garbage. Employee A then gathered the new dressing items from the recliner next to her (located beside the resident's bed), and without washing her hands, placed a new foil sheet next to the resident with her bare hands. Employee A then donned new gloves without washing her hands, opened a packet of skin prep and applied the prep to the outer edges of the resident's wounds, then placed the used skin prep pad back on the clean foil next to her supplies. The nurse then obtained a pair of scissors (which had previously been placed on the bed when gathering supplies) and a pre-opened package of Medi-Honey, and cut a small square. The nurse placed the scissors on the bed and held the medicated pad with her gloved hands and placed on the resident's wound. The nurse then took the scissors and picked up a package of calcium alginate and cut a square piece, picked the piece up with her hands, and placed on the resident's wound. The employee then opened a package with an Xtrasorb dressing, took a sharpie pen that was on the bed, dated and initialed the dressing, and placed the dressing on the wound. The sharpie pen was then placed on the resident's bed next to the scissors. The nurse then gathered all of her supplies, placed them in a large Ziploc baggie, and assisted the resident to be repositioned. An interview was conducted with Employee A, LPN, on 04/14/2016 at 10:30 AM. She was asked when and with what product does she clean the scissors that she used for the dressing change. The employee replied, I will clean them when I go out of the room and will clean them with alcohol. The employee was also asked if she washed her hands after removing the old dressing and applying the new one, and she confirmed she did not follow proper procedure for handwashing. An interview was conducted with the Director of Nursing on 04/14/2016 at 10:42 AM, and she confirmed Employee A did not perform proper hand washing and infection control practices, and should have washed her hands in between removing old gloves and donning new ones, and after removing the soiled dressing, cleaning the wound, and applying the new dressing. The DON was asked for the procedure on cleaning the scissors used for dressing changes and she stated, We use alcohol, we didn't know that we needed to use something else. A review was conducted of the facility's Policy & Procedure (P&P) for Infection Control Guidelines for All Nursing Procedures, dated August 2012, and it read, Employees must wash their hands for ten to fifteen seconds using anti-microbial soap and water under the following conditions: before and after direct contact with residents, any contact with other body fluids, after removing gloves, after handling items potentially contaminated items with blood, body fluids, and secretions. (Photographic evidence obtained) A review of the facility's P&P for Hand washing/Hand hygiene, dated 8/2015, read, Use anti-microbial or non-anti-microbial soap and water for: Before and after direct contact with residents, after handling clean or soiled dressings, contaminated equipment, and after removing gloves. The use of gloves does not replace hand washing/hand hygiene. (Photographic evidence obtained) A review was conducted of the facility's P&P for Cleaning and Disinfection of Resident Care Items and Equipment, dated 7/2014, which read, For Semi-Critical items which consist of items that may come in contact with mucous membranes or non-intact skin. Such devices should be free from all microorganisms, must be cleaned and disinfected before reuse by another resident. (Photographic evidence obtained) An interview was conducted with Employee A on 04/14/2016 at 11:30 AM, and she was asked for the facility's P&P for wound care. She replied, We don't have a specific P&P for wound care. Employee A confirmed she has been performing wound care on the residents since December and has never received formal wound care training. She stated, I'm not really a wound care nurse, but since I have come back, I have been doing it. The employee was questioned how was she trained and she stated, I have done training on my own. The LPN was asked if she was the staff member performing the wound care assessments and she replied, Yes, and confirmed she was not aware an LPN could not assess wounds. An interview was conducted on 04/14/2016 at 11:49 AM with the Administrator, Director of Nursing (DON), Employee A, and Employee C, LPN (infection control nurse), and all confirmed they were not aware that an LPN could not do measurements or assess a wound. The DON stated, I thought it was okay for an LPN to do it as long as she has RN supervision. An interview was conducted with Employee C, LPN, on 04/14/2016 at 12:28 PM, and was asked how often the facility trains employees on infection control and what program the facility uses. She replied, We don't really have an infection control program or training for the facility. The employees take that with their annual training on-line. When asked if the facility had conducted any in-services or had any skills check list to make sure staff were educated on infection control, she replied, Honestly, no. She was then asked how do new staff and nurses know what to clean re-usable equipment with and gather information on that? She replied, I'm not sure but I'm sure they get told that during orientation.

Based on observations, record reviews, and staff interviews, the facility failed to update the care plan for changes in stages of a pressure ulcer and wound care for Resident #16, out of 26 sampled residents. The findings include: An interview was conducted with Employee D, Licensed Practical Nurse (LPN) on 04/12/2016 at 11:16 AM. The employee confirmed the resident had an unstageable pressure ulcer to her coccyx. A record review for Resident #16 revealed a date of admission of 2/20/2016, with [DIAGNOSES REDACTED]. A 30 day Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) of a 6 out 15, and was totally dependent for activities of daily living (ADLs). Skin conditions listed a Stage II pressure ulcer with an onset date of 2/26/2016, and all other pressure areas were marked 'no'. An MDS, dated [DATE], was reviewed and under Skin Conditions, it listed Stage II pressure ulcer with onset date of 2/26/2016. A review of the Care Plan, dated 2/29/16, revealed Resident #16 had a pressure ulcer to coccyx related to admitted with scar to bony prominence, with history of pressure ulcer to coccyx, Stage 2 to coccyx. On 3/14/16, plan changed to unstageable, covered with slough due to Cardiovascular Accident ([MEDICAL CONDITION]), right sided weakness, total dependence on staff for all areas of care, incontinence, non-verbal communication. Interventions included but not limited to hospice wound nurse consult on 4/5/2016, med pass supplemental 60ml TID, apply santyl ointment, cover with [MEDICATION NAME] to right buttocks decubitus, use saline wet to dry dressing q 2 days, assess and record area around the pressure ulcer, and assess and document weekly. A review conducted of the wound progress notes by Employee A, Licensed Practical Nurse (LPN), dated 4/12/16 at 3:32PM stated, Pressure area to right buttocks has shown no changes since implementation of new dressing orders. Measures 2.2 centimeters (cm), x 2.6 cm. X .02 cm, wound edges are red, and edges are covered in yellow/green slough. A progress note by Employee A, dated 4/9/16 at 5:45 PM, stated, Dressing change to coccyx changed due to being soiled. Wound is white with black circle to center of wound. Odor present, pad 50% covered, with brown exudate. Resident tolerated the procedure well, but refused pain medication, scant bleeding around circumference, staff turning resident every 2 hours. A note, dated 4/5/2015 at 9:49 AM, stated, Pressure to right buttocks shows no improvement from last review. Measures 2.5 x 3 cm, wound bed with green yellow slough and center site 0.02 cm in depth, wound edges are red and macerated. A review of progress notes, dated 4/5/2015, by Employee A stated, The Interdisciplinary Team (IDT) met regarding pressure area to right buttocks. Site continues at an unstageable state. A review was conducted of the Weekly Skin Integrity Reviews for Resident #16 and it revealed on the date of 4/11/2016, stage II to coccyx; 4/4/2016, old pressure ulcer to buttocks; 3/28/2016, Stage II to coccyx; 3/21/2016, no mention of pressure ulcer; and 3/14/2016, Stage II pressure ulcer to coccyx. An interview with Employee A, LPN, on 4/14/2016 at 10:30AM confirmed the wound for Resident #16 on her coccyx was unstageable and not a stage II. An interview with Employee C, LPN, on 04/14/2016 at 1:08 PM confirmed the MDS and care plan for Resident #16 were not accurate and updated.

Based on observations, record review, and staff interviews, the facility failed to comprehensively and accurately access a change in staging of a pressure ulcer for Resident #16, and a skin tear for Resident #25, out of 26 sampled residents. The findings include: 1. An interview was conducted with Employee D, Licensed Practical Nurse (LPN), on 04/12/2016 at 11:16 AM, and she confirmed that Resident #16 had an unstageable pressure ulcer to her coccyx. A record review for Resident #16 revealed a date of admission of 2/20/2016, with [DIAGNOSES REDACTED]. A 30-day Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of a 6 out 15, and was totally dependent for activities of daily living (ADLs). Skin conditions listed a Stage II pressure ulcer with an onset date of 2/26/2016, and all other pressure areas were marked 'no'. An MDS, dated [DATE], was reviewed and under skin conditions, it listed Stage II pressure ulcer with onset date of 2/26/2016. A review of a Care Plan, dated 2/29/16, revealed Resident #16 had a pressure ulcer to coccyx related to admitted with scar to bony prominence with history of pressure ulcer to coccyx, Stage 2 to coccyx. On 3/14/16, the care plan was changed to unstageable, covered with slough due to Cardiovascular Accident ([MEDICAL CONDITION]), right sided weakness, total dependence on staff for all areas of care, incontinence, nonverbal communication. Interventions included but not limited to hospice wound nurse consult on 4/5/2016, med pass supplemental 60ml TID, apply santyl ointment, cover with [MEDICATION NAME] to right buttocks decubitus, use saline wet to dry dressing q 2 days, assess and record area around the pressure ulcer and assess and document weekly. A review conducted of the wound progress notes by Employee A, Licensed Practical Nurse (LPN), dated 4/12/16 at 3:32PM stated, Pressure area to right buttocks has shown no changes since implementation of new dressing orders. Measures 2.2 centimeters (cm), x 2.6 cm. X .02 cm, wound edges are red, and edges are covered in yellow/green slough. A progress note by Employee A, LPN, dated 4/9/16 at 5:45PM read, Dressing change to coccyx changed due to being soiled. Wound is white with black circle to center of wound. Odor present, pad 50% covered, with brown exudate. Resident tolerated the procedure well, but refused pain medication, scant bleeding around circumference, staff turning resident every 2 hours. A note dated 4/5/2015 at 9:49 AM read, Pressure to right buttocks shows no improvement from last review. Measures 2.5 x 3 cm, wound bed with green yellow slough and center site 0.02 cm in depth, wound edges are red and macerated. A review of progress notes, dated 4/5/2015, by Employee A, LPN read, The Interdisciplinary Team (IDT) met regarding pressure area to right buttocks. Site continues at an unstageable state. A review was conducted of the Weekly Skin Integrity Reviews for Resident #16, and it revealed that on the date of 4/11/2016, stage II to coccyx; 4/4/2016, old pressure ulcer to buttocks; 3/28/2016, Stage II to coccyx; 3/21/2016, no mention of pressure ulcer; and 3/14/2016, Stage II pressure ulcer to coccyx. An interview with Employee A, LPN, on 4/14/2016 at 10:30 AM confirmed the wound for Resident #16 on her coccyx was unstageable and not a stage II. An interview with Employee C, LPN, on 04/14/2016 at 1:08 PM confirmed the MDS and care plan for Resident #16 was not accurate and updated. She stated, We are doing a significant change right now. 2) Multiple observations were conducted of Resident #25 from 4/12/2016 at 9:05 AM to 4/13/2016 at 3PM, with a skin tear to her right forearm with steri stripes applied. A record review was conducted for Resident #25 and it revealed a date of admission of 10/8/2015. [DIAGNOSES REDACTED]. A quarterly MDS, dated [DATE], revealed severe cognitive impairment, and total dependence with ADLs. A review of the nurse's weekly skin integrity review, dated 4/7/2016, read skin intact. (There's no documentation of skin tear to right forearm.) On 3/24/2016, skin intact. (Photographic evidence obtained.) A review of the nurse's progress notes for Resident #25 from 4/1/2016 - 4/13/2016 revealed no documentation in regards to a skin tear to the right forearm. On 04/13/2016 at 3:30 PM, an interview was conducted with Employee A, LPN. The employee was asked when Resident #25 obtained the skin tear to her right forearm. The employee reviewed the skin integrity book for Resident #25 and she was not able to locate documentation of when or how the skin tear appeared for Resident #25. She stated, I don't see it, but I will go and find out. On 04/13/2016 at 3:58 PM, Employee A confirmed there was no documentation in regards to the skin tear for Resident #25. She stated, There were no progress notes and we have no idea when it happened. A review of the facility's Policy and Procedure for Accidents and Incidents- Investigating and Reporting, dated 2/2014, stated, All accidents or incidents involving residents, employees, visitors, etc. occurring on our premises shall be investigated and reported to the administrator. The nurse supervisor/ charge nurse and the department director or supervisor shall promptly initiate and document investigation of the accident of incident. Fill out of incident/ accident form. On 04/14/2016 at 8:34 AM, an interview with the DON confirmed she was not made aware of the skin tear for Resident #25, and she found out that the resident obtained a skin tear of unknown origin on Sunday, 4/10. She stated, The nurse on that day was passing her 2pm medications and realized that the resident had a skin tear, she applied first aid, but she didn't document any of it.

Based on observations, record reviews, and staff interviews, the facility failed to prevent the spread of infection by the failure of washing hands, and to provide care in a safe and sanitary manner while providing wound care for 1 resident (Resident #16) who was sampled for pressure ulcers. The findings include: An observation was conducted on 04/14/2016 from 10:18 AM - 10:29 AM of wound care being performed for Resident #16 for an unstageable pressure ulcer (exhibits a full-thickness tissue loss in which the base of ulcer is covered in slough in the wound bed) to her coccyx by Employee A, Licensed Practical Nurse (LPN). Employee A gathered her supplies and washed hands before starting the dressing change. Resident #16 was informed of the dressing change and was rolled to her right side by Employee B, Certified Nursing Assistant (CNA), who was assisting to turn/hold the resident during the dressing change. Employee A walked to the bedside of the resident and donned gloves and gathered her dressing items from a recliner that was located to the left side of the resident's bed. She placed a sheet of foil on the bed, and placed her 4X4 gauze and wound cleaner on the foil sheet. The nurse gathered the 4x4 gauze, applied a moderate amount of wound cleaner to the gauze, and placed the gauze back on the foil sheet. The nurse then proceeded to remove the old dressing from the resident's wound on her coccyx and placed the used dressing on the foil sheet next to her clean gauze and cleaner. Employee A wiped the wound and then folded the 4x4 gauze, cleaned the wound from the center out, and again the folded the gauze. The employee then picked up the bottle of wound cleaner and placed more solution on the used gauze and wound and placed it on the resident's bed, proceeded to wipe the wound again, then placed the dirty gauze on the foil sheet. The employee removed her gloves, gathered the items on the foil sheet, and then disposed of items in the garbage. Employee A then gathered the new dressing items from the recliner next to her (located beside the resident's bed), and without washing her hands, placed a new foil sheet next to the resident with her bare hands. Employee A then donned new gloves without washing her hands, opened a packet of skin prep and applied the prep to the outer edges of the resident's wounds, then placed the used skin prep pad back on the clean foil next to her supplies. The nurse then obtained a pair of scissors (which had previously been placed on the bed when gathering supplies) and a pre-opened package of Medi-Honey, and cut a small square. The nurse placed the scissors on the bed and held the medicated pad with her gloved hands and placed on the resident's wound. The nurse then took the scissors and picked up a package of calcium alginate and cut a square piece, picked the piece up with her hands, and placed on the resident's wound. The employee then opened a package with an Xtrasorb dressing, took a sharpie pen that was on the bed, dated and initialed the dressing, and placed the dressing on the wound. The sharpie pen was then placed on the resident's bed next to the scissors. The nurse then gathered all of her supplies, placed them in a large Ziploc baggie, and assisted the resident to be repositioned. An interview was conducted with Employee A, LPN, on 04/14/2016 at 10:30 AM. She was asked when and with what product does she clean the scissors that she used for the dressing change. The employee replied, I will clean them when I go out of the room and will clean them with alcohol. The employee was also asked if she washed her hands after removing the old dressing and applying the new one, and she confirmed she did not follow proper procedure for handwashing. An interview was conducted with the Director of Nursing on 04/14/2016 at 10:42 AM, and she confirmed Employee A did not perform proper hand washing and infection control practices, and should have washed her hands in between removing old gloves and donning new ones, and after removing the soiled dressing, cleaning the wound, and applying the new dressing. The DON was asked for the procedure on cleaning the scissors used for dressing changes and she stated, We use alcohol, we didn't know that we needed to use something else. A review was conducted of the facility's Policy & Procedure (P&P) for Infection Control Guidelines for All Nursing Procedures, dated August 2012, and it read, Employees must wash their hands for ten to fifteen seconds using anti-microbial soap and water under the following conditions: before and after direct contact with residents, any contact with other body fluids, after removing gloves, after handling items potentially contaminated items with blood, body fluids, and secretions. (Photographic evidence obtained) A review of the facility's P&P for Hand washing/Hand hygiene, dated 8/2015, read, Use anti-microbial or non-anti-microbial soap and water for: Before and after direct contact with residents, after handling clean or soiled dressings, contaminated equipment, and after removing gloves. The use of gloves does not replace hand washing/hand hygiene. (Photographic evidence obtained) A review was conducted of the facility's P&P for Cleaning and Disinfection of Resident Care Items and Equipment, dated 7/2014, which read, For Semi-Critical items which consist of items that may come in contact with mucous membranes or non-intact skin. Such devices should be free from all microorganisms, must be cleaned and disinfected before reuse by another resident. (Photographic evidence obtained) An interview was conducted with Employee C, LPN, on 04/14/2016 at 12:28 PM, and was asked how often the facility trains employees on infection control and what program the facility uses. She replied, We don't really have an infection control program or training for the facility. The employees take that with their annual training on-line. When asked if the facility had conducted any in-services or had any skills check list to make sure staff were educated on infection control, she replied, Honestly, no. She was then asked how do new staff and nurses know what to clean re-usable equipment with and gather information on that? She replied, I'm not sure but I'm sure they get told that during orientation.

Based on observations, staff interviews, and record review, the facility failed to properly store and lock medications for Resident #59 for 1 out 2 medication carts in the facility. The findings include: An observation was conducted on 4/13/2016 from 10:03 - 10:08 AM of a clear plastic bag labeled for Resident #59 containing the medication Azelastine HCL 1% nasal spray. The medication was sitting on top of the medication cart unattended and out of sight of the nurse who was working that cart (Employee D, Licensed Practical Nurse (LPN). An observation was conducted on 4/13/2016 at 10:08 AM of Employee D returning to her cart and obtaining the medication and locking it inside the medication cart. An interview was conducted on 4/13/2016 at 10:10 AM with Employee D, LPN, who confirmed she left the medication for Resident #59 on top of her cart and didn't secure the medication before walking away. She stated, I saw that I left it out and I'm sorry, I shouldn't have done that. An interview with Employee A, LPN, on 4/14/2016 at 2:40 PM confirmed medications should be stored and locked in the medication cart upon the nurse leaving the cart. A review was conducted of the facility's Policy and Procedure for Medication Storage in the facility (not rated) which read, No medications are to be kept on the top of the cart.

Based on observation the facility failed to serve food in a sanitary manner in the main dining room for the lunch meal service. The findings include: On 12/02/13 at 11:45 am the lunch meal service was observed in the main dining room. The Dietary Manager was observed with vinyl gloves on, standing next to the steam table in the main dining room and leaning on the trash can waiting for the meal trays to be prepared. When a tray was ready he took the tray and placed it on the cart, and then resumed his position leaning on the garbage can to wait for the next tray. He did not take off the gloves, wash his hands, and don new gloves after touching the garbage can before handling the next tray. The Dietary Manager was observed to stand with his gloved hands on his hips while waiting for the meal trays to be prepared. He did not remove the gloves, wash his hands and put on new gloves before handling the food trays. Employee #3 was observed holding the tops of drinking cups, where the resident would put their mouth, with her bare hands while preparing drinks for two different residents. On 12/03/13 at 11:50 am the lunch meal service was observed in the main dining room. The Dietary Manager was observed to pick up a dining room chair with gloved hands, and move the chair to another table. After touching the chair he went to the steam table and picked up a plate of food and brought it to the resident in the chair. He did not remove the gloves, wash his hands and don new gloves before going to the tray line and picking up a plate of food for the resident. The Dietary Manager was then observed to leave the dining room with his gloves on and return within a few minutes. He did not remove his gloves, wash his hands and don new gloves before handling food trays when he returned to the dining room. He was observed to be putting his hands on his hips, taking his eyeglasses on and off his face, and putting his hands in his pockets between handling the food trays. At no time was he observed to remove his gloves, wash his hands and don new gloves after contaminating his gloves. On 12/04/13 at 11:55 am the lunch meal service was observed in the main dining room. The Dietary Manager had vinyl gloves on while assisting with meal service. He was observed to take his hat off his head and put it back on, and put his hands on his hips while waiting for the plates to be filled. He then proceeded to deliver food trays and dishes to the residents in the dining room without removing his gloves, washing his hands and donning new gloves. .

Based on electronic medical record review and staff interview the facility failed to provide drugs and biologicals to one resident (Resident #7) out of 29 sampled residents. The findings include: A review of the electronic medical record revealed a physician's orders [REDACTED]. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The documentation on the MAR indicated [REDACTED]." An interview on 12/04/13 at 4:15 pm with the Director of Nursing (DON) revealed when asked about the documentation on the MAR indicated Yes, it looks like it wasn't given. Let me find out why." An interview on 12/04/13 at 4:30 pm with the DON revealed she stated, "The pharmacy did not have it in stock and it really depends on the pharmacy. There isn't much we can do about it if they don't have it in stock." She stated that if it wasn't given and it was documented that it was unavailable then that meant that the pharmacy didn't have it in stock. An interview on 12/05/13 at 8:40 am with the DON revealed she stated she interviewed the nurse who had documented that the medication was unavailable on 11/15/13 and 11/30/13. The nurse told her that she did not call the physician to notify him about the medication being unavailable, or to find out if he wanted to substitute a different medication. She stated that per the facility policy, the nurse is expected to call and notify the physician in this circumstance, and she did not. The DON stated, "She just didn't do it." An interview on 12/05/13 at approximately 11:50 am with the Administrator revealed she expects the nurses to call the physician if a medication is unavailable to find out what the physician wants to do. She stated she would make sure to have an in-service with the nurses to re-educate them on the policy and procedure. A review of the Procedure For Unavailable Medication form provided by the DON revealed the procedure read: "It is not acceptable to document that 'medication not available.' You must search for the medication, and locate it. If you are unable to locate the mediation, call Pharmacy. If Pharmacy is unable to provide it, you must call the physician to notify that med is unavailable, and ask if a substitute is available, or obtain an order that it is OK to miss the dose. Document in the progress notes what you have done. Notify DON of incident. "

Based on electronic medical record review and staff interview the facility failed to adequately monitor the administration of blood pressure medication for one resident (Resident #7) out of 29 sampled residents. The findings include: A review of the electronic medical record for Resident #7 revealed a physician's orders [REDACTED]. A review of the Medication Administration Record (MAR) dated 11/04/13 through 12/04/13 revealed that the resident was given [MEDICATION NAME] when his blood pressure was below 140/90. On 11/16/13 his B/P was 136/85, on 11/21/13 it was 128/87, on 11/22/13 it was 120/69 and on 11/23/13 it was 118/74. The resident's blood pressure was recorded and the MAR was initialed the same as on the days when the medication was administered, with no documentation to show that the medication had been held. During an interview on 12/04/13 at 4:15 pm with the DON she explained that the physician's orders [REDACTED]. When asked for documentation that the medication was held as ordered on the days when the resident's blood pressure was less than 140/90 she stated, "Oh, I don't know why it wasn't documented, but let me look." She then looked at the MAR and the nursing notes in the electronic medical record to see if there was some documentation as to why the medication was not held on 11/16/2013, 11/21/13, 11/22/13 and 11/23/13 when the resident's blood pressure was not within the parameters set by the physician. After reviewing the electronic MAR she stated, "I see what you're saying and I don't find any documentation that the medication was held on those days." During an interview on 12/05/13 at 8:40 am with the DON she stated she had researched the issue regarding administration of Resident #7's blood pressure medication, and explained that the way the facility computer software system is set up, it allows the nurses the choice of whether or not to document on the MAR if the medication was held or given. She stated that she had contacted the three nurses who initialed the MAR on the 11/6/13, 11/21/13, 11/22/13 and 11/23/13, and they all confirmed that they had not given the medication to the resident on those dates due to the blood pressure being out of the parameters, but had not documented that it was held anywhere in the resident's medical record. Interview on 12/05/13 at 9:02 am with Employee #1 revealed she stated that she did not give the blood pressure medication to Resident #7 on 11/16/13 because his blood pressure was not within the parameters ordered by the physician. She stated that she did not document it as not given on the MAR. Interview on 12/05/13 at 9:40 am with Employee #2 revealed she stated that she did not give the blood pressure medication to Resident #7 on 11/16/13 because his blood pressure was not within the parameters ordered by the physician. She indicated that she did not document it as not given on the MAR. Interview on 12/05/13 at approximately 11:50 am with the DON and the Administrator revealed that they were not sure if the computer system could be adjusted to make it mandatory for the nurse to document on the MAR when a medication was held for a blood pressure reading that was outside the parameters ordered. The DON stated, "I will call the company and ask if they can make the changes to our system. If they can't then I'll have to do some nurse education." The administrator indicated she agreed. An interview on 12/05/13 at 12:30 pm with the DON revealed she called the software company and they told her that the system could not be changed. She stated, "I'll be doing some training with the nurses on this." .